INITIAL COMMENTS
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Based on the concerns arising from COVID-19, The Department of Drug and Alcohol Programs, Bureau of Quality Assurance for Prevention and Treatment, has implemented temporary procedures for conducting an annual renewal inspection.
The inspection will be divided into two parts.
1, an abbreviated off-site inspection, will be conducted off site, and will require the submission of administrative information via email to a Licensing Specialist.
2, an abbreviated on-site inspection, will be conducted on-site at a later date and will include a review of client/patient records, and a physical plant inspection.
This report is a result of Part 2, an abbreviated on-site inspection, conducted on January 27, 2021 through January 29, 2021 by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Not all regulations were reviewed, the remainder of the regulations were reviewed during Part 1.
Based on the findings of Part 2, an abbreviated on-site inspection, Aldie Counseling System 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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705.24 (7) LICENSURE Bathrooms.
705.24. Bathrooms.
The nonresidential facility shall:
(7) Maintain each bathroom in a functional, clean and sanitary manner at all times.
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Observations
Based on a physical plant inspection, the facility failed to ensure that all bathrooms were maintained in a functional, clean and sanitary manner.
The side of the bathroom stall in the men's public bathroom was covered in graffiti.
The findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
The side bathroom stall has been repainted and the graffiti has been removed. Staff and office cleaning contractors have been instructed to periodically monitor the condition of the client bathrooms. Any issues dealing with functionality, cleanliness, or sanitary conditions must be reported to the CEO who will then arrange for the appropriate corrective action. |
709.28 (c) (1) 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 must be in writing and include, but not be limited to:
(1) Name of the person, agency or organization to whom disclosure is made.
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Observations
Based on the review of patient records, the facility failed to document the name of the person to whom the disclosure was to be made to on all consent to release information forms in one of thirteen patient records.
Patient #7 was admitted into the outpatient drug-free level of care on July 19, 2019 and was active at the time of inspection. A release information form was signed and dated by the client on July 19, 2019; however, the consent form did not include the specific name of the person or agency to whom the disclosure was to be made.
The findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
The management team discussed the issue and resolved to hold a training for all personnel that have responsibility for consent forms. The training will be held on February 17th and will be conducted by the Clinical Director and Assistant Clinical Director. All aspects of properly completing consent forms will be reviewed. Thereafter clinical supervisors will review compliance in group and individual supervision. |
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 must be in writing and include, but not be limited to:
(2) Specific information disclosed.
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Observations
Based on a review of patient records, the facility failed to document the specific information to be disclosed on all consent to release information forms in one of thirteen patient records.
Patient #3 was admitted into the outpatient maintenance level of care on February 2, 2015 and was active at the time of inspection. A release of information form to a funding source was signed and dated by the client on June 1, 2019; however, the consent form did not have the specific information to be disclosed included.
The findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
The management team discussed the issue and resolved to hold a training for all personnel that have responsibility for consent forms. The training will be held on February 17th and will be conducted by the Clinical Director and Assistant Clinical Director. All aspects of properly completing consent forms will be reviewed. Thereafter clinical supervisors will review compliance in group and individual supervision. |
709.28 (d) LICENSURE Confidentiality
§ 709.28. Confidentiality.
(d) A copy of a client consent shall be offered to the client and a copy maintained in the client record.
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Observations
Based on a review of patient records, the facility failed to ensure that a copy of all client consent forms are offered to the client in two of thirteen patient records reviewed.
Patient #2 was admitted into the outpatient maintenance level of care on July 17, 2017 and was active at the time of inspection.
Patient # 6 was admitted into the outpatient maintenance level of care April 18, 2019 and was discharged December 8, 2020.
The findings were discussed with facility staff during the licensing process.
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Plan of Correction
The management team discussed the issue and resolved to hold a training for all personnel that have responsibility for consent forms. The training will be held on February 17th and will be conducted by the Clinical Director and Assistant Clinical Director. All aspects of properly completing consent forms will be reviewed. Thereafter clinical supervisors will review compliance in group and individual supervision. |
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 and document that a random urinalysis was conducted at least monthly in one of six applicable records reviewed.
Patient # 6 was admitted into the outpatient maintenance level of care April 18, 2019 and was discharged December 8, 2020. There were no documented urinalysis screenings documented for the months of October 2020 and November 2020.
The findings were discussed with facility staff during the licensing process.
