INITIAL COMMENTS
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This report is the result of an on-site licensure renewal inspection conducted on November 6, 2012 and November 7, 2012, by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, PA Associates, LLC d/b/a Mount Pocono Medical 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
Based on a review of personnel and training records, the facility failed to ensure that clinical supervisors and lead counselors who have not functioned for 2 years as supervisors in the provision of clinical services completed a core curriculum in clinical supervision approved by the Department.
The findings include:
One personnel record for the position of Lead Counselor/Clinical Supervisor was reviewed on November 6, 2012. The facility failed to ensure that clinical supervisors and lead counselors who have not functioned for 2 years as supervisors in the provision of clinical services completed a core curriculum in clinical supervision approved by the Department in one of one record reviewed, personnel record #5.
Employee # 5 was hired on November 11, 2011. The job description was signed for clinical supervisor. As of the date of the inspection the records failed to contain documentation that the employee had a minimum of two years experience in the provision of clinical supervision or that the employee had completed a core curriculum training in clinical supervision.
The findings were reviewed with the clinical supervisor.
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Plan of Correction
The clinic director has reviewed the standard 704.6(c) and will ensure that when a lead counselor is hired they will have functioned in that capacity for at least 2 years and will also complete the core curriculum in clinical supervision that is approved by DOH. This training will also be added to the individual training plan and the supervisor will assess staff to ensure they have received the training needed in the required areas and are competent. This was instituted on 12/31/12. |
704.7(b) LICENSURE Counselor Qualifications
704.7. Qualifications for the position of counselor.
(a) Drug and alcohol treatment projects shall be staffed by counselors proportionate to the staff/client and counselor/client ratios listed in 704.12 (relating to full-time equivalent (FTE) maximum client/staff and client/counselor ratios).
(b) Each counselor shall meet at least one of the following groups of qualifications:
(1) Current licensure in this Commonwealth as a physician.
(2) A Master's Degree or above from an accredited college with a major in chemical dependency, psychology, social work, counseling, nursing (with a clinical specialty in the human services) or other related field which includes a practicum in a health or human service agency, preferably in a drug and alcohol setting. If the practicum did not take place in a drug and alcohol setting, the individual's written training plan shall specifically address a plan to achieve counseling competency in chemical dependency issues.
(3) A Bachelor's Degree from an accredited college with a major in chemical dependency, psychology, social work, counseling, nursing (with a clinical specialty in the human services) or other related field and 1 year of clinical experience (a minimum of 1,820 hours) in a health or human service agency, preferably in a drug and alcohol setting. If a person's experience did not take place in a drug and alcohol setting, the individual's written training plan shall specifically address a plan to achieve counseling competency in chemical dependency issues.
(4) An Associate Degree from an accredited college with a major in chemical dependency, psychology, social work, counseling, nursing (with a clinical specialty in the human services) or other related field and 2 years of clinical experience (a minimum of 3,640 hours) in a health or human service agency, preferably in a drug and alcohol setting. If a person's experience was not in a drug and alcohol setting, the individual's written training plan shall specifically address a plan to achieve counseling competency in chemical dependency issues.
(5) Current licensure in this Commonwealth as a registered nurse and a degree from an accredited school of nursing and 1 year of counseling experience (a minimum of 1,820 hours) in a health or human service agency, preferably in a drug and alcohol setting. If a person's experience was not in a drug and alcohol setting, the individual's written training plan shall specifically address a plan to achieve counseling competency in chemical dependency issues.
(6) Full certification as an addictions counselor by a statewide certification body which is a member of a National certification body or certification by another state government's substance abuse counseling certification board.
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Observations
Based on a review of personnel records, the facility failed to ensure that each counselor met the qualifications for the position.
The findings include:
Two personnel records required to include documentation of the qualifications for the position of counselor were reviewed on November 6, 2012. The facility failed to provide documentation of counselor qualifications in one of two records reviewed, personnel record # 6.
Employee # 6 was hired as a counselor assistant on October 24, 2011, and promoted to counselor on April 30, 2012. The employee met the educational requirements with a bachelor's degree; however, there was no documentation in the personnel record showing that the employee had the required 1 year of clinical experience.
