INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection and Methadone and Buprenorphine monitoring conducted on July 8, 2019 to July 10, 2019 by staff from the Department of Drug and Alcohol Programs, Bureau of Quality Assurance for Prevention and Treatment. Based on the findings of the on-site inspection, Aldie Counseling Center 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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704.6(c) LICENSURE Core Curriculum - Supervisor Training
704.6. Qualifications for the position of clinical supervisor.
(c) Clinical supervisors and lead counselors who have not functioned for 2 years as supervisors in the provision of clinical services shall complete a core curriculum in clinical supervision. Training not provided by the Department shall receive prior approval from the Department.
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Observations
The facility failed to ensure that each clinical supervisor or lead counselor who has not functioned for 2 years as supervisors in the provision of clinical services completed a core curriculum in clinical supervision.
Employee # 4 was hired as a clinical supervisor on March 11, 2018. There was no documentation of the 30-hour DDAP sponsored clinical supervision training, or a department approved clinical supervision training on file at the time of the inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Human Resource Manager will check the DDAP website on a weekly basis to determine the next available 30-hour clinical supervisory training. The supervisors in need of the training will be registered and will be required to attend. The Clinical Director will ensure compliance and communicate the results to the Human Resource Manager who will then document completion of the training. |
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
The facility failed to ensure that three employees did not exceed the outpatient 35 to 1 counselor to client ratio.
The counselor Full Time Equivalent (FTE) is determined by dividing the total number of hours the counselor devotes to their clients by the facility's workweek. Then, in order to obtain the counselor's ratio, the total number of clients on the counselor's outpatient caseload is divided by the FTE.
Employee # 2 was hired as a clinical supervisor on March 11, 2018. The ratio calculation was as follows: 8/40 = 0.2(FTE); 8/0.2 = 40, which equals to a client/counselor ratio of 40:1.
Employee # 6 was hired as a counselor on March 21, 2019. The ratio calculation was as follows: 40/40 = 1(FTE); 37/1 = 37, which equals to a client/counselor ratio of 37:1.
Employee # 13 was hired as a counselor on August 28, 2012. The ratio calculation was as follows: 40/40 = 1(FTE); 37/1 = 37, which equals to a client/counselor ratio of 37:1
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Aldie is in the process of hiring two new therapists to alleviate the overage in the counselor to client ratio. One individual has been hired and is schedule to start in mid-August. Interviews are being scheduled and a second therapist can be expected to start work by August 31, 2019 when the matter will be resolved. |
709.24 (a) (3) LICENSURE Treatment/rehabilitation management.
§ 709.24. Treatment/rehabilitation management.
(a) The governing body shall adopt a written plan for the coordination of client treatment and rehabilitation services which includes, but is not limited to:
(3) Written procedures for the management of treatment/rehabilitation services for clients.
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Observations
The facility failed to follow the project's written procedures for the management of treatment/rehabilitation services for clients in 1 of 8 client records.
Client #5 was admitted on October 11, 2018 and was discharged on June 21, 2019. The written procedure manual stated that the biopsychosocial histories and the client intake evaluation (psychosocial evaluation) must be developed within 30 days from admission; however, the complete biopsychosocial histories were not received until December 23, 2018, and the psychosocial evaluation was not developed until May 21, 2019.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Aldie hired a Clinical Director on July 17, 2019. Part of the responsibilities for the position is to ensure compliance with treatment documentation and protocol. To this end the Clinical Director will conduct a training for all clinical staff in the month of August on the requirements for the timely completion of documentation. The matter will also be reinforced in clinical supervision and monitored during monthly chart audits. |
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 to release information form prior to the disclosure of information in 1 of 8 client records.
Client #7 was admitted on September 22, 2017 and was discharged on May 24, 2019. There was documentation that multiple urine samples were sent to a urinalysis lab monthly; however, there was no consent to release information on file prior to the disclosure.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Clinical Director will conduct a staff training during the month of August on confidentiality and the importance of maintaining current release of information forms. The matter will also be reinforced in clinical supervision. The file clerk has been trained on ensuring that release forms are contained in patient chart and will verify completeness as part of regular filing activities. Monthly chart audits will also ensure compliance. |
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
The facility failed to document the name of the person, agency or organization to whom the disclosure was to be made to on a consent form in 1 of 8 client records.
Client # 4 was admitted on December 31, 2018 and was active at the time of the inspection. There was a consent form to " Managed Care Organization for MA " and a consent for a primary care physician signed and dated by the client on January 14, 2019; however, the consent forms did not include the specific name of the person, agency or organizations to whom the disclosure would be made to.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Clinical Director will conduct a staff training during the month of August on confidentiality and the importance of maintaining current release of information forms. The training will focus on the necessity to complete the forms in their entirety and to include specific names of all entities. The matter will also be reinforced in clinical supervision. The file clerk has been trained on ensuring that release forms are contained in patient chart and will verify completeness as part of regular filing activities. Monthly chart audits will also ensure compliance.
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709.28 (c) (3) 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:
(3) Purpose of disclosure.
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Observations
The facility failed to document the purpose of disclosure on the consent form in 1 of 8 client records.