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Plan of Correction
The management team reviewed the deficiency and resolved to hold a training for all staff involved in urine testing. The training, which will be held on February 24th, will be conducted by the Clinical Director and the Assistant Clinical Director. The focus will be on daily checking of the computer system that tracks the frequency of UDS for each client. Prior to each counseling session the counselor must check the system to ensure that a UDS has been completed as scheduled, and at least monthly. Compliance will be checked by the clinical supervisors in individual and group supervision. |
715.20(1) LICENSURE Patient transfers
A narcotic treatment program shall develop written transfer policies and procedures which shall require that the narcotic treatment program transfer a patient to another narcotic treatment program for continued maintenance, detoxification or another treatment activity within 7 days of the request of the patient.
(1) The transferring narcotic treatment program shall transfer patient files which include admission date, medical and psychosocial summaries, dosage level, urinalysis reports or summary, exception requests, and current status of the patient, and shall contain the written consent of the patient.
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Observations
Based on a review of patient records, the facility failed to document, in the patient record, what specific patient files were transferred to the receiving narcotic treatment program in one of one applicable patient record reviewed.
Patient # 5 was admitted September 16, 2020 and was discharged/transferred on January 14, 2021. The only documentation in the record that indicated patient files were transferred to the receiving narcotic treatment program was a fax transmission note; however, there was no specific indication of what was sent.
The findings were discussed with facility staff during the licensing process.
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Plan of Correction
The management team has reviewed the deficiency and resolved to hold a training on February 24th for all staff involved in patient transfers. The training will be conducted by the Clinical Director and Assistant Clinical Director. The impetus for the deficiency appears to be the absence of a separate identifiable transfer packet with supporting documentation. While Aldie believes that all necessary information was sent to the new facility, the documentation was then re-filed instead of being maintained as separate supporting materials. The issue will then be monitored in group and individual supervision by clinical supervisors. |
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
Based on the review of patient records, the facility failed to ensure that treatment and rehabilitation plans were reviewed and updated at least every 60 days in seven of thirteen patient records reviewed.
Patient #2 was admitted into the outpatient maintenance level of care on July 17, 2017 and was active at the time of inspection. A treatment plan update was completed on March 11, 2020 and the next update was due no later than May 11, 2020. However, the update was not completed until June 8, 2020. Additionally, a treatment plan update was completed on June 8, 2020 and the next update was due no later than August 8, 2020. However, the update was not completed until September 14, 2020. Finally, a treatment plan update was completed on September 14, 2020 and the next update was due no later than November 11, 2020. However, the update was not completed until January 19, 2021.
Patient #3 was admitted into the outpatient maintenance level of care on February 2, 2015 and was active at the time of inspection. A treatment plan update was completed on June 30, 2020 and the next update was due no later than August 30, 2020. However, the update was not completed until October 30, 2020. Additionally, a treatment plan update was completed on October 30, 2020 and the next update was due no later than December 30, 2020. However, the treatment plan was not completed as of the date of the inspection.
Patient # 6 was admitted into the outpatient maintenance level of care April 18, 2019 and was discharged December 8, 2020. A treatment plan update was completed on August 5, 2020 and a treatment plan update was due no later than October 5, 2020. However, the treatment plan was not completed as of the date of the inspection.
Patient #9 was admitted into the outpatient drug free level of care on December 12, 2019 and was active at the time of inspection. A treatment plan update was completed on February 10, 2020 and the next update was due no later than April 10, 2020. However, the update was not completed until July 22, 2020.
Patient #11 was admitted into the outpatient drug free level of care on December 30, 2018 and was discharged January 8, 2020. A treatment plan update was completed on May 16, 2019 and the next update was due no later than July 16, 2019. However, the update was not completed until September 19, 2019.
Patient #12 was admitted into the outpatient drug free level of care on April 7, 2020 and was discharged November 17, 2020. A treatment plan update was completed on April 30, 2020 and the next update was due no later than June 30, 2020. However, the update was not completed prior to discharge.
Patient #13 was admitted into the outpatient drug free level of care on February 18, 2019 and was discharged December 18, 2019. A comprehensive treatment plan was completed on February 25, 2019 and a treatment plan update was due no later than April 25, 2019. However, the update was not completed until June 11, 2019.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The deficiency was reviewed by the management team and it was resolved to hold a training for all clinical staff. The training will be conducted by the Clinical Director and Assistant Clinical Director and will be held on February 24, 2021. The training will consist of the proper methods to complete clinical documentation was well as the systems that are used to track due dates. While enhancements to the EHR as being implemented, the focus will be on training and reinforcing procedures to comply with the required timelines. As this issue was more widespread than others, the matter will be the focus on clinical supervision during the month of March. Thereafter, ongoing compliance will be monitored in group and individual supervision. |