INITIAL COMMENTS
|
This report is a result of an on-site licensure renewal inspection conducted on August 1, 2017 and August 2, 2017 by staff from the Division of Drug and Alcohol Program Licensure. 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:
|
Plan of Correction
|
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.
|
Observations
Fourteen personnel records were reviewed on August 1, 2017 through August 2, 2017. Two records were required to document a core curriculum in clinical supervision was completed. The facility failed to document that a core curriculum in clinical supervision was completed in one of two records.
Employee #6 was hired as a counselor on May 14, 2014 and was promoted to clinical supervisor on November 1, 2016. There was no documentation contained in the record that showed that the employee functioned for two years as a supervisor in the provision of clinical services or that the employee completed a core curriculum in clinical supervision.
These findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
The Executive Director has instructed the Program Director to register for and complete the next available clinical supervision training. Both individuals will regularly monitor the DDAP website and other communications to learn of the next available training session. The Executive Director will ensure that the Program Director completes the training. |
704.11(c)(1) LICENSURE Mandatory Communicable Disease Training
704.11. Staff development program.
(c) General training requirements.
(1) Staff persons and volunteers shall receive a minimum of 6 hours of HIV/AIDS and at least 4 hours of tuberculosis, sexually transmitted diseases and other health related topics training using a Department approved curriculum. Counselors and counselor assistants shall complete the training within the first year of employment. All other staff shall complete the training within the first 2 years of employment.
|
Observations
Fourteen personnel records were reviewed on August 1, 2017 through August 2, 2017. Six personnel records were required to have documentation of HIV/AIDS and tuberculosis, sexually transmitted disease (TB/STD) training. The facility did not provide documentation of the HIV/AIDS and TB/STD trainings within the required time frame in three of fourteen personnel records reviewed.
Employee #12, a receptionist, was hired on February 9, 2015 . HIV/AIDS training was to be completed within two years of hire, by February 9, 2017. The personnel record contained no documentation of HIV/AIDS training.
Employee #13, a receptionist, was hired on June 23, 2014. TB/STD training was to be completed within two years of hire, by June 23, 2016. The personnel record contained no documentation of TB/STD training.
Employee #14, an administrative assistant, was hired on December 1, 2014. TB/STD training was to be completed within one year of hire, by December 1, 2016. The personnel record contained no documentation of TB/STD training.
These findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
The Executive Director has addressed the matter with the Office Manager who supervises the subject staff. All staff will complete the next available training. Based upon a review of current offerings the trainings should be completed by October 31, 2017. As a longer term strategy the agency is considering having medical staff conduct the training on-site. A draft curriculum will be sent to DDAP for approval by December 31, 2017. The in-house training will only impact new hires. |
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.
|
Observations
Fifteen client records were reviewed from August 1, 2017 through August 2, 2017. The facility failed to obtain a consent to release information form in one of fifteen records reviewed.
Client #3 was admitted into the outpatient maintenance activity on January 16, 2017 and was still an active client at the time of the inspection. The client record contained documentation indicating that the facility released patient identifying information to a treatment provider on January 16, 2017 and failed to obtain an informed and voluntary consent prior to the disclosure.
Additionally, based on the review of the facility's grievance log, the facility exceeded 4 PA. Code
4 Pa. Code states:
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 this section, 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.
The facility's grievance log contained documentation that indicated that the facility released information to a funding source that exceeded 4 PA. Code on July 17, 2017. Specifically, the facility released progress notes detailing what was discussed in the client's individual sessions with their counselor.
These findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
Staff training on confidentiality and 4 PA Code occurs annually. The Executive Director will schedule the next training to occur within 90 days. Program Directors will reinforce confidentiality regulations and protocol in group and individual supervision during the months of August and September and thereafter on a not less than bi-monthly basis. In addition to the above the Provider has a clinical chart auditing process whereby two charts per clinician are audited each month. The adherence to confidentiality regulations and the release of information are part of the chart audits. With respect to the release of information to a funding source the Executive Director is typically the only staff member to respond to these request. The violation is so noted and has been reviewed by management staff and will be incorporated into the confidentiality trainings. |
709.30 (2) LICENSURE Client rights
§ 709.30. Client rights.
The project shall develop written policies and procedures on client rights and document written acknowledgement by clients that they have been notified of those rights.
(2) The project may not discriminate in the provision of services on the basis of age, race, creed, sex, ethnicity, color, national origin, marital status, sexual orientation, handicap or religion.
|
Observations
Fifteen client records were reviewed for client rights on August 1, 2017 through August 2, 2017. The facility failed to include on the facility's Ackowledgement of Rights form the following verbiage: creed, color, national origin, marital status, handicap and religion.
These findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
The Pharmacotherapy Program Director has added the following verbiage: creed, color, national origin, martial status, handicap and religion, to the Acknowledgement of Rights form as of Rights form as of August 18, 2017. The Pharmacotherapy Director has also informed all staff to discard the old form and to use only the new form. The use of the new form will be monitored by the Program Director during supervision and checked by the assessor during chart audits. |
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
|
Observations
Based on a review of physician's hours, the facility failed to provide narcotic treatment physician services at least 1 hour per week onsite for every ten patients in two of three weeks reviewed.
During the week of March 12-18, 2017, the facility reported a census of 267. The facility was required to provide at least 26.7 physician hours. There was 8.25 physician hours documented. The amount of physician hours documented is less than the amount of hours required.
During the week of March 19-25, 2017, the facility reported a census of 268. The facility was required to provide at least 26.8 physician hours. There was 4.25 physician hours documented. The amount of physician hours documented is less than the amount of hours required.
These findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
The deficiency was the result of the medical director being on vacation. Several strategies are being pursued. First of all the Provider will be adding additional hours for the psychiatrist on a permanent basis, and in particular to ensure coverage to meet the regulatory requirement during the medical director's time off. In addition, the Provider is in the process of adding a part-time doctor to the staff to assist with patient census growth and to provide coverage during time off. It is the goal of the Provider to have additional coverage by September 30, 2017. |