INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on October 29 - 30, 2014 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Axiom Family Counseling Services, 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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705.28 (a) (1) (i) LICENSURE Fire safety.
705.28. Fire safety.
(a) Exits.
(1) The nonresidential facility shall:
(i) Ensure that stairways, hallways and exits from rooms and from the nonresidential facility are unobstructed.
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Observations
Based on observation during a physical plant inspection, the facility failed to ensure that exits from the nonresidential facility were unobstructed and operable at all times.
The findings include:
A physical plant inspection was conducted with the lead counselor on October 30, 2014 at approximately 9:00 AM. The main entrance to the facility is a glass door that was observed to have a double keyed deadbolt lock. This door is also posted as an emergency exit. The double keyed deadbolt lock would prevent this exit door from being operable at all times. The facility failed to ensure that exits from the nonresidential facility were unobstructed and operable at all times.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The main entrance door key lock has been updated. The facility exits will now be unobstructed and operable at all times.
The facility director will monitor the entrances and locks to ensure they are properly working at all times. |
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. The consent shall be in writing and include, but not be limited to:
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Observations
Based on a review of client records, the facility failed to obtain a written, informed and voluntary consent forms from the client prior to the disclosure of information contained in the client record in one of seventeen client records. In addition, the facility failed to document written consents to release information forms that included the specific information to be disclosed in seventeen of seventeen client records.
The findings include:
Seventeen client records were reviewed for written, informed and voluntary consent to release information forms on October 29 - 30, 2014. The facility failed to obtain a written, informed and voluntary consent form from the client prior to disclosing information contained in client record # 2. The facility failed to document written consent to release information forms that included the specific information to be disclosed in client records # 1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13, 14, 15, 16 and 17.
Client # 2 was admitted into treatment on August 16, 2014. Information contained in the client record was release to a physician and funding entity on August 16, 2014. There was no documentation of a written consent to release information form for the physician and funding entity in client record # 2, as of October 30, 2014.
The findings were reviewed with facility staff during the licensing process.
This is a repeat citation from the March 1, 2013, August 7 - 8, 2013 and January 7, 2014 licensing inspections.
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Plan of Correction
The pharmacy release of information was updated with specific information to be released to pharmacies.
A staff meeting was held to discuss this update as well as the importance of obtaining a written, informed and voluntary consent for every consumer prior to releasing information.
Lead Counselor and therapist (ED) will conduct chart audits to ensure that every consumer has appropriate releases before disclosure of information and that all staff are utilizing the new pharmacy release which includes the specific information to be released.
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715.9(a)(2) 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:
(2) Verify the individual 's identity, including name, address, date of birth, emergency contact and other identifying data.
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Observations
Based on a review of patient records the facility failed to verify the individual's identity including name, address and date of birth prior to the administration of a narcotic agent in three of eleven patient records.
The findings include:
Seventeen client records were reviewed on October 29 - 30, 2014. Fifteen patients were prescribed buprenorphine. Eleven of these patient records were reviewed for verification of the individual's identity including name, address and date of birth. The facility failed to verify the individual's identity including the address in patient records # 1, 4 and 16. The facility failed to verify the individual's identity including name and date of birth in patient record # 16.
Patient # 1 was admitted into treatment and prescribed buprenorphine on September 11, 2014. The facility failed to verify the identity of patient # 1, including the address, prior to the administration of a narcotic agent.
Patient # 4 was admitted into treatment and prescribed buprenorphine on June 6, 2014. The facility failed to verify the identity of patient # 4, including the address, prior to the administration of a narcotic agent.
Patient # 16 was admitted into treatment and prescribed buprenorphine on September 11, 2014. The facility failed to verify the identity of patient # 16, including name, address and date of birth, prior to the administration of a narcotic agent.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Axiom will not accept any future consumer without valid photo identification and verification of identity.
Facility Director and Lead Counselor conducted a staff meeting with all staff including administrators to discuss procedures.