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Plan of Correction
The facility failed to comply with regulation 704.7 by not properly documenting that the counselor assistant has successfully completed 1 year of clinical experience. On 12/17/12 the facility director/clinical supervisor will insure that when a counselor in training is hired, the potential employee will provide documentation of one year of clinical experience with supervision as required and will remain in that role until they have 1 year of drug and alcohol experience. The supervisor will assess the staff to ensure they have received the training needed in the required areas and are competent. |
704.9(a) LICENSURE Counselor Asst Supervision
704.9. Supervision of counselor assistant.
(a) Supervision. A counselor assistant shall be supervised by a full-time clinical supervisor or counselor who meets the qualifications in 704.6 or 704.7 (relating to qualifications for the position of clinical supervisor; and qualifications for the position of counselor).
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Observations
Based on a review of personnel and supervision records, the facility failed to ensure the supervision of counselor assistants by a full time clinical supervisor or lead counselor meeting the qualifications in 704.6 or 704.7 (relating to qualifications for the position of clinical supervisor; and qualifications for the position of counselor).
The findings include:
Two personnel records requiring documentation of supervision by a clinical supervisor or a lead counselor were reviewed on November 6, 2012. The facility failed to document that the lead counselor providing the clinical supervision met the requirements for the position.
The findings were reviewed with the clinical supervisor and not disputed.
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Plan of Correction
The clinic director has reviewed the standard 704.9 and will ensure that when a counselor in training is hired, they will be provided with the supervision as required and will remain in the role of counselor assistant until they have met standard of 1 year of drug and alcohol experience. The supervisor will assess the staff to ensure they have received the training needed in the required areas and are competent. This was instituted on 12/31/12. |
704.9(c) LICENSURE Supervised Period
704.9. Supervision of counselor assistant.
(c) Supervised period.
(1) A counselor assistant with a Master's Degree as set forth in 704.8 (a)(1) (relating to qualifications for the position of counselor assistant) may counsel clients only under the close supervision of a trained counselor or clinical supervisor for at least the first 3 months of employment.
(2) A counselor assistant with a Bachelor's Degree as set forth in 704.8 (a)(2) may counsel clients only under the close supervision of a trained counselor or clinical supervisor for at least the first 6 months of employment.
(3) A registered nurse as set forth in 704.8 (a)(3) may counsel clients only under the close supervision of a trained counselor or clinical supervisor for at least the first 6 months of employment.
(4) A counselor assistant with an Associate Degree as set forth in 704.8 (a)(4) may counsel clients only under the close supervision of a trained counselor or clinical supervisor for at least the first 9 months of employment.
(5) A counselor assistant with a high school diploma or GED equivalent as set forth in 704.8 (a)(5) may counsel clients only under the direct observation of a trained counselor or clinical supervisor for the first 3 months of employment. For the next 9 months, the counselor assistant may counsel clients only under the close supervision of a lead counselor or a clinical supervisor.
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Observations
Based on a review of personnel and supervision records, the facility failed to ensure that counselor assistants were supervised as per the supervision period based on their degree.
The findings include:
Two counselor assistant personnel records were reviewed on November 6, 2012 for documentation of the required supervision. The facility failed provide documentation of supervision in one of two records reviewed, #6.
Employee # 6 was hired on October 24, 2011, as a counselor assistant. The employee was promoted to the position of counselor on April 30, 2012. The personnel record documented supervision from August 6, 2012. The personnel record not document supervision during the first six months of employment.
The findings were reviewed with the clinical supervisor and not disputed.
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Plan of Correction
The clinic director has reviewed the standard 704.9 and will ensure that when a counselor in training is hired, they will be provided with the supervision as required and will remain in the role of counselor assistant until they have met standard of 1 year of drug and alcohol experience. The supervisor will assess the staff to ensure they have received the training needed in the required areas and are competent. A log will be kept of all supervision and will be available for future inspections. This task will be done by the lead counselor. This was instituted on 12/31/12. |
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
Based on a review of personnel and training records, the facility failed to ensure that staff and volunteers received a minimum of 6 hours HIV/AIDS and at lest 4 hours of tuberculosis, sexually transmitted diseases and other health related topics training using a Department approved curriculum in accordance with the regulation.
The findings include:
One personnel record requiring documentation of the mandatory HIV/AIDS and TB/STD training was reviewed on November 6, 2012. The facility failed to document completed training in one of one record reviewed, record # 6.
Employee # 6, a counselor, was hired on October 24, 2011. As of the date of the inspection, November 6, 2012, there was no documentation of the completion of the HIV/AIDS or TB/STD training in the record.
The findings were reviewed with the facility director, quality improvement staff member and project director.
