INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on July 20-21, 2016 by staff from the Department of Drug and Alcohol Programs, Program Licensure Division. Based on the findings of the on-site inspection, Addiction Medicine and Health Advocate, 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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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
On July 20-21, 2016, eight personnel and training records were reviewed. One of two Clinical Supervisor records was required to document a core curriculum in clinical supervision was completed.
Employee #3 was hired on November 1, 2010 and was promoted on October 26, 2015. No documentation was available to show that employee #3 functioned for 2 years as a supervisors in the provision of clinical services. Additionally, there was no documentation available to show that employee #3 completed a core curriculum in clinical supervision.
This information was reviewed with the facility staff.
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Plan of Correction
Employee #3 will be scheduled for and attend the core curriculum clinical supervisor training, or a DDAP pre-approved clinical supervisor training by 12/31/2016. Clinical Program Manager will be responsible for identifying the training and ensuring attendance. |
705.22 (2) LICENSURE Building exterior and grounds.
705.22. Building exterior and grounds.
The nonresidential facility shall:
(2) Keep the grounds of the facility clean, safe, sanitary and in good repair at all times for the safety and well being of clients, employees and visitors. The exterior of the building and the building grounds or yard shall be free of hazards.
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Observations
Based on a physical plant inspection, it was observed that the facility failed to keep the building grounds free from hazards.
During the physical plant inspection it was observed that the facility had a water heater mounted directly under the sink basins in the client restroom across from the main check-in area; the pressure relief valve on the water heater was not properly installed as it failed to include a diversion pipe that would direct hot water within six inches from the floor or below the floor, as per the safety instructions printed on the water heater. Additionally, the water heater appeared to be in poor condition with corrosion on the water pipes, and rust and corrosion on the top surface of the unit.
This information was reviewed with the facility staff.
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Plan of Correction
AMHA will contract with a plumber to assess the condition of the water heater and make necessary repairs or replace, based on findings by 09/05/2016. Additionally, AMHA will have the appropriate diversion pipe installed, per the safety instructions, by 08/15/2016. Safety Committee will monitor condition of all water heaters as part of their semi-annual facility inspection. Program Director will be responsible for ensuring the completion of this maintenance. |
705.22 (3) LICENSURE Building exterior and grounds.
705.22. Building exterior and grounds.
The nonresidential facility shall:
(3) Keep exterior exits, stairs and walkways lighted at night if in use.
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Observations
The facility failed to light interior exits and stairs at all times.
During the physical plant inspection it was observed that the staircase from the rear emergency exit on the west side of the building was not illuminated. Attempts to turn on lights in the starwell by the facility staff were unsuccessful.
This information was reviewed with the facility staff.
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Plan of Correction
An electrical contractor was brought in to assess and repair the lighting in the identified stairwell. The stairwell is now appropriately illuminated.
The Program Director was responsible for making sure these repairs were made. The Health and Safety Committee will monitor the lighting as part of their quarterly facility inspection. |
705.24 (3) LICENSURE Bathrooms.
705.24. Bathrooms.
The nonresidential facility shall:
(3) Have hot and cold water under pressure. Hot water temperature may not exceed 120F.
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Observations
The facility failed to maintain hot water temperatures below 120 degrees F.
During the physical plant inspection the water temperature in the restroom used by the facility to collect urine samples (UDS restroom) was measured at 123 degree F. Additionally, the water temperature in the female staff restroom in the west hallway was measured at 122 degrees F.
This information was reviewed with the facility staff.
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Plan of Correction
The temperature setting on the water heaters in both bathrooms have been respectively reduced and the temperatures are below 120 degrees F. The safety committee will monitor water temperature as part of their semi-annual facility review. The Clinical Program Manager will be responsible for monitoring. |
705.28 (a) (1) (iii) LICENSURE Fire safety.
705.28. Fire safety.
(a) Exits.
(1) The nonresidential facility shall:
(iii) Maintain each ramp, interior stairway and outside steps exceeding two steps with a well-secured handrail and maintain each porch that has over an 18 inch drop with a well-secured railing.
