INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection and monitoring inspection for the approval to use a narcotic agent, specifically methadone in the treatment of narcotic addiction. The inspection was conducted on October 20-21, 2014 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Pennsylvania Associates LLC dba Mount Pocono Medical 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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704.7(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
Based on a review of personnel records on October 20, 2014, the facility failed to ensure that each counselor met the qualifications for the position in two of five counselor records reviewed.
The findings include:
The facility failed to ensure that Employee # 4 renewed her licensure to the State of New York for Credentialed Alcoholism and Substance Abuse Counselor prior to the expiration date of 7-23-2014.
Employee # 6 did not meet the qualifications of a Counselor. There was no documentation of a practicum nor clinical experience on job application and resume.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Facility Director reviewed the standard 704.7 (b) and will ensure that credentials meet the qualifications. An interview questionnaire form was developed and will be utilized during the screening process by the Facility Director effective immediately. The experience and relevant work experience will be documented. Employees who only have a certification/license to qualify them as a counselor need to maintain their certification/license. The Facility Director will track certifications on a spreadsheet. |
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 the fire drill logs and an interview with the Facility Director, the facility failed to prepare alternate exit routes to be used during fire drills.
The findings include:
A review of the fire drill logs was conducted prior to inspection of October 20-21, 2014. The fire drills conducted from November 2013- September 2014 were reviewed. The facility did not document alternate exits used during fire drills. The exit doors listed on the logs state "all egress routes accessible" for each fire drill. The facility was unable to provide documentation verifying that alternate exits were used.
An interview with the Facility Director was conducted on October 20, 2014. It was confirmed that all exit routes were used rather than alternate routes for each fire drill throughout the year.
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Plan of Correction
The Facility Director reviewed standard 705.28 (d) (5). Effective immediately the fire drill log will note exit routes used.
Alternate exits will be used during fire drills. The Facility Director will review all fire drill logs to ensure alternate exits were used before approving the drill. A fire drill was conducted on 11/5/2014 and the alternate exit was used and noted on fire drill log.
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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 on October 21, 2014, the facility was using a general consent to release information which is prohibited by state and federal laws.
The findings included:
The Consent to Use or Disclose information for Treatment, Payment of Health Care Operations fails to include each of the items identified at 28 PA Code subsection 709.28 (c) and 42 CFR Part 2 Subpart (c) Subsection 2.31.
Client records 1 thru 5 contained a consent to release information form that exceeded what is permissible under 4 Pa. Code 255.5.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Facility Director reviewed standard 709.28(c) regarding confidentiality.
All patient records will be reviewed for any HIPAA consent forms and those forms will be voided and left in the patient record. A new form which will be a form documenting that the HIPAA Notice of Privacy Practices was reviewed with the patient and a copy was presented to them will be completed and put in the patient record.
the HIPPA form was changed to the HIPAA Acknowledge Form to reflect that information as an acknowledgement form and not a consent form. The form has been updated to clearly indicate the intent which is an acknowledgement of the patients awareness of all federal and state privacy and confidentiality protections. The clinical staff will be trained in the new form by 12/31/14. The old form will be removed from circulation. The new form will be circulated effective 12/31/14. The Facility Director will ensure that HIPAA information is not released unless it is in compliance with CFR42, 4 PA Code 255.5 and Act 63 of 1972 and its on the proper release of records/consent form by reviewing all HIPAA released information. |