INITIAL COMMENTS
|
This report is a result of an on-site licensure renewal inspection, and inspection conducted for the approval to use a narcotic agent, specifically methadone and buprenorphine in the treatment of narcotic addition. This inspection was conducted on June 27 - 28, 2016 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Aldie Counseling Center was found not to be in compliance with the applicable chapters 28 PA Code, which pertain to the facility. The following deficiencies were identified during this inspection:
|
Plan of Correction
|
704.6(e) LICENSURE Supervisory Meetings
704.6. Qualifications for the position of clinical supervisor.
(e) Clinical supervisors are required to participate in documented monthly meetings with their supervisors to discuss their duties and performance for the first 6 months of employment in that position. Frequency of meetings thereafter shall be based upon the clinical supervisor's skill level.
|
Observations
Based on a review of personnel records, the facility failed to document that the clinical supervisor participated in monthly meetings with their supervisor to discuss their duties and performance for the first six months of employment.
Employee # 3 was hired at the facility on June 10, 2013 and was promoted to the position of clinical supervisor on July 13, 2015. Employee #3 was required to participate in documented monthly meetings with their supervisor from August 2015 - January 2015. The facility failed to document monthly supervision for August 2015.
These findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
The executive director maintains a binder and tracking system of all clinical supervision sessions. The failure to provide supervision in one of the six required sessions was merely an oversight which resulted in part from a change in the organizational structure and reporting hierarchy within the agency.
When a new clinical supervisor is hired or promoted from within the executive director will conduct the first session within two weeks of the appointment. Thereafter supervision will occur monthly for at least six continuous months. |
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.
|
Observations
A review of the July 2015 through May 2016 fire drill record was reviewed during the annual licensing inspection. During the months of July 2015, August 2015, November 2015, December 2015, January 2016, and May 2016, the facility failed to document the time of the fire drill, the exit route used, problems encountered and/or whether or not the fire alarm system was operative.
These findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
The executive director has restructured job duties and the responsibility for maintaining the fire drill log now rests with the Office Manager. The Office Manager has been maintaining similar records in the facility's other location and is experienced in this regard. During regular monthly supervision the office manager will review the fire drill log with the executive director to ensure that all of the required elements are documented in the report. |
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.
|
Observations
Based on the review of client records, the facility failed to document an informed and voluntary consent to release information form in client record # 3.
#3 - It was documented in the client chart that the client's therapist faxed information to another drug and alcohol treatment provider on June 17, 2016 without obtaining proper consent to release information forms.
The findings were reviewed with facility staff during the licensing inspection.
|
Plan of Correction
The executive director has reviewed this issue with management staff. The program coodinators have reviewed, and retrained where necessary, the information with clinical staff on the requirement to obtain release of information forms prior to requesting information from any third party.
The program coodinators will continue to review compliance with this requirement in regular supervision sessions with clinicans. In addition, the executive director has instructed the fiscal technician to include this item as part of the monthly random quality assurance chart reviews. If further instances of non-compliance are identified the fiscal technician will inform the executive director who will institute further corrective action. |
709.34 (c) (4) LICENSURE Reporting of unusual incidents
§ 709.34. Reporting of unusual incidents.
(c) To the extent permitted by State and Federal confidentiality laws, the project shall file a written unusual incident report with the Department within 3 business days following an unusual incident involving:
(4) Event at the facility requiring the presence of police, fire or ambulance personnel.
|
Observations
The facility's unusual incident report log was reviewed on June 28, 2016. The facility failed to report to the Department events that required the presence of police or ambulance personnel onsite. These documented events occurred on 11/16/15, 3/15/16, and 5/1/16.
This finding was reviewed with facility staff during the licensing process.
|
Plan of Correction
The executive director has reviewed this issue with management staff. The assessment coordinator, with the responsibility of maintaining the incident report records, provided a training to all staff on incident report requirements and procedures on May 17, 2016.
Management staff will review incident reports at bi-monthly meetings and the requirement of when and how to prepare the reports will be reinforced monthly by the executive director. The program coodinators will reinforce compliance with clinical staff monthly at team meetings. |
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.
|
Observations
Five buprenorphine client records were reviewed on June 27-28, 2016. All five records required that a photograph of the client, which includes the client's name and birth date, be maintained onsite. The facility failed to maintain onsite a photograph of client # 12.
Client # 12 was admitted into treatment on 10/22/15 and was discharged on 6/15/16. A photograph of the client was not documented in the client's record. The facility confirmed that a photograph of the client was not maintained onsite.
This finding was reviewed with facility staff during the licensing process.
|
Plan of Correction
The executive director has reviewed this issue with the outpatient program coordinator who has the responsibility of managing the buprenorphine program. The program coordinator has also instructed staff about this requirement as part of admission into the program and prospective clients are instructed to bring a photograph as part of the admissions process.
The facility has also revised its program admission and quality assurance check list forms to include a client photograph. As such for admission into the program the coordinator must check the form indicating that the photograph was obtained. As part of quality assurance the fiscal technical will review this information during chart audits. |