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Observations
The facility failed to maintain an interior stairway with a well-secured handrail.
During the physical plant inspection it was observed that the staircase from the ground floor to the second floor, adjacent to the main entrance to the facility, had a railing on the west wall that was not properly secured to the wall. Additionally, there was a broken mounting bracket that allowed the hand rail to be lifted vertically, creating instability, which also exposed jagged metal from the broken mounting point creating an additional hazard. Also, the metal newel post on the east side of the same staircase was broken at the bottom where it mounts to the floor creating instability in that railing as well.
This information was reviewed with the facility staff.
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Plan of Correction
AMHA will bring in a contractor to make the necessary repairs including the broken mounting bracket, broken metal newel post and properly secure the railing to the wall. The Safety Committee will monitor stairway condition and safety during their semi-annual facility inspection. Program Director will ensure completion of project by 08/18/2016 |
705.28 (c) (4) LICENSURE Fire safety.
705.28. Fire safety.
(c) Fire extinguishers. The nonresidential facility shall:
(4) Instruct staff in the use of the fire extinguisher upon staff employment. This instruction shall be documented by the facility.
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Observations
Based on a review of Staffing Requirements Facility Summary Report, staff records and conversation with facility staff, the facility failed to instruct staff in the use of the fire extinguisher upon staff employment in one of eight records.
Employees #8 was hired as a dispensing nurse on May 14, 2016 however the fire extinguisher training was not completed until May 29, 2016.
This information was reviewed with the facility staff.
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Plan of Correction
AMHA will review with current supervisors, who conduct new staff orientations, program policy on fire extinguisher and fire safety training to ensure that this training takes place upon hire, or no later than seven days from date of employment. Clinical Program Manager will be responsible for reviewing this policy with supervisors by 08/23/2016 |
705.29 (2) (iii) LICENSURE Child care.
705.29. Child care.
When a nonresidential facility admits children for services or for custodial care, the following requirements apply:
(2) Interior space. The nonresidential facility shall:
(iii) Maintain protective caps over each electrical outlet.
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Observations
The facility failed to maintain protective caps over each electrical outlet.
During the physical plant inspection it was observed that two electrical outlets in the child care area were not equipped with protective covers. Additionally, a container of alcohol-based hand sanitizer was stationed on a shelf that allowed for access by children. Staff members confirmed that the hand sanitizer is generally kept in this location which presents an ingestion hazard.
This information was reviewed with the facility staff.
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Plan of Correction
AMHA has replaced all missing protective electrical outlet covers in the child care area and maintains a supply of additional protective covers in the event that lost or broken covers need to be replaced. The parent-child specialist is responsible for frequent inspection of the child care area to ensure that the electrical outlets remain covered. The parent-child specialist will conduct these inspections at the start of everyday, while children are in the area and after children have left the child care area. Additionally, the hand sanitizer has been moved to a locked desk drawer that is only accessible by the parent-child specialist.
The Clinical Program Manager is responsible for overall monitoring and compliance with applicable regulations regarding the child care area. |
709.28 (b) LICENSURE Confidentiality
§ 709.28. Confidentiality.
(b) The project shall secure hard copy client records within locked storage containers. Electronic records must be stored on secure, password protected data bases.
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Observations
The facility failed to secure hard copy client records within locked storage containers.
Based on the physical plant inspection, it was observed that file cabinets in which the active client records are stored in each therapist's office were not consistently locked. The offices where these observations were made were not in use on the day of the inspection as those clinical staff were out of the office that day. Additionally, a conversation with the facility staff revealed that, although the doors to the offices are kept locked, the maintenance and cleaning staff have unaccompanied access to these offices.
This information was reviewed with the facility staff.
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Plan of Correction
AMHA conducted a staff meeting on 07/28/2016 during which patient record confidentiality and the need to consistently lock office cabinets, at the end of each day, was reviewed. The Clinical Program Manager will be responsible for ensuring ongoing compliance with policy and regulation. |
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
Based on the review of client records, the facility failed to limit the release of information to what is permissible according to 4 Pa. Code 255.5 in client records #3 and 5.