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Plan of Correction
The facility failed to comply with regulation 704.11(c)(1) mandating that all staff receive a minimum of 6 hours of HIV/AIDS training and at least 4 hours of tuberculosis, sexually transmitted diseases and other health related topics using a Department approved curriculum. It is the responsibility of the clinical supervisor to ensure that all clinical staff has attended approved training sessions as mandated and the responsibility of the facility director to ensure that all staff attend and receive mandated training. January 2013 Mt Pocono Medical will be implementing a training tracking form that will be completed monthly by the clinic supervisor and reviewed monthly by the facility director to ensure that all staff are in compliance with mandatory training sessions. A copy of all certificates will be placed in the employees training binder. |
705.23 (3) LICENSURE Counseling or activity areas and office space
705.23. Counseling or activity areas and office space.
The nonresidential facility shall:
(3) Ensure privacy so that counseling sessions cannot be seen or heard outside the counseling room. Counseling room walls shall extend from the floor to the ceiling.
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Observations
Based on observation during the physical plant inspection, the facility failed to ensure that counseling sessions could not be heard outside the counseling room.
The findings include:
The physical plant inspection was conducted on November 7, 2012, at 1:30 p.m.. At the time of the physical plant inspection, the Licensing Specialist could overhear the counseling session that was taking place in the office at the end of the hall.
The findings were discussed with the facility director and not disputed.
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Plan of Correction
The facility failed to comply with regulation 705.23. In addition to the music that we have playing in the hallway, the facility director will add noise reduction devices in strategic locations by December 31, 2012 |
705.28 (d) (5) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(5) Prepare alternate exit routes to be used during fire drills.
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Observations
Based on a review of the fire drill logs, the facility failed to prepare alternate exit routes to be used during fire drills.
The findings include:
A review of the fire drill logs was conducted on November 7, 2012. The fire drills conducted from November 2011 - October 2012 were reviewed. The facility did not document any alternate exits used during fire drills. The exit routes used during the fire drill were the front and side door. According to the fire drill log, the log stated "building not evacuated" on February 27, 2012; March 28, 2012; April 13, 2012; May 16, 2012; July 30, 2012; August 27, 2012 and September 25, 2012.
An interview with the facility director was conducted on November 7, 2012. It was confirmed that alternate exit routes were not used.
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Plan of Correction
The facility failed to comply with regulation 705.28 by not including alternate exit routes during fire drills. The facility director will begin effective December 5, 2012 documenting the exits being used in the description and evaluation of the drill. The facility director will ensure that the use of different exits occur during fire drills so employees are able to demonstrate knowledge of and ability to carry out the exit plan. |
709.28(c)(2) LICENSURE Confidentiality
709.28. Confidentiality.
(c) The project shall obtain an informed and voluntary consent from the client for the disclosure of information contained in the client record. The consent shall be in writing and include, but not be limited to:
(2) Specific information disclosed.
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Observations
Based on the review of patient records, the facility failed to ensure that the information allowed to be released on the consent to release information forms did not exceed that which is permissible under 4 Pa. Code, Subsection 255.5(b).
The findings included:
Three patient records requiring consent to release information forms were reviewed on November 7, 2012. The facility failed to ensure that the information allowed to be released on the consent to release information forms did not exceed that which is permissible under 4 Pa. Code, Subsection 255.5(b) in two out of three records reviewed, records # 5 and 6.
4 PA Code 255.5(b) limits the information that may be released as follows:
(b) Restrictions. Information released to judges, probation or parole officers, insurance company health or hospital plan or governmental officials, under subsection (a)(1), (2), (4), (7) and (8), is for the purpose of determining the advisability of continuing the client with the assigned project and shall be restricted to the following:
(1) Whether the client is or is not in treatment.
(2) The prognosis of the client.
(3) The nature of the project.
(4) A brief description of the progress of the client.
(5) A short statement as to whether the client has relapsed into drug, or alcohol abuse and the frequency of such relapse.
Patient record # 5 contained a consent to release information form that allowed for the release of the patient's medication and dose to the probation officer. A letter in the patient record, dated February 9, 2012, documented that the information was released to the probation officer.
Patient record # 6 contained a consent to release information form that allowed for the release of the patient's medication and dose to the funding source. A letter in the patient record, dated April 11, 2012, documented that the information was released to the funding source.
The findings were reviewed with the facility director, quality improvement staff member and project director and not disputed.