No client will be entered into treatment without a valid photo id and verification of identity. The discussion also included ways to obtain a photo id without the use of a driver's license in the event the consumer does not have one and other means of identifying the individual.
Lead Counselor and therapist ED will conduct chart audits after intake to ensure proper photo id and verification of identity has occurred. |
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 maintain onsite a photograph of each patient which includes the patient's name and birth date in three of eleven patient records.
The findings include:
Seventeen client records were reviewed on October 29 - 30, 2014. Fifteen patients were prescribed buprenorphine. Eleven of these records were reviewed for patient photographs. The facility failed to maintain onsite a photograph of each patient which includes the patient's name and birth date in patient records # 1, 4 and 16.
Patient # 1 was admitted into treatment on September 11, 2014. The facility failed to maintain onsite a photograph including the name and birth date of patient # 1, as of October 30, 2014.
Patient # 4 was admitted into treatment on June 6, 2014. The facility failed to maintain onsite a photograph including the name and birth date of patient # 4, as of October 30, 2014.
Patient # 16 was admitted into treatment on July 23, 2014. The facility failed to maintain onsite a photograph including the name and birth date of patient # 16, as of October 30, 2014.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Axiom will not accept any future consumer without valid photo identification and verification of identity.
Facility Director and Lead Counselor conducted a staff meeting with all staff including administrators to discuss procedures.
No client will be entered into treatment without a valid photo id and verification of identity. The discussion also included ways to obtain a photo id without the use of a driver's license in the event the consumer does not have one and other means of identifying the individual.
Lead Counselor and therapist ED will conduct chart audits after intake to ensure proper photo id and verification of identity has occurred. |
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
Based on a review of patient records, the facility failed to complete a random monthly urinalysis in three of fifteen patient records.
The findings include:
Seventeen client records were reviewed on October 29 - 30, 2014. Fifteen patients were prescribed buprenorphine. These records were reviewed for documentation of a random monthly drug screening urinalysis. The facility failed to complete a monthly random drug screening urinalysis in patient records # 6, 7 and 13.
Patient # 6 was admitted into treatment on July 17, 2012. Patient record # 6 did not include documentation of a random drug screening urinalysis for the following months: July and August 2014.
Patient # 7 was admitted into treatment on August 4, 2014. Patient record # 7 did not include documentation of a random drug screening urinalysis for September 2014.
Patient # 13 was admitted into treatment on June 24, 2014. Patient record # 13 did not include documentation of a random drug screening urinalysis for September 2014.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
A staff meeting was held to discuss obtaining random urine screenings and documentation procedures for urine screenings. Reviewed regulations of monthly screenings.
SB will oversee urine screenings to ensure compliancy with regulation. ED and JK will conduct monthly chart audits to ensure compliancy with regulation. Primary therapists of the consumer will also audit charts to ensure monthly screenings are occurring. |
715.15(b) LICENSURE Medication dosage
(b) The narcotic treatment physician shall determine the proper dosage level for a patient, except as otherwise provided in this section. If the narcotic treatment physician determining the initial dose is not the narcotic treatment physician who conducted the patient examination, the narcotic treatment physician shall consult with the narcotic treatment physician who performed the examination before determining the patient 's initial dose and schedule.
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Observations
Based on a review of patient records, the facility's physician failed to adhere to the dosing protocol listed on the medication by ordering that single dose Suboxone film be halved. The medication packaging identifies this as a single dose medication.
The findings include:
The physician prescribed Suboxone 8 mg/2 mg SL film, 1/2 film twice daily for patient # 5 on August 8 and August 22, 2014. The physician also prescribed Suboxone 8 mg/2 mg SL film, 1/2 film daily for patient # 5 on October 17, 2014.
The physician prescribed Suboxone 8 mg/2 mg SL film, 1/2 film daily for patient # 6 on October 3 and October 17, 2014. The physician also prescribed patient Suboxone 2 mg/.5 mg SL film, 1/2 daily for patient # 6 on October 3 and October 17, 2014.