4 Pa. Code states that information released to judges, probation or parole officers, insurance company, health or hospital plan or governmental officials, pursuant to paragraphs (1), (2), (4),(7), (8) or subsection (a) of the code, is for the purpose of determining the advisability of continuing the client with the assigned project and shall be restricted to the following:
(1) Whether the client is or is not in treatment.
(2) Client's prognosis.
(3) The nature of the project.
(4) A brief description of the client's progress.
(5) A short statement as to whether the client has relapsed into drug or alcohol abuse and the frequency of such relapse.
Additionally, client record #7 was missing the date of the signature, record #9 failed to obtain a consent to release information and record #10 failed to list the name of the agency.
Client record #3 had a consent to release information form dated 6/2/16 to a funding source that had "Urinalysis (Routine, Drug Screen, pregnancy)" checked as information to be released.
Client record #5 had a two consent to release information forms to funding sources dated 9/12/14 and 2/12/14, that had "Urinalysis (Routine, Drug Screen, pregnancy)" checked as information to be released.
Client record #7 had a two consent to release information forms to a treatment provider dated 4/25/16 that did not have the date of the client's signature.
Client record #9 contained documentation of a letter dated 2/9/16 being sent but it could not be determined to whom it was sent.
Client record #10 had a consent form dated 11/5/15 that did not indicate the name of the agency to whom information was to be sent.
The information was reviewed with facility staff.
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Plan of Correction
AMHA conducted a staff training on 08/09/2016 on PA code 255.5. This training highlighted the limitations and restrictions surrounding patient confidentiality and appropriate completion of consent forms.
Additionally, AMHA will identify the patient's records containing inappropriately completed consents and will obtain a new and appropriate consent from the patient to file in their respective record, this will be completed by 08/17/2016.
The Program Director was responsible for the completion of this training, and in conjunction with the Clinical Program Manager, will be responsible for ongoing monitoring and adherence to PA code 255.5. |
709.28 (d) LICENSURE Confidentiality
§ 709.28. Confidentiality.
(d) A copy of a client consent shall be offered to the client and a copy maintained in the client record.
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Observations
Based on the review of client records, the facility failed to document whether the client was offered a copy of the consent form in records, #10 and 11.
Client #10 - A consent form to an agency dated 11/5/15 did not indicate whether the client was offered a copy of the consent.
Client #11 - A consent form to a treatment provider dated 4/28/16 did not indicate whether the client was offered a copy of the consent.
The information was reviewed with the facility staff.
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Plan of Correction
AMHA conducted a staff training on 08/09/2016 on PA code 255.5. This training highlighted the limitations and restrictions surrounding patient confidentiality and appropriate completion of consent forms.
Additionally, AMHA will offer a copy of consents and document acceptance or refusal for the identified patients whom this was not documented at the time of the inspection. This will be completed by 08/17/2016.
The Program Director was responsible for the completion of this training, and in conjunction with the Clinical Program Manager, will be responsible for ongoing monitoring and adherence to PA code 255.5.
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709.34 (a) (6) LICENSURE Reporting of unusual incidents
§ 709.34. Reporting of unusual incidents.
(a) The project shall develop and implement policies and procedures to respond to the following unusual incidents:
(6) Event at the facility requiring the presence of police, fire or ambulance personnel.
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Observations
Ten unusual incident reports were reviewed in the facility log that met the criteria for reporting to the Department in that an ambulance or emergency personnel were called to the facility. A conversation with the facility staff confirmed that these incidents were not reported as required.
This information was reviewed with the facility.
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Plan of Correction
Clinical Program Manager reviewed, on 08/03/2016, the policy and procedure concerning reporting of unusual incidents with the Health and Safety staff assigned to submit the reports to the Department in order to ensure compliance with agency's policy as well as with PA 709.34 (a) (6).
Clinical Program Manager will be responsible for monitoring that all unusual incidents have been appropriately submitted to the Department. |
715.9(a)(1) 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:
(1) Verify that the individual has reached 18 years of age.
