INITIAL COMMENTS
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This report is a result of an onsite licensure renewal and methadone and buprenorphine monitoring inspection. The inspection was conducted on September 7 - 8, 2017 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the onsite inspection, Clear Choices, 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 the inspection:
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Plan of Correction
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704.7(b) LICENSURE Counselor Qualifications
704.7. Qualifications for the position of counselor.
(a) Drug and alcohol treatment projects shall be staffed by counselors proportionate to the staff/client and counselor/client ratios listed in 704.12 (relating to full-time equivalent (FTE) maximum client/staff and client/counselor ratios).
(b) Each counselor shall meet at least one of the following groups of qualifications:
(1) Current licensure in this Commonwealth as a physician.
(2) A Master's Degree or above from an accredited college with a major in chemical dependency, psychology, social work, counseling, nursing (with a clinical specialty in the human services) or other related field which includes a practicum in a health or human service agency, preferably in a drug and alcohol setting. If the practicum did not take place in a drug and alcohol setting, the individual's written training plan shall specifically address a plan to achieve counseling competency in chemical dependency issues.
(3) A Bachelor's Degree from an accredited college with a major in chemical dependency, psychology, social work, counseling, nursing (with a clinical specialty in the human services) or other related field and 1 year of clinical experience (a minimum of 1,820 hours) in a health or human service agency, preferably in a drug and alcohol setting. If a person's experience did not take place in a drug and alcohol setting, the individual's written training plan shall specifically address a plan to achieve counseling competency in chemical dependency issues.
(4) An Associate Degree from an accredited college with a major in chemical dependency, psychology, social work, counseling, nursing (with a clinical specialty in the human services) or other related field and 2 years of clinical experience (a minimum of 3,640 hours) in a health or human service agency, preferably in a drug and alcohol setting. If a person's experience was not in a drug and alcohol setting, the individual's written training plan shall specifically address a plan to achieve counseling competency in chemical dependency issues.
(5) Current licensure in this Commonwealth as a registered nurse and a degree from an accredited school of nursing and 1 year of counseling experience (a minimum of 1,820 hours) in a health or human service agency, preferably in a drug and alcohol setting. If a person's experience was not in a drug and alcohol setting, the individual's written training plan shall specifically address a plan to achieve counseling competency in chemical dependency issues.
(6) Full certification as an addictions counselor by a statewide certification body which is a member of a National certification body or certification by another state government's substance abuse counseling certification board.
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Observations
The facility failed to ensure that each counselor met the qualifications for the position in two of four records.
The personnel records were reviewed on September 7, 2017. Three new counselors, and one counselor assistant were hired in the last licensing year. Employee # 5 and #6 did not meet the experiential qualifications for the position of counselor.
These findings were reviewed with facility staff during the licensing process.
This is a repeat citation from the July 2015, and August 2016 annual inspections.
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Plan of Correction
Facility Director and Clinical Supervisor will review potential counselor's resume qualifications to ensure that the individual has a whole year of transferable skills which include individual and group counseling, case management, treatment planning and other skills necessary for their employment. Facility Director and Clinical Supervisor will monitor for compliance through employee chart audits and will maintain documentation on site for review during audits.
Both Clinicians #5 and #6 will receive close supervision from the Clinical Supervisor for their first year of employment to ensure that they meet the drug and alcohol counseling requirement for their position as counselor. Clinical Supervisor will document the close supervision and will maintain that documentation for review as needed.
Both clinicians will be moved to a Counselor Assistant position until such time as they have completed the necessary requirements for the Counselor position. |
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.
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Observations
The facility failed to obtain an informed and voluntary consent from the client for the disclosure of information contained in the client record.
The client records were reviewed on September 7 - 8, 2017.
Record #6 included a release of information form which was signed by the client, but the form was blank for the agency/organization to whom the information would be disclosed, the specific information to be disclosed, the purpose for the disclosure, the witness signature, the expiration date, and the date of the client's signature. Record #6 also included another patients medication order.
Record #7 included prescriptions for buprenorphine from the facility physician. A prescription, containing client identifying information, was faxed to the pharmacy. A release of information for the pharmacy was not signed. Record #7 did not include a release of information for the funding source.
Record #8 did not include a release of information for the funding source.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Facility Director and Clinical Supervisor will hold an in-house training by 10/20/17 to review the components of a complete and accurate consent in addition to necessity of releases for funding sources, pharmacies and other outside agencies who will receive identifying patient information. Documentation of the training will be maintained on site for review during audits. Facility Director and Clinical Supervisor will monitor for compliance through random chart audits as well as peer chart review. |
709.32 (b) LICENSURE Medication control
§ 709.32. Medication control.
