INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on June 26 - 28, 2013 by staff from the Division of Drug and Alcohol Program Licensure. 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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704.11(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 records and the Staffing Requirements Facility Summary Report, the facility failed to provide documentation of TB/STD training in two of four personnel records.
The findings include:
Fourteen personnel records and the Staffing Requirements Facility Summary Report were reviewed on June 26, 2013. Four personnel records were reviewed for documentation of TB/STD training. The facility failed to provide documentation of TB/STD training in personnel training records # 13 and 14.
Employee # 13 is a counselor and was hired on July 1, 2011. TB/STD training was due to be completed no later than July 1, 2012. The facility failed to provide documentation of TB/STD training for employee # 13.
Employee # 14 is a counselor and was hired on February 27, 2012. TB/STD training was due to be completed no later than February 27, 2013. The facility failed to provide documentation of TB/STD training for employee # 14.
.The project/facility director and clinical supervisor were interviewed throughout the licensing inspection and confirmed the findings.
This is a repeat citation from the March 1 - 2, 2011, March 8 - 9, 2012 and July 30 - August 1, 2012 licensing inspections.
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Plan of Correction
Employee #13 completed TB/STD/Hepatitis training on July 9, 2013
Employee #14 completed TB/STD/Hepatitis training on July 1, 2013.
The Project Director has hired a part-time employee to manage training transcripts. That employee will produce a quarterly report to all employees and supervisors on the status of required training.
Each employee is responsible for achieveing their training. Clinical Supervisor and Lead Counselors are responsible for monitoring training on a quarterly basis. |
704.11(f)(2) LICENSURE Trng Hours Req-Coun
704.11. Staff development program.
(f) Training requirements for counselors.
(2) Each counselor shall complete at least 25 clock hours of training annually in areas such as:
(i) Client recordkeeping.
(ii) Confidentiality.
(iii) Pharmacology.
(iv) Treatment planning.
(v) Counseling techniques.
(vi) Drug and alcohol assessment.
(vii) Codependency.
(viii) Adult Children of Alcoholics (ACOA) issues.
(ix) Disease of addiction.
(x) Aftercare planning.
(xi) Principles of Alcoholics Anonymous and Narcotics Anonymous.
(xii) Ethics.
(xiii) Substance abuse trends.
(xiv) Interaction of addiction and mental illness.
(xv) Cultural awareness.
(xvi) Sexual harassment.
(xvii) Developmental psychology.
(xviii) Relapse prevention.
(3) If a counselor has been designated as lead counselor supervising other counselors, the training shall include courses appropriate to the functions of this position and a Department approved core curriculum or comparable training in supervision.
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Observations
Based on a review of personnel records, the facility failed to document the completion of 25 clock hours of annual training required for counselors in one of three personnel records.
The findings include:
Eleven counselor personnel records were reviewed on June 26, 2013. Three of the counselor personnel records required documentation of 25 clock hours of annual training. Eight counselors were new hires. The training year reviewed was from January 1, 2012 through December 31, 2012. The facility failed to document 25 clock hours of annual training for the 2012 training year in personnel record # 13.
Employee # 13 is a counselor and was hired on July 1, 2011. Personnel record # 13 only included documentation of 16 clock hours of annual training for the 2012 training year. The facility failed to document 25 clock hours of annual training for employee # 13.
The clinical supervisor was interviewed throughout the licensing inspection and confirmed the findings.
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Plan of Correction
Clinical Supervisor spoke with Employee #13 and reminded her of her responsibility to to complete 25 clock hours of annual training.
The Project Director has hired a part-time employee to manage training transcripts. That employee will produce a quarterly report to all employees and supervisors on the status of required training.
Each employee is responsible for achieveing their training. Clinical Supervisor and Lead Counselors are responsible for monitoring training on a quarterly basis.
Employee #13 is supervised by a Lead Counselor who will closely monitor her progress toward completing 25 training hours. |
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 fire drill records, the facility failed to prepare alternate exit routes to be used during fire drills.