Client # 4 was admitted on December 31, 2018 and was active at the time of the inspection. There was a consent to a government agency signed and dated by the client on January 14, 2019; however, the consent to release form did not specify the purpose for disclosure.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Clinical Director will conduct a staff training during the month of August on confidentiality and the importance of maintaining current release of information forms. The training will focus on the necessity to complete the forms in their entirety and to include the specific purpose for disclosure. The matter will also be reinforced in clinical supervision. The file clerk has been trained on ensuring that release forms are contained in patient chart and will verify completeness as part of regular filing activities. Monthly chart audits will also ensure compliance.
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709.28 (c) (4) 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:
(4) Dated signature of client or guardian as provided for under 42 CFR 2.14(a) and (b) and 2.15 (relating to minor patients; and incompetent and deceased patients).
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Observations
The facility failed to document the dated signature of a client on a consent to release information form in 1 of 8 client records.
Client # 8 was admitted on May 11, 2015 and was discharged on February 18, 2019. There was a consent to release information form to a urinalysis lab signed by the client; however, the consent form did not include the date of the client's signature.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Clinical Director will conduct a staff training during the month of August on confidentiality and the importance of maintaining current release of information forms. The training will focus on the necessity to complete the forms in their entirety and to include the specific date when the form is signed.The matter will also be reinforced in clinical supervision. The file clerk has been trained on ensuring that release forms are contained in patient chart and will verify completeness as part of regular filing activities. Monthly chart audits will also ensure compliance.
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715.6(d) LICENSURE Physician Staffing
(d) A narcotic treatment program shall provide narcotic treatment physician services at least 1 hour per week onsite for every ten patients
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Observations
The facility failed to provide at least one hour of onsite physician time a week for every ten patients for once of 1 of 16 weeks reviewed.
Two physician's time sheets were reviewed for the months of March, April, May and June 2019. The following weeks were not in compliance:
-During the week of March 17-23, 2019, the patient census was 311. The facility was required to provide at least 31 physician hours. There were 19.5 physician hours documented. The amount of physician hours documented is less than the 31 hours required for that week.
-During the week of March 24-30, 2019, the patient census was 314. The facility was required to provide at least 31 physician hours. There were 27.25 physician hours documented. The amount of physician hours documented is less than the 31 hours required for that week.
-During the week of May 19-25, 2019, the patient census was 320. The facility was required to provide at least 32 physician hours. There were 29.25 physician hours documented. The amount of physician hours documented is less than the 32 hours required for that week.
-During the week of May 26, 2019 to June 1, 2019, the patient census was 323. The facility was required to provide at least 32 physician hours. There were 28 physician hours documented. The amount of physician hours documented is less than the 32 hours required for that week.
-During the week of June 23-29, 2019, the patient census was 334. The facility was required to provide at least 33 physician hours. There were 27.5 physician hours documented. The amount of physician hours documented is less than the 33 hours required for that week.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
All of the referenced deficiency periods were the result of one of the two physicians being on vacation. Aldie will make arrangements with a staffing agency to have on-site coverage during the time-periods when a physician is on vacation or otherwise unavailable. The CEO will facilitate the arrangement with the staffing agency. |
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
The facility failed to complete a monthly urinalysis screening in 1 of 8 client records.
Client # 1 was admitted on June 27, 2007 and was still an active client at the time of the inspection. There were no documented drug screen urinalyses for the month of January 2019.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Clinical Director will conduct a training to all clinical and medical staff on the requirement to obtain a urinalysis screening at least one time per month. The matter will be reinforced in supervision and compliance will be further checked as part of monthly chart audits. |
715.20(4) 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.
(4) The receiving narcotic treatment program shall document in writing that it notified the transferring narcotic treatment program of the admission of the patient and the date of the initial dose given to the patient by the receiving narcotic treatment program.
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Observations
The facility failed to document that they notified the referring narcotic treatment program of the client's admission and date of initial dose in one of one applicable client record.
Client # 4 was admitted on December 31, 2018 and was active at the time of the inspection.
This finding was reviewed with facility staff during the licensing inspection.
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Plan of Correction
A form has been created to notify referring narcotic treatment programs of a client's admission date and initial dose. The CEO has instructed the nursing staff to complete the form and to transmit it to the referring facility. The form will be maintained in the client chart. |
715.23(b)(5) LICENSURE Patient records
(b) Each patient file shall include the following information:
(5) The results of all annual physical examinations given by the narcotic treatment program which includes an annual reevaluation by the narcotic treatment physician.
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Observations
The facility failed to document the results of an annual physical examination given by the narcotic treatment program which includes an annual reevaluation by the narcotic treatment physician in one client record.
Client # 7 was admitted on September 22, 2017 and was discharged on May 23, 2019. The last physical was completed on October 11, 2017.
This finding was reviewed with facility staff during the licensing inspection.
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Plan of Correction
The Clinical Director will ensure that a system is in place to verify that all MMT clients have a documented annual physical. In addition, a training will be conducted with medical and clinical staff to reinforce the requirement. Compliance will be verified in monthly chart audits and during clinical supervision. |