INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection and methadone monitoring inspection conducted on June 19, 2019 through June 21, 2019 by staff from the Department of Drug and Alcohol Programs, Bureau of Quality Assurance for Prevention and Treatment. Based on the findings of the on-site inspection, The Consortium was found not to be in compliance with the applicable chapters of 28 PA Code which pertain to the facility. The following deficiencies were identified during this inspection:
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Plan of Correction
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704.6(c) LICENSURE Core Curriculum - Supervisor Training
704.6. Qualifications for the position of clinical supervisor.
(c) Clinical supervisors and lead counselors who have not functioned for 2 years as supervisors in the provision of clinical services shall complete a core curriculum in clinical supervision. Training not provided by the Department shall receive prior approval from the Department.
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Observations
The facility failed to ensure that employee #3 completed a core curriculum in clinical supervision. Employee #3 was promoted to a clinical supervisor on July 9, 2018. Based on the employee ' s resume, the employee did not have at least 2 years as a supervisor in the provision of clinical services prior to the promotion.
The findings were discussed with facility staff during the licensing process.
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Plan of Correction
Effective 7/18/2019, Facility Director and Human Resources Director will ensure that this training is completed in a timely fashion for any future supervisory staff not meeting the 2 year supervisor experience provision.
By 7/31/2019, Facility Director and Human Resources Director will ensure employee #3 is enrolled in the next regional clinical supervisor core curriculum training.
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704.11(b)(1) LICENSURE Individual training plan.
704.11. Staff development program.
(b) Individual training plan.
(1) A written individual training plan for each employee, appropriate to that employee's skill level, shall be developed annually with input from both the employee and the supervisor.
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Observations
The facility failed to ensure that employee #6, a counselor, had an individual training plan documented in the employee's personnel/training record for the current training year.
The findings were discussed with facility staff during the licensing process.
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Plan of Correction
Effective 7/18/2019, Facility Director and Human Resources Director will ensure that individual training plans for all employees are tracked and checked in to ensure presence.
By 7/31/2019, Facility Director and Human Resources Director will ensure that employee #6 has a training plan reviewed and signed by employee and Supervisor which will be entered into the employee file.
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704.11(c)(1) LICENSURE Mandatory Communicable Disease Training
704.11. Staff development program.
(c) General training requirements.
(1) Staff persons and volunteers shall receive a minimum of 6 hours of HIV/AIDS and at least 4 hours of tuberculosis, sexually transmitted diseases and other health related topics training using a Department approved curriculum. Counselors and counselor assistants shall complete the training within the first year of employment. All other staff shall complete the training within the first 2 years of employment.
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Observations
The facility failed to ensure that all staff persons received a minimum of 6 hours of HIV/AIDS training or at least 4 hours of TB/STD and other health related topics within the regulatory timeframe, based on a review of the facility's Staffing Requirement Facility Report and the employee personnel files.
Employee #15 was hired as support staff on June 19, 2017. The employee was required to have the HIV/AIDS training no later than June 19, 2019; however, the file did not contain documentation of the training at the time of the inspection.
Employee #16 was hired as a support staff on March 20, 2017. The employee was required to have the TB/STD and other health related topics training no later than March 20, 2019; however, the file did not contain documentation of the training at the time of the inspection.
The findings were discussed with facility staff during the licensing process.
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Plan of Correction
Effective 7/18/2019, Facility Director and Human Resources Director will ensure that core trainings of HIV/AIDS and TB/STD for all employees are tracked and checked in to ensure presence.
By 7/31/2019, Facility Director and Human Resources Director will ensure that Employee #15 will be enrolled in HIV/AIDS training and Employee #16 will be enrolled in TB/STD training. Facility Director and Human Resources Director will take steps to train nursing staff to conduct these trainings internally, rather than coordinating external trainings for staff.
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705.26 (2) LICENSURE Heating and cooling.
705.26. Heating and cooling.
The nonresidential facility:
(2) May not permit in the facility heaters that are not permanently mounted or installed.