The findings include:
Fire drill records were reviewed on June 26, 2013. The time period reviewed was August 2012 through May 2013. The front door was the only exit utilized during the fire drills conducted on the following dates: August 20, 2012, September 17, 2012, October 31, 2012, November 26, 2012, December 21, 2012, January 25, 2013, February 27, 2013, March 14, 2013 and April 25, 2013. The fire drill for May 17, 2013 did not document the exit used. The facility failed to prepare alternate exit routes for the fire drills conducted August 2012 through May 2013.
The project/facility director was interviewed throughout the licensing inspection and confirmed the findings.
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Plan of Correction
Going forward, exit routes used during monthly fire drills shall be alternately used. The rear exit shall be used during odd numbered months, and the front exit shall be used during even numbered months. The Project Director shall be responsible for scheduling and conducting fire drills and shall be responsible for utilizing the correct exit during the fire drills. |
715.9(a)(4) LICENSURE Intake
(a) Prior to administration of an agent, a narcotic treatment program shall screen each individual to determine eligibility for admission. The narcotic treatment program shall:
(4) Have a narcotic treatment physician make a face-to-face determination of whether an individual is currently physiologically dependent upon a narcotic drug and has been physiologically dependent for at least 1 year prior to admission for maintenance treatment. The narcotic treatment physician shall document in the patient 's record the basis for the determination of current dependency and evidence of a 1 year history of addiction.
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Observations
Based on a review of patient records, the facility's physician failed to document in the patient's record the basis for the determination of current dependency and evidence of a one year history of addiction in two of six patient records.
The findings include:
Sixteen patient records were reviewed on June 27 - 28, 2013. Six patient records were reviewed for documentation that the physician made a face-to-face determination of whether the individual was currently physiologically dependent upon a narcotic drug and had been physiologically dependent for at least one year prior to admission for maintenance treatment and the basis for this determination. The physician failed to document in the patient's record the basis for determination of current dependency and evidence of a one year history of addiction in patient records # 5 and 7.
Patient # 5 was admitted into treatment on April 2, 2013. The physician conducted a face-to-face visit with patient # 5 on April 2, 2013 and prescribed 8 mg/2 mg Suboxone BID. The physician signed a form dated April 2, 2013 that stated the patient was currently physiologically dependent upon a narcotic drug and had been physiologically dependent for at least one year prior to admission for maintenance treatment. The physician failed to document the basis for this determination.
Patient # 7 was admitted into treatment on April 12, 2013. The physician conducted a face-to-face visit with patient # 7 on April 12, 2013 and prescribed 8 mg/2 mg Suboxone BID. The physician failed to document whether patient # 7 was currently physiologically dependent upon a narcotic drug and had been physiologically dependent for at least one year prior to admission for maintenance treatment and the basis for the determination.
The clinical supervisor was interviewed throughout the licensing inspection and confirmed the findings.
This is a repeat citation from the March 8, 2013 plan of correction follow-up inspection.
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Plan of Correction
By August 1, 2013 Medical Director will train all physicians on how to correctly document physiological dependency and dependency of one year.
Lead Nurse will review the chart of each new admission to assure that dependency and dependency of one year are being documented. |
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 June 26 - 28, 2013. 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 # 10.
Patient # 10 was admitted into treatment on May 25, 2010. A driver's license photograph was obtained from the patient during the intake process on May 25, 2010. The photograph was due to be updated no later than May 25, 2013. There was no documentation of an updated photograph in patient record # 10, as of June 28, 2013.
The clinical supervisor was interviewed throughout the licensing process and confirmed the findings.
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Plan of Correction
By July 17, Clinical Director will produce a list of all patients in treatment more than three years. Office Manager will obtain updated photo identification at patients' next visits, not later than July 31.
By December 31, 2013, IT Consultant will develop a mechanism to take and enter patient photos into electronic data base. Office Manager will take and enter photos. DB will produce with automatic reminder for Office Manger as patient approaches three years intreatment.
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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 client records, the facility failed to include the type and frequency of treatment and rehabilitation services on the individual treatment and rehabilitation plans in two of eight client records.
The findings include:
Sixteen client records were reviewed on June 27 - 28, 2013. Eight client records were reviewed for individual treatment plans that included the type and frequency of treatment and rehabilitation services. The facility failed to document the type and frequency of group counseling sessions in client records # 6 and 8.
