INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on May 1 - 2, 2014 by staff from the Program Licensure Division. Based on the findings of the on-site inspection, Freedom Healthcare Services, LLC 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 the Staffing Requirements Facility Summary Reports (SRFSR) and a review of personnel records, the project failed to ensure that all clinical supervisors and lead counselors, with less than 2 years of supervisory experience, completed a Department approved core curriculum in clinical supervision.
The findings include:
The Staffing Requirements Facility Summary Report form was reviewed on May 1, 2014. The SRFSR indicated there was one lead counselor with less than 2 years of supervisory experience. The project failed to ensure that employee # 9 completed a Department approved core curriculum in clinical supervision.
Employee # 9 was hired to the project on January 29, 2010 and promoted to a lead counselor on January 2, 2013. Employee # 9 does not have 2 years of supervisory experience. There was no documentation that employee # 9 had completed a Department approved core curriculum in clinical supervision, as of May 2, 2014.
An interview with the Clinical Supervisor confirmed the findings on May 2, 2014.
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Plan of Correction
Employee #9 has been registered for and will attend the Department approved core curriculum in clinical supervision scheduled for June 9 to 13, 2014. Clinical Director will monitor attendance.
The Lead Counselor, hired 05/12/14 will attend the same training.
Any additional Lead Counselors with less than two years of supervisory experience will take the core curriculum in clinical supervision, as required. The employee will be responsible for locating and registering for the training. Clinical Director will monitor quarterly in supervision until accomplished.
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709.28(c) 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:
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Observations
Based on a review of patient records, the facility failed to obtain a written, informed and voluntary consent from the patient for the disclosure of information contained in the client record in four of eleven patient records.
The findings include:
Sixteen patient records were reviewed on May 1 - 2, 2014. Eleven patient records were reviewed for written, informed and voluntary consents from the patient. The facility failed to obtain a written, informed and voluntary consent from the patient prior to disclosing information contained in the patient record in records # 3, 4, 5 and 9.
Patient # 3 was admitted into treatment on June 24, 2010. The facility failed to obtain a written, informed and voluntary consent from patient # 3 prior to disclosing information contained in the patient record to the funding entity.
Patient # 4 was admitted into treatment on November 12, 2013. The facility failed to obtain a written, informed and voluntary consent from patient # 4 prior to disclosing information contained in the patient record to a pharmacy.
Patient # 5 was admitted into treatment on November 13, 2013. The facility failed to obtain a written, informed and voluntary consent from patient # 5 prior to disclosing information contained in the patient record to a pharmacy.
Patient # 9 was admitted into treatment on October 3, 2013. The facility failed to obtain a written, informed and voluntary consent from patient # 9 prior to disclosing information contained in the patient record to a pharmacy.
The findings were confirmed by the clinical supervisor on May 2, 2014.
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Plan of Correction
Pharmacies
Clinical Director has begun to establish QSAs with the pharmacies most commonly used by FHS patients. When patients identify pharmacies without QSAs, they will be directed to a pharmacy with a QSA. Additionally the Clinical Director will then establish a QSA (qualified service organization agreement) with the newly identified pharmacy. All phoned in prescriptions will be reviewed weekly to assure that a QSA or consents are in place.
Insurance
As of January 1, 2014 FHS put in place a protocol to obtain new consents for all patients admitted in that month. Before the start of a new month, the Clinical Director produces a list of all patients admitted in any year, but that month, e.g. January. Counselors review with their patients all consents and obtain new consents for insurance (and all other) consents due to expire that month.
For the remainder of 2014, Clinical Director has directed all Counselors to review the charts of all patients admitted in months June through December and obtain new consents for any insurance (and all other) consents that have expired. |
715.13(b) LICENSURE Patient identification
(b) A narcotic treatment program shall maintain onsite a photograph of each patient which includes the patient 's name and birth date. The narcotic treatment program shall update the photograph every 3 years.
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Observations
Based on a review of patient records, the facility failed to ensure the photograph maintained onsite of each patient was updated every three years in one of one patient record.
The findings include:
Sixteen patient records were reviewed on May 1 - 2, 2014. One record pertained to a patient that had been in treatment more than three years and required documentation of an updated photograph. The facility failed to ensure the photograph maintained onsite of each patient was updated every three years in patient record # 2.
Patient # 2 was admitted into treatment on December 9, 2009. A driver's license photograph was obtained from the patient during the intake process on December 9, 2009. The photograph was due to be updated no later than December 9, 2012. There was no documentation of an updated photograph in patient record # 2, as of May 2, 2014.
The clinical supervisor was interviewed throughout the licensing inspection and confirmed the findings.
This is a repeat citation from the June 26 - 28, 2013 licensing inspection.
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Plan of Correction
As of January 1, 2014 FHS put in place a protocol to obtain new photo identification for all patients admitted in that month. Before the start of a new month, the Clinical Director produces a list of all patients admitted in any year, but that month, e.g. January. Counselors obtain from their patients new photo identification. (This system is in place and there were no citations for patients admitted in months January through May.)
For the remainder of 2014, Clinical Director has directed all Counselors to review the charts of all patients admitted in months June through December and obtain new photo identification for all patients whose photo identification is more than three years old.
For the future, before the start each new month, the Clinical Director will use the data base of all active patients to produce a list of all patients admitted in any year, but that month, e.g. all patients admitted in June 2009, 2010, 2011, 2012, 2013. List will be provided to Counselors who will obtain from their patients new photo identification annually.
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715.14(a) LICENSURE Urine testing
(a) A narcotic treatment program shall complete an initial drug-screening urinalysis for each prospective patient and a random urinalysis at least monthly thereafter.
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Observations
Based on a review of patient records, the facility failed to complete a random monthly urinalysis in four of ten patient records.
The findings include:
Sixteen patient records were reviewed on May 1 - 2, 2014. Ten patients were prescribed Suboxone and were reviewed for documentation of a random monthly drug screening urinalysis. The facility failed to complete a monthly random drug screening urinalysis in patient records # 1, 4, 6 and 8.
Patient # 1 was admitted into treatment on September 3, 2013. Patient record # 1 did not include documentation of a random drug screening urinalysis for the following months: October and December 2013.
Patient # 4 was admitted into treatment on November 12, 2013. Patient record # 4 did not include documentation of a random drug screening urinalysis for the following months: January 2014.
Patient # 6 was admitted into treatment on September 23, 2013. Patient record # 6 did not include documentation of a random drug screening urinalysis for the following months: December 2013 and March 2014.
Patient # 8 was admitted into treatment on September 18, 2013. Patient record # 8 did not include documentation of a random drug screening urinalysis for the following months: December 2013.
The clinical supervisor was interviewed throughout the licensing inspection and confirmed the findings.
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Plan of Correction
FHS's contracted IT Specialist has created a random screen procedure using the patient electronic medical record that assures each patient will be screen no less frequently than every 28 days. Counselors will monitor their individual patients. Lead Counselors and Clinical Director will conduct monthly random monitoring. |