(b) Verbal orders for medication can be given only by a physician or other medical professional authorized by State and Federal law to prescribe medication and verbal orders may be received only by another physician or medical professional authorized by State and Federal law to receive verbal orders. When a verbal or telephone order is given, it has to be authenticated in writing by a physician or other medical professional authorized by State and Federal law to prescribe medication. In detoxification levels of care, written authentication shall occur no later than 24 hours from the time the order was given. Otherwise, written authentication shall occur within 3 business days from the time the order was given.
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Observations
The facility failed to have the physician sign verbal orders within three business days of the when the order was given.
Record #1 - A Verbal Order was given on 4-14-2017, and was never signed by the physician.
Record #2 - A Verbal Order was given on 12-22-2016, and signed on 12-26-2016. A Verbal Order was given on 5-17-2017, and signed on 5-22-2017.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Facility Director will hold an in house training with all medical staff to review and reinforce the necessity of medical orders to be signed by the physician within 3 business days. Documentation of the training will be maintained on site for review during audits. Facility Director and Clinical Supervisor will monitor for compliance through random chart audits. |
709.34 (c) (1) 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:
(1) Physical or sexual assault by staff or a client.
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Observations
The facility failed to submit an unusual incident to the Department within three business days.
During the last licensing year, the facility had a death and an event at the facility requiring the presence of an ambulance. Both are unusual incidents that need to be documented, and reported to the Department.
These findings were reviewed with the facility staff during the licensing process.
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Plan of Correction
Facility Director will hold an in house training for all staff related to defining and reporting requirements for unusual incidents. Facility Director will review protocol to ensure all staff can achieve compliance. Documentation of the training will be maintained on site for review during audits. Facility Director will monitor for compliance through random incident reporting binder review. |
715.17(c)(1)(i-vi)) LICENSURE Medication control
(c) A narcotic treatment program shall develop and implement written policies and procedures regarding the medications used by patients which shall include, at a minimum:
(1) Administration of medication.
(i) A narcotic treatment physician shall determine the patient 's initial and subsequent dose and schedule. The physician shall communicate the initial and subsequent dose and schedule to the person responsible for the administration of medication. Each medication order and dosage change shall be written and signed by the narcotic treatment physician.
(ii) An agent shall be administered or dispensed only by a practitioner licensed under the appropriate Federal and State laws to dispense agents to patients.
(iii) Only authorized staff and patients who are receiving medication shall be permitted in the dispensing area.
(iv) There shall be only one patient permitted at a dispensing station at any given time.
(v) Each patient shall be observed when ingesting the agent.
(vi) Administering and dispensing shall be conducted in a manner that protects the patient from disruption or annoyance from other individuals.
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Observations
The facility failed to document that each medication order and subsequent dose and schedule change was written and signed by the narcotic treatment physician in six of six patient records reviewed on September 7 - 8, 2017.
Patient records # 1, 2, 3, 4, 5, and 6 had documented verbal orders. The physician was present at the facility at the time of the verbal orders. The orders were documented by the nurse and were not written by the physician.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Facility Director will hold a training for all medical staff to review that all patient orders must be written by the physician giving the order for the patient medication change. Facility Director will maintain documentation of the training on site for review as needed and will monitor compliance through random medical chart audits. |
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
The facility failed to provide Patient #1, #3, and #7 an average of 2.5 hours of psychotherapy per month during the first 2 years of treatment. This occurred in three of six patient records reviewed on September 7 - 8, 2017.
These findings were reviewed with the facility staff during the licensing process.
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Plan of Correction
Facility Director and Clinical Supervisor will hold an in house training to review the counseling requirements for maintaining participation in treatment. Facility Director and Clinical Supervisor will maintain documentation of the training on site for review and will monitor for compliance through random chart audits as well as peer chart review. |
709.91(b)(6) LICENSURE Intake and admission
709.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(6) Psychosocial evaluation.
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Observations
The facility failed to complete psychosocial evaluations in three of six patient records reviewed on September 7 - 8, 2017.
Patient records #5, 7, and 8 did not contain a psychosocial evaluation.
These findings were reviewed with the facility staff during the licensing process.
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Plan of Correction
Facility Director and Clinical Supervisor will hold an in house training to review the time frames for completion on necessary chart documentation including completion of the psychosocial evaluation. Facility Director and Clinical Supervisor will maintain documentation of the training on site for review and will monitor for compliance through random chart audits as well as peer chart review. |
709.92(a) 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:
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Observations
The facility failed to include the type and frequency of treatment and rehabilitation services in three of six patient records reviewed on September 7 - 8, 2017.
Records # 3 and # 5 failed to document the frequency of services on the treatment plan.
Record #7 failed to document the type and frequency of services on the treatment plan.
These findings were reviewed with the facility staff during the licensing process.
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Plan of Correction
Facility Director and Clinical Supervisor will hold an in house training to review adding the type and frequency of clinical interventions into the treatment planning for all individuals in treatment. Facility Director and Clinical Supervisor will maintain documentation of the training on site for review and will monitor for compliance through random chart audits as well as peer chart review. |