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Plan of Correction
The facility failed to comply with regulation 709.28. The facility director will conduct a staff training by December 14, 2012 on 4 Pa code 255.5 to ensure that the staff has a clear understanding of what can and cannot be disclosed. Ongoing trainings will be held by facility director and lead counselor quarterly to ensure competency and efficiency. |
709.30(6) LICENSURE Client Rights
709.30. Client rights.
(6) The client has the right to submit rebuttal data or memoranda to his own records.
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Observations
Based on the review of patient records, the facility policy and procedure manual, and the patient handbook, the facility failed to ensure that patients are informed of their right to submit rebuttal data or memoranda to their records.
The findings included:
Four patient records requiring documentation of "client rights" were reviewed on November 7, 2012. The facility failed to document that the patients were informed of their right to submit rebuttal data or memoranda to their record in four out of four records reviewed, # 1, 4, 5 and 6.
The facility gives the patient a handbook as part of the orientation process. The patient also signs a form entitled "Program Guidelines" that includes the patient rights. The patient rights provided to the patient via the handbook and the form did not include the patient's right to submit rebuttal data or memoranda to the patient records.
The findings were reviewed with the facility director, quality improvement staff member and project director and not disputed.
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Plan of Correction
The facility failed to comply with regulation 709.30. The following has already been added by the secretary as of December 7, 2012 to the existing "Medication Assisted Treatment Patients' Rights" documentation that is given at the patients at the time of admission:
#14. Patients have a right to submit rebuttal data or memoranda to his/her own records.
The patient will sign off indicating receipt of this document and the signed document will become part of the patient file. Additionally, all currently active patients admitted prior to this change will be given a memo alerting patients to these rights by their counselor and the patient will sign off acknowledging receipt of the change. The lead counselor and counselor's will ensure this is completed through peer audits and regular chart audits done by the supervisor.
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715.21(1)(i-iv) LICENSURE Patient termination
A narcotic treatment program shall develop and implement policies and procedures regarding involuntary terminations. Involuntary terminations shall be initiated only when all other efforts to retain the patient in the program have failed.
(1) A narcotic treatment program may involuntarily terminate a patient from the narcotic treatment program if it deems that the termination would be in the best interests of the health or safety of the patient and others, or the program finds any of the following conditions to exist:
(i) The patient has committed or threatened to commit acts of physical violence in or around the narcotic treatment program premises.
(ii) The patient possessed a controlled substance without a prescription or sold or distributed a controlled substance, in or around the narcotic treatment program premises.
(iii) The patient has been absent from the narcotic treatment program for 3 consecutive days or longer without cause.
(iv) The patient has failed to follow treatment plan objectives.
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Observations
Based on the review of patient records, the facility failed to restrict the reasons for involuntary termination to those reasons allowed by regulation.
The findings include:
Two patient records requiring documentation that the reason for involuntary discharge were in compliance with the regulation were reviewed on November 7, 2012. One out of two records reviewed, # 1, contained documentation of the patient being discharged for reasons other than those listed by regulation.
Patient # 4 was admitted on 12/6/2011 and discharged on 10/31/2012. On 10/19/2012, an order was written for decreasing the patient's dose by 10 mg per day due to group and financial noncompliance.
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Plan of Correction
The facility failed to comply with regulation 715.21 The facility director and clinic supervisor will provide a comprehensive training to all counselors by December 18, 2012 regarding compliance with involuntary termination guidelines, necessary documentation and appropriate treatment interventions. Ongoing clinical supervision will be provided by the facility director to senior counselor to ensure compliance. |
709.91(b)(3)(ii) LICENSURE Intake and admission
709.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(3) Histories, which include the following:
(ii) Drug or alcohol history, or both.
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Observations
Based on a review of client records, the facility failed to document the lengths and patterns related to the patient's progression of drug and alcohol use.
The findings were:
Three patient records requiring documentation of a drug and alcohol history that included length and patterns related to the patient's progression of use were reviewed on November 7, 2012. The facility failed to document the length and patterns related to the patient's progression of use in patient records # 1, 5 and 6.
The findings were reviewed with the facility director, quality improvement staff member and project director and not disputed.
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Plan of Correction
The facility failed to comply with regulation 709.91. Staff will be trained again by December 31, 2012 to include the progression of substance abuse relative to the lengths and patterns of use. The senior counselor will review the responsible for ongoing compliance. |
709.92(a)(2) LICENSURE Treatment and rehabilitation services
709.92. Treatment and rehabilitation services.
(a) An individual treatment and rehabilitation plan shall be developed with a client. This plan shall include, but not be limited to, written documentation of:
(2) Type and frequency of treatment and rehabilitation services.