Suboxone film is not formulated to be cut into smaller doses. Prescriptions need to be for the manufactured quantities of 12 mg/3 mg, 8 mg/2 mg, 4 mg/1 mg or 2 mg/.5 mg doses.
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Plan of Correction
Facility Director and Lead Counselor will review dosing protocol with physician to include single dosing of medication.
Lead Counselor will notify Facility Director if dosing issues continue.
Auditing of charts will be completed by facility director, lead counselor and therapist-ED to ensure appropriate dosing is occurring. Any issues that are identified will be brought to the attention of the prescribing physician. |
709.91(b)(7) LICENSURE Intake and admission
709.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(7) Preliminary treatment and rehabilitation plan.
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Observations
Based on a review of client records, the facility failed to document a preliminary treatment and rehabilitation plan in twelve of thirteen client records.
The findings include:
Thirteen client records were reviewed for preliminary treatment and rehabilitation plans on October 29 - 30, 2014. The facility failed to document a preliminary treatment and rehabilitation plan in client records # 1, 3, 4, 7, 8, 11, 12, 13, 14, 15, 16 and 17.
Client # 1 was admitted into treatment on September 11, 2014. The intake process was completed on September 11, 2014. There was no documentation of a preliminary treatment plan in client record # 1, as of October 30, 2014.
Client # 3 was admitted into treatment on May 7, 2014. The intake process was completed on May 7, 2014. There was no documentation of a preliminary treatment plan in client record # 3, as of October 30, 2014.
Client # 4 was admitted into treatment on June 6, 2014. The intake process was completed on June 6, 2014. There was no documentation of a preliminary treatment plan in client record # 4, as of October 30, 2014.
Client # 7 was admitted into treatment on August 4, 2014. The intake process was completed on August 4, 2014. There was no documentation of a preliminary treatment plan in client record # 7, as of October 30, 2014.
Client # 8 was admitted into treatment on June 23, 2014. The intake process was completed on June 23, 2014. There was no documentation of a preliminary treatment plan in client record # 8, as of October 30, 2014.
Client # 11 was admitted into treatment on September 25, 2014. The intake process was completed on September 25, 2014. There was no documentation of a preliminary treatment plan in client record # 11, as of October 30, 2014.
Client # 12 was admitted into treatment on August 26, 2014. The intake process was completed on August 26, 2014. There was no documentation of a preliminary treatment plan in client record # 12, as of October 30, 2014.
Client # 13 was admitted into treatment on June 24, 2014. The intake process was completed on June 24, 2014. There was no documentation of a preliminary treatment plan in client record # 13, as of October 30, 2014.
Client # 14 was admitted into treatment on July 28, 2014. The intake process was completed on July 28, 2014. There was no documentation of a preliminary treatment plan in client record # 14, as of October 30, 2014.
Client # 15 was admitted into treatment on June 9, 2014. The intake process was completed on June 9, 2014. There was no documentation of a preliminary treatment plan in client record # 15, as of October 30, 2014.
Client # 16 was admitted into treatment on July 23, 2014. The intake process was completed on July 23, 2014. There was no documentation of a preliminary treatment plan in client record # 16, as of October 30, 2014.
Client # 17 was admitted into treatment on August 5, 2014. The intake process was completed on August 5, 2014. There was no documentation of a preliminary treatment plan in client record # 17, as of October 30, 2014.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Axiom has changed its treatment plan procedures to include an initial treatment plan on the date of intake to then follow with Axiom's comprehensive treatment plan.
The new treatment plan procedures were discussed at staff meeting by the facility director and lead counselor.
Staff was trained on the correct utilization of both treatment plans to ensure proper documentation.
Lead Counselor and therapist (ED) will conduct chart audits to ensure new initial treatment plan form is utilized on the date of intake.
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