Client # 6 was admitted into treatment on April 22, 2013. An individual treatment plan was completed on May 20, 2013. Per the record of services provided, client # 6 is participating in weekly individual and group counseling sessions. The facility failed to document the type and frequency of group counseling sessions on the treatment plan of client # 6.
Client # 8 was admitted into treatment on April 8, 2013. An individual treatment plan was completed on May 6, 2013. Per the record of services provided, client # 8 is participating in weekly individual and group counseling sessions. The facility failed to document the type and frequency of group counseling sessions on the treatment plan of client # 8.
The clinical supervisor was interviewed throughout the licensing inspection and confirmed the findings.
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Plan of Correction
Clinical Supervisor trained all counselors at staff meeting of July 22, 2013 to assure that all of a patient's service, together with their frequency are indicated on the treatment plan
Clinical Supervisor and Lead Counselors will conduct random chart reviews. |
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 a review of client records, the facility failed to document a treatment plan update that included an assessment of the client's progress in relationship to the stated treatment plan goals in four of five client records. In addition, the facility failed to document a treatment plan update at least every 60 days in two of five client records.
The findings include:
Sixteen client records were reviewed on June 27 - 28, 2013. Five client records were reviewed for treatment plan updates. The facility failed to document treatment plan updates that included an assessment of the client's progress in relationship to the stated treatment plan goals in client records # 1, 4, 9 and 10. The facility failed to document treatment plan updates every 60 days in client records # 3 and 9.
Client # 1 was admitted into treatment on December 21, 2012. The individual treatment plan was completed on February 8, 2013. Treatment plan updates were completed on March 22 and May 31, 2013. The treatment plan updates did not include an assessment of the client's progress in relationship to the stated treatment plan goals.
Client # 3 was admitted into treatment on March 6, 2013. The individual treatment plan was due to be completed no later than April 6, 2013. A treatment plan update was due to be completed no later than June 6, 2013. The treatment plan update was not completed until June 26, 2013.
Client # 4 was admitted into treatment on January 3, 2012. The individual treatment plan was completed on January 31, 2012. Treatment plan updates were reviewed for the time period of September 2012 through May 2013. The treatment plan updates completed on March 12, 2013 and May 17, 2013 did not include an assessment of the client's progress in relationship to the stated treatment plan goals.
Client # 9 was admitted into treatment on January 11, 2013. The individual treatment plan was completed on February 8, 2013. Treatment plan updates were due to be completed no later than April 8, 2013 and June 8, 2013. The treatment plan updates were not completed until May 17, 2013 and June 14, 2013 and did not include an assessment of the client's progress in relationship to the stated treatment plan goals.
Client # 10 was admitted into treatment on May 25, 2010. The individual treatment plan was completed on June 25, 2010. Treatment plan updates were reviewed for the time period of August 2012 through May 2013. The treatment plan updates completed on August 13, 2012, October 22, 2012, December 10, 2012, February 4, 2013 and March 21, 2013 did not include an assessment of the client's progress in relationship to the stated treatment plan goals.
The clinical supervisor was interviewed throughout the licensing inspection and confirmed the findings.
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Plan of Correction
At a staff meeting on July 1, 2013 Clinical Supervisor instructed all Counselors to enter comments on treatment plan progress reports (updates) when no or some progress has been made on actions steps.
IT Consultant and Clinical Supervisor have begun meeting to develop a revision of the treatment plan and update, to be completed by August 15, 2013. Counselors to be trained by September 1 and new treatment plan implemented not later than September 1, 2013.
Supervisors will review each progress report/treatment plan update when submitted every 60 days.
By July 26 Clinical Supervisor and Lead Counselors will meet with Counselors who submitted late treatment plans and updates. Will assure that they are using the current tracking sheet to remain timely.
IT Consultant and Clinical Supervisor are meeting to develop a method for data base/electronic record to track and prompt for updates. System to produce monitoring report for Clinical Supervisor and Lead Counselors. To be completed not later than September 1, 2013.
From this system reports of due treatments will be updated constantly and always available to counselors and supervisors. Monitored by supervisors weekly. |