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Observations
Based on a review of patient records, the facility failed to document the type and frequency of treatment and rehabilitation services on the individual treatment and rehabilitation plan.
The findings were:
Four patient records requiring documentation the type and frequency of treatment services on the individual treatment plans were reviewed on November 7, 2012. The facility failed to docuemnt the type and frequency of treatment and rehabilitation services in two out of four records reviewed, # 5 and 6.
Patient # 5 was admitted on January 9, 2012. The individual treatment and rehabilitation plan was developed and signed by the patient on March 11, 2012. Individual and group was stated on the treatment plan for 2.5 hours minimum; however, it was unclear as to how often individual or group therapy would be provided.
Patient # 6 was admitted on March 28, 2012. The individual treatment and rehabilitation plan was developed and signed by the patient on April 27, 2012. Individual and group was stated on the treatment plan for 2.5 hours minimum; however, it was unclear as to how often individual or group therapy would be provided.
The findings were reviewed with the facility director, quality improvement staff member and project director and not disputed.
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Plan of Correction
The facility failed to comply with regulation 709.92. There will be a review of these charts by December 31, 2012 to illustrate the non compliance to Pinnacle Treatment Centers policy with the clinic staff. There will be immediate and ongoing monitoring to ensure that our policies are being met and adhered to. An in-service will be held by December 31, 2012 highlighting policies relating to those clinic areas. The senior counselor will ensure compliance. |
709.92(a)(3) LICENSURE Treatment and rehabilitation services
709.92. Treatment and rehabilitation services.
(a) An individual treatment and rehabilitation plan shall be developed with a client. This plan shall include, but not be limited to, written documentation of:
(3) Proposed type of support service.
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Observations
Based on a review of patient records, the facility failed to document the proposed type of support service on the individual treatment and rehabilitation plan in two of four patient records.
The findings were:
Six patient records were reviewed on November 7, 2012. Four records contained individual treatment and rehabilitation plans which are required to include the the proposed type of support services. The individual treatment and rehabilitation plans contained in client records # 5 and 6 did not include the proposed type of support service.
Patient # 5 was admitted on January 9, 2012. The individual treatment and rehabilitation plan was developed and signed by the patient on March 11, 2012. The support service was AA/NA circled from a list without individualized services.
Patient # 6 was admitted on March 28, 2012. The individual treatment and rehabilitation plan was developed and signed by the patient on April 27, 2012. No support services were identified on the plan.
The findings were reviewed with the facility director, quality improvement staff member and project director and not disputed.
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Plan of Correction
The facility failed to comply with regulation 709.92. There will be a review of these charts by December 31, 2012 to illustrate the non compliance to Pinnacle Treatment Centers policy with the clinic staff. There will be immediate and ongoing monitoring to ensure that our policies are being met and adhered to. An in-service will be held highlighting policies relating to those clinic areas. The senior counselor will ensure compliance. |
709.93(a)(10) LICENSURE Client records
709.93. Client records.
(a) There shall be a complete client record on an individual which includes information relative to the client's involvement with the project. This shall include, but not be limited to, the following:
(10) Discharge summary.
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Observations
Based on a review of patient records, the facility failed to document a discharge summary that included the patient's reason for treatment, services offered, response to treatment and/or the patient status upon discharge.
The findings include:
Four patient records requiring discharge summaries were reviewed on November 7, 2012. The facility failed to document a discharge summary that included the patient's reason for treatment, services offered, response to treatment and/or the patient status upon discharge in four of four records reviewed, records # 1, 2, 3 and 4.
Patient # 1 was admitted on 1/17/2012 and discharged on 6/14/2012. The discharge summary failed to document the patient's status upon discharge.
Patient # 2 was admitted on 12/2/2010 and discharged on 9/25/2012. The discharge summary failed to document the patient's status upon discharge.
Patient # 3 was admitted on 11/15/2011 and discharged on 7/23/2012. The discharge summary failed to document the reasons for treatment, and the patient's status upon discharge.
Patient # 4 was admitted on 12/6/2011 and discharged on 10/31/2012. The discharge summary failed to document the reasons for treatment, and the patient's status upon discharge.
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Plan of Correction
The facility failed to comply with regulation 709.93. Facility director will conduct an in-service by 12/18/2012 to address these areas of weakness and the lead counselor will review all discharges to ensure that the charts are in compliance with this regulation. |