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Observations
The facility failed to ensure that all heaters were permanently mounted or installed as a space heater was discovered in counselor room #147 during the physical plant inspection.
These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
Effective 7/18/2019, Facilities Manager removed the space heater from the building. Facility Director will discuss this rules about such devices at the next all-staff meeting to ensure that all staff understand that no space heaters are allowed on the premises. Additionally, Facility Director will issue an all-staff bulletin to remind staff that space heaters are not permitted in the building. Facilities Team will conduct monthly walkthroughs of the building to ensure staff is maintaining compliance to this regulation. |
709.34 (a) (2) LICENSURE Reporting of unusual incidents
§ 709.34. Reporting of unusual incidents.
(a) The project shall develop and implement policies and procedures to respond to the following unusual incidents:
(2) Selling or use of illicit drugs on the premises.
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Observations
The facility failed to include in their written unusual incident policy and procedures how the facility would respond to the selling or use of illicit drugs on the premises.
These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
By 7/31/2019, Facility Director and COO will have revised policy 709.34(a)(2) to include into written unusual incident policy and procedures how the facility would respond to the selling or use of illicit drugs on the premises. |
715.6(d) LICENSURE Physician Staffing
(d) A narcotic treatment program shall provide narcotic treatment physician services at least 1 hour per week onsite for every ten patients
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Observations
The facility failed to provide at least one hour of onsite physician time a week for every ten patients for once of 1 of 16 weeks reviewed.
Two physician's and 1 CRNP's time sheets were reviewed for the months of February, March, April, and May 2019. During the week of May 20-26, 2019, the patient census was 270. The facility was required to provide at least 27 physician hours. There were 6 physician hours documented. The amount of physician hours documented is less than the 9 hours required for that week.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Effective 7/18/2019, Facility Director and Nursing Director will ensure a weekly check is done to verify that scheduled doctors hours meet the standard of 1 hour per 10 clients on the patient census. Facility Director and Nursing Director will ensure if a Doctor is scheduled out, that adequate hours are scheduled with other staff physicians to ensure this threshold is still met. |
715.9(a)(4) LICENSURE Intake
(a) Prior to administration of an agent, a narcotic treatment program shall screen each individual to determine eligibility for admission. The narcotic treatment program shall:
(4) Have a narcotic treatment physician make a face-to-face determination of whether an individual is currently physiologically dependent upon a narcotic drug and has been physiologically dependent for at least 1 year prior to admission for maintenance treatment. The narcotic treatment physician shall document in the patient 's record the basis for the determination of current dependency and evidence of a 1 year history of addiction.
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Observations
The facility failed to provide documentation that the narcotic treatment physician conducted the initial face-to-face with the client prior to the administration of a narcotic drug. Additionally, the required documentation of the client ' s 1-year history of physiological dependence and current dependency was not completed by the physician in one of six client records reviewed.
Client #2 was admitted on January 17, 2019 and was still active at the time of the inspection. The facility began administering methadone to the client on January 18, 2019. The initial face-to-face meeting was conducted by the Certified Registered Nurse Practitioner and not the narcotic physician. Additionally, the documentation of the client's current dependence and 1-year history was completed by the CRNP on January 18, 2018.
At the time of the inspection, the facility did not have, nor have they applied for, a federal exemption to allow Physician Assistants and Certified Registered Nurse Practitioners to make the face-to-face determination of whether an individual is currently physiologically dependent upon a narcotic drug and has been physiologically dependent for at least 1 year.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Effective 7/1/2019, Facility Director and Nursing Director will ensure that treatment physician conducts the initial face-to-face with all clients prior to the administration of narcotic drugs, and that the treatment physician completes the 1 year history of physiological dependence/current dependency for all clients. This will be handled at time of scheduling by Nursing Director, to ensure that these types of events are scheduled only with our doctors and not with our CRNP. Facility Director will apply for federal exemption to allow for CRNP to provide initial face-to-face meeting, but Nursing Director will ensure these meetings are scheduled only with treatment physician until exemption is conferred. |
715.15(b) LICENSURE Medication dosage
(b) The narcotic treatment physician shall determine the proper dosage level for a patient, except as otherwise provided in this section. If the narcotic treatment physician determining the initial dose is not the narcotic treatment physician who conducted the patient examination, the narcotic treatment physician shall consult with the narcotic treatment physician who performed the examination before determining the patient 's initial dose and schedule.
