INITIAL COMMENTS
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Based on the concerns arising from COVID-19, The Department of Drug and Alcohol Programs, Bureau of Program Liscensure, 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 March 30, 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, Axiom Family Counseling, Inc. 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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704.11(c)(2) LICENSURE CPR CERTIFICATION
704.11. Staff development program.
(c) General training requirements.
(2) CPR certification and first aid training shall be provided to a sufficient number of staff persons, so that at least one person trained in these skills is onsite during the project's hours of operation.
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Observations
During a review of nine personnel on June 25, 2020, the facility failed to ensure CPR certification and first aid training was provided to a sufficient number of staff persons, so that at least one person trained in these skills is onsite during the project's hours of operation. The facility does not have first aid coverage during the following days and times:
Monday from 4:00 - 5:00
Tuesday from 4:00 - 7:00
Wednesday from 4:00 - 7:00
Thursday from 4:00 - 7:00
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
704.11(c)(2) Licensure CPR Certification
This citation was approved on 7/7/2020 during the first part of the licensing inspection. The project manager will train the facility director on how to accurately report drug and alcohol facility hours and will review required DDAP licensing paperwork before submission for accuracy. To ensure that there is sufficient FA/CPR trained staff to cover all hours of operations, the facility director will schedule at least two staff who are trained in FA/CPR during those hours of operation. On July 30, 2020 Axiom is having an all staff training on FA/CPR training.
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704.12(a)(6) LICENSURE OutPatient Caseload
704.12. Full-time equivalent (FTE) maximum client/staff and client/counselor ratios.
(a) General requirements. Projects shall be required to comply with the client/staff and client/counselor ratios in paragraphs (1)-(6) during primary care hours. These ratios refer to the total number of clients being treated including clients with diagnoses other than drug and alcohol addiction served in other facets of the project. Family units may be counted as one client.
(6) Outpatients. FTE counselor caseload for counseling in outpatient programs may not exceed 35 active clients.
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Observations
Based on the review of the Staffing Requirements Facility Summary Report, the facility failed to keep client/staff ratios at or below the regulation limit of 35/1.
Employee #2 was hired as the Facility Director on June 5, 2020 and was still acting in that position. Employee #2 was reported to have 40 hours per week devoted to their 15 clients on their caseload.
The counselor Full Time Equivalent (FTE) is determined by dividing the total number of hours the counselor devotes to their clients by facility ' s work week. Then, in order to obtain the counselor ' s ratio, the total number of clients on the counselor's caseload is divided by the FTE.
The FTE Facility Director's caseload calculation is as follows: 15/40 = .375(FTE); 15/.375 = 40 which equals to a client/counselor ratio of 40:1.
Employee #4 was hired as a counselor on June 5, 2020 and was still acting in that position. Employee #4 was reported to have 40 hours per week devoted to their 5 clients on their caseload.
The FTE counselor ' s caseload calculation is as follows: 5/40 = .125(FTE); 5/.125 = 40, which equals to a client/counselor ratio of 40:1.
Employee #5 was hired as a counselor on January 5, 2020 and was still acting in that position. Employee #5 was reported to have 40 hours per week devoted to their 18 clients on their caseload.
The FTE counselor ' s caseload calculation is as follows: 18/40 = .45(FTE); 18/.45 = 40, which equals to a client/counselor ratio of 40:1.
The overall client to counselor for the entire project was 37:1, which was also over the limit of 35:1.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
704.12(a)(6) OutPatient Caseload:
The Facility Director will review the active client case loads on a weekly basis to ensure that Axiom Family Counseling Inc., is compliant with the 35 to 1 ratio.
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705.28 (d) (4) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(4) Maintain a written fire drill record including the date, time, the amount of time it took for evacuation, the exit route used, the number of persons in the facility at the time of the drill, problems encountered and whether the fire alarm or smoke detector was operative.
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Observations
Based on a review of nine fire drill logs provided, the facility failed to include problems encountered during the fire drill on the facility fire drill log.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
705.28 (D)(4) Fire Safety
This citation was approved on 7/7/2020 during the first part of the licensing inspection. To ensure that Axiom Family Counseling Inc., is in compliance with the fire safety regulations 705.28 (D)(4) at the Jeannette facility, a new fire log was developed on 6/25/2020 and will replace the existing fire log. The new fire log indicates if there were any "problems encountered" during the evacuation of the facility. If there are identified issues, it will be stated on the log and a plan of correction will be developed correct such issues.
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705.28 (d) (7) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(7) Set off a fire alarm or smoke detector during each fire drill.
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Observations
Based on a review of nine fire drill logs provided, the facility failed to set off a fire alarm or smoke detector during each fire drill. Four fire drills indicate a verbal alarm was utilized.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
705.28 (D)(7) Fire Safety
This citation was approved on 7/2/2020 during the first part of the licensing inspection. To ensure that Axiom Family Counseling Inc., is in compliance of the fire safety regulations705.28 (D)(7) at the Jeannette's facility, it will no longer be the practice to conduct verbal fire drills. Effective 6/25/2020, the Facility Director or designated staff member selected by the Facility Director will activate a smoke alarm/detector that is located within the facility. During each random drill a different smoke alarm/detector will be activated. The Facility Director/designated staff member will indicate what smoke alarm/detector was activated during the drill and that specific alarm/detector will be recorded on the fire drill log.
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715.19(1) LICENSURE Psychotherapy services
A narcotic treatment program shall provide individualized psychotherapy services and shall meet the following requirements:
(1) A narcotic treatment program shall provide each patient an average of 2.5 hours of psychotherapy per month during the patient 's first 2 years, 1 hour of which shall be individual psychotherapy. Additional psychotherapy shall be provided as dictated by ongoing assessment of the patient.
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Observations
Based on one out of four patient records reviewed the narcotic treatment program failed to provide each patient an average of 2.5 hours of psychotherapy per month during the
patient's first 2 years, 1 hour of which shall be individual psychotherapy.
Patient #5 was admitted on October 22, 2020 and was active at the time of the inspection. The patient had two and a half hours of individual psychotherapy in December 2020, one and half hours of individual psychotherapy in January 2021 and one and a quarter hour of individual psychotherapy in February 2021.
These findings were reviewed with the program staff during the licensing process.
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Plan of Correction
715.19(1) Psychotherapy services:
As a result of the exit interview held on 3/30/21 with the DDAP representative, the Facility Director met with the treatment staff on 4/6/21 during the Axiom's weekly "staff meeting" and discussed regulation 715.19 Psychotherapy services. The Facility Director conveyed to the staff the importance of conducting at minimum of 2.5 hours of psychotherapy services per month. In order to comply with the 715.19 regulation requiring 2.5 hours of psychotherapy. If Axiom provides a combination of group and individual therapy Axiom will require at minimum of 1 hour of individual therapy per month. To ensure that the 2.5 hours of psychotherapy services per month is occurring, the Facility Director will conduct bi weekly chart audits on all clients who are receiving narcotic treatment at Axiom Family Counseling Inc.
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