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Observations
Based on a review of client records the facility failed to document verification that an individual had reached 18 years of age.
Client #7 was admitted on 11/24/15 and was still an active client at the time of the licensing inspection. There was no Photo I.D. documented in the patient record as of the date of the inspection.
this information was reviewed with the facility staff.
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Plan of Correction
It is the policy of AMHA to obtain a copy a person's state issued picture ID during the intake process and file it in the client's record upon admission. This is done to verify, not only identity, but minimum age of 18 years. This policy has been reviewed with our intake coordinator who will be responsible for ensuring that all clinical records, for new and transfer patients, have a copy of a valid ID present.
Please note that at the time of the licensing inspection client #7 was an inactive client as she had been discharged from AMHA on 05/23/2016. Due to this reason AMHA will be unable to obtain a copy of the client's ID to place on record.
The Clinical Program Manager will be responsible for monitoring the compliance with this policy. |
715.23(b) LICENSURE Patient records
(b) Each patient file shall include the following information:
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Observations
Based on a review of client records the facilty failed to include documentation of patient histories in one of fourteen records.
Client #2 was admitted on 2/9/16 and was still an active client at the time of the licensing inspection. There was no documented Drug and alcohol or personal history in the patient record at the time of the inspection.
This information was reviewed with the facility staff.
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Plan of Correction
It is the policy of AMHA to obtain a complete personal and drug and alcohol history, by means of completing a Biopsychosocial History, within the initial 21 days of the patient's treatment. The Clinical Program Manager has reviewed this policy with the clinical staff during a staff meeting held on 07/28/2016. Additionally, the Clinical Supervisors will be responsible for reviewing the records of their respective supervises for completion of the required Biopsychosocial History. The identified chart has been reviewed and the biopsychosocial history was found to be misfiled.
The Clinical Program Manager will be responsible for the ongoing monitoring for compliance with this policy. |
715.23(b)(15) LICENSURE Patient records
(b) Each patient file shall include the following information:
(15) Psychosocial evaluations of the patient.
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Observations
Based on a review of client records the facilty failed to include documentation of a psychosocial evaluation in one of fourteen records.
Client #2 was admitted on 2/9/16 and was still an active client at the time of the licensing inspection. There was no documented psychosocial evaluation in the patient record at the time of the inspection.
This information was reviewed with the facility staff.
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Plan of Correction
It is the policy of AMHA to complete a Psychosocial Evaluation within the initial 21 days of the patient's treatment. The Clinical Program Manager has reviewed this policy with the clinical staff during a staff meeting held on 07/28/2016. Additionally, the Clinical Supervisors will be responsible for reviewing the records of their respective supervises for completion of the required Psychosocial Evaluation. The missing Psychosocial Evaluation on the identified chart has been completed and filled.
The Clinical Program Manager will be responsible for the ongoing monitoring for compliance with this policy. |
709.93(a)(11) LICENSURE Client records
709.93. Client records.
(a) There shall be a complete client record on an individual which includes information relative to the client's involvement with the project. This shall include, but not be limited to, the following:
(11) Follow-up information.
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Observations
Based on a review of client records the facilty failed to include documentation of follow-up information in two of six records.
Client #13 was admitted on 2/1/07 and was discharged on 4/25/16. There was no documented follow-up information in the patient record at the time of the inspection.
Client #14 was admitted on 6/27/13 and was discharged on 2/24/16. There was no documented follow-up information in the patient record at the time of the inspection.
This information was reviewed with the facility staff.
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Plan of Correction
It is the policy and procedure of AMHA to complete post-discharge follow up for all discharged clients from AMHA within 30 days. The front desk receptionist is responsible for follow up contact and attempts to complete a follow up patient satisfaction survey. These contacts are logged and documented in a spreadsheet as well as on follow up forms, which are maintained by the front desk receptionist. At the time of the inspection, AMHA failed to provide the Department Staff with these documents prior to the conclusion of their site visit. The Clinical Program Manager will ensure that this information is provided to the Department Staff during the time of their next inspection |