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Observations
The facility failed to ensure that the narcotic treatment physician was reviewing the dosage levels of clients in one of six client records reviewed.
Client #2 was admitted on January 17, 2019 and was still active at the time of the inspection. Each dose review conducted in the client ' s record was reviewed and documented by the facility ' s Certified Registered Nurse Practitioner and not the facility ' s narcotic treatment physician.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Effective 7/1/2019, Medical Director and Nursing Director will ensure that treatment physician conducts the reviews of dosage levels of all clients receiving narcotic treatment. Nursing Director in charge of scheduling will ensure these service types are scheduled only with treatment physician and not with CRNP. |
715.23(c)(1-7) LICENSURE Patient records
(c) An annual evaluation of each patient 's status shall be completed by the patient 's counselor and shall be reviewed, dated and signed by the medical director. The annual evaluation period shall start on the date of the patient 's admission to a narcotic treatment program and shall address the following areas:
(1) Employment, education and training.
(2) Legal standing.
(3) Substance abuse.
(4) Financial management abilities.
(5) Physical and emotional health.
(6) Fulfillment of treatment objectives.
(7) Family and community supports.
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Observations
The facility failed to either document an annual evaluation of the patient or failed to address one of the required areas in the documented annual evaluation in two of three applicable client records reviewed.
Client #1 was admitted on November 29, 2010 and was still active at the time of the inspection. There was an annual evaluation completed on October 23, 2018; however, the evaluation failed to address and document the fulfillment of treatment objectives.
Client #6 was admitted on May 15, 2007 and was discharged on August 8, 2018. There was no 2018 annual evaluation documented in the client ' s record prior to the client ' s discharge.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Effective 7/18/2019, Facility will utilize the Quality Assurance Specialist position to ensure that annual evaluations are tracked for timeliness and audited for quality to ensure that they are done within the appropriate timeframe and contain all of the necessary information. QA Specialist will conduct weekly audits of the document tracking system in order to ensure that the tracker is accurate and that documents are done in a timely and quality fashion. Charts of Clients #1 and #6 will be reviewed and used as part of the internal process improvement in this area. |
709.92(b) LICENSURE Treatment and rehabilitation services
709.92. Treatment and rehabilitation services.
(b) Treatment and rehabilitation plans shall be reviewed and updated at least every 60 days.
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Observations
The facility failed to provide treatment plan updates within the regulatory timeframe in three of six client records reviewed.
Client #3 was admitted on November 8, 2018 and was active at the time of inspection. The comprehensive treatment plan was completed on December 19, 2018 and the first update was due no later than February 19, 2019. However, the update was not completed until March 6, 2019.
Client #5 was admitted on August 31, 2018 and was discharged on April 16, 2019. The comprehensive treatment plan was completed on September 21, 2018 and the first update was due no later than November 21, 2018. However, the update was not completed until December 19, 2018.
Client #6 was admitted on May 15, 2007 and was discharged on August 8, 2018. A treatment plan update was completed on January 30, 2018 and the next update was due no later than March 30, 2018. However, the update was not completed until June 11, 2018.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Effective 7/18/2019, Facility will utilize the Quality Assurance Specialist position to ensure that treatment plans are tracked for timeliness in addition to being audited for quality to ensure that they are done within the appropriate timeframe. QA Specialist will audit and review all treatment plans and will log the date they are completed in a centralized tracker. This will allow for easy tracking of timeliness in addition to the quality audit conducted by the QA Specialist. Charts of Clients #3, #5, and #6 will be reviewed and used as part of the internal process improvement in this area. |