INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on January 24-25, 2013 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Clinical Outcomes Group, 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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704.9(c) LICENSURE Supervised Period
704.9. Supervision of counselor assistant.
(c) Supervised period.
(1) A counselor assistant with a Master's Degree as set forth in 704.8 (a)(1) (relating to qualifications for the position of counselor assistant) may counsel clients only under the close supervision of a trained counselor or clinical supervisor for at least the first 3 months of employment.
(2) A counselor assistant with a Bachelor's Degree as set forth in 704.8 (a)(2) may counsel clients only under the close supervision of a trained counselor or clinical supervisor for at least the first 6 months of employment.
(3) A registered nurse as set forth in 704.8 (a)(3) may counsel clients only under the close supervision of a trained counselor or clinical supervisor for at least the first 6 months of employment.
(4) A counselor assistant with an Associate Degree as set forth in 704.8 (a)(4) may counsel clients only under the close supervision of a trained counselor or clinical supervisor for at least the first 9 months of employment.
(5) A counselor assistant with a high school diploma or GED equivalent as set forth in 704.8 (a)(5) may counsel clients only under the direct observation of a trained counselor or clinical supervisor for the first 3 months of employment. For the next 9 months, the counselor assistant may counsel clients only under the close supervision of a lead counselor or a clinical supervisor.
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Observations
Based on the review of supervision notes and employee personnel records, the facility failed to document weekly case reviews with each counselor assistant for the required time period in one of one record reviewed.
The findings include:
One employee record requiring documentation of weekly supervision and supervision notes were reviewed on January 24-25, 2013. The facility failed to document weekly case reviews with each counselor assistant for the required time period in one of one records, specifically employee record # 5. .
Employee # 5 was hired as a counselor assistant on 3/1/12. The employee was required to have close supervision for 6 months beginning on 3/1/12. The facility documented supervision and case reviews for this employee, however, it was not being completed weekly on a consistent basis. The facility documented a total of 21 weeks of supervision. There should have been 24 weeks worth of supervision documented.
The Facility Director confirmed the findings.
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Plan of Correction
Facility Director/Clinical Supervisor will meet with the Counselor Assistant for three (3) one hour individual supervision sessions to complete close supervision. The supervison will be conducted on the following dates: 2/1, 2/8 & 2/15/2013. After completion of the close supervision and if the Counselor Assistant continues to progress, group supervision will be offered weekly. Individual supervision will be offered on an as needed basis. The facility will be in full compliance with close supervision of the Counselor Assistant by February 15, 2013. The facility director/clinical supervisor will continue to offer weekly group supervison to the counselor assistant and all clinical staff on a weekly basis. |
709.24(d) LICENSURE Treatment/Rehabilitation Management
709.24. Treatment/rehabilitation management.
(d) Provisions shall be made, through written agreement with a licensed hospital or physician, for 24-hour emergency psychiatric and medical coverage.
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Observations
Based on a review of letters of agreement, the facility failed to provide documentation of a written agreement with a licensed hospital or physician for 24-hour emergency medical coverage.
The findings include:
The letters of agreement were reviewed on January 24, 2013. No letter of agreement regarding 24- hour emergency medical coverage was documented.
The Facility Director confirmed the findings and informed the Licensing Specialist they will be working on that immediately.
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Plan of Correction
The Facility Director will have a referral agreement for 24-hour emergency medical coverage by 2/6/2013 with the local hospital. The agreement will be updated as indicated but not longer than every two years, unless terminated by either institution in writing. The facility will be in full compliance by 2/6/2013. The facility director will monitor the referral agreement with the 24-hour emergency medical facility and ensure that it remains in effect. |
709.33(a) LICENSURE Notification of Termination
709.33. Notification of termination.
(a) Project staff shall notify the client, in writing, of a decision to involuntarily terminate the client's treatment at the project. The notice shall include the reason for termination.
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Observations
Based on a review of client records, the facility failed to inform the client, in writing, of a decision to involuntarily terminate the client's treatment at the project in one of one record reviewed.
The findings include:
One client record requiring documentation of notification of involuntary termination was reviewed on January 24, 2013. The facility failed to document notification of termination in one of one client records, specifically client record # 3.
Client # 3 was admitted into treatment on 8/27/12 and discharged from treatment on 11/21/12 due to being non-compliant with treatment. At the time of inspection, there was no documentation of notification of termination in the client file.
The Facility Director confirmed the findings.
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Plan of Correction
Facility Director will review with all staff the policy on the documentation for involuntary termination of services for clients. All clients being terminated as a result of non-compliance with program rules will be sent a letter informing them that they are in jeopardy of being discharged from the program. In the letter they will be offorded an opportunity to contact the agency should they want to remain engaged in treatment prior to their discharge. Facility Director will meet with the clinical staff member responsible for client #3 and inquire about client discharge. If at the time of discussion it is deemed necessary, a letter informing the client that he was discharged from the program will be sent.
The facility director will continue to monitor client records on a monthly basis to ensure compliance. Facility will be in full compliance by March 10, 2013. Should clinical staff fail to follow the policy then individual supervision will be conducted with staff member to ensure understanding of policy requirements. |
709.33(b) LICENSURE Notification of Termination
709.33. Notification of termination.
(b) The client shall have an opportunity to request reconsideration of a decision terminating treatment.
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Observations
Based on a review of client records, the facility failed to inform the client of their opportunity to request reconsideration of a decision terminating treatment in one of one record reviewed.
The findings include:
One client record requiring documentation of notification of involuntary termination and the opportunity to request reconsideration of termination was reviewed on January 24, 2013. The facility failed to document notification of termination and the opportunity to request reconsideration of a decision to terminate treatment in one of one client records, specifically client record # 3.
Client # 3 was admitted into treatment on 8/27/12 and discharged from treatment on 11/21/12 due to being non-compliant with treatment. At the time of inspection, there was no documentation of notification of termination or the client's right to request reconsideration of a decision terminating treatment in the client file.
The Facility Director confirmed the findings.
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Plan of Correction
Facility Director will meet with the clinical staff member assigned to client #3 and write a letter to the client informing him that he was discharged from the program but offord him an opportunity to re-engage in the program. Clinical staff will be informed of the policy on involuntary termination during supervision within 14 days or 2/8/13 from the date of the citation. Facility will be in full compliance with client #3 by March 10, 2013. Facility Director will monitor client records on a monthly basis to ensure compliance. |
715.9(a)(4) 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:
(4) Have a narcotic treatment physician make a face-to-face determination of whether an individual is currently physiologically dependent upon a narcotic drug and has been physiologically dependent for at least 1 year prior to admission for maintenance treatment. The narcotic treatment physician shall document in the patient 's record the basis for the determination of current dependency and evidence of a 1 year history of addiction.
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Observations
Based on the review of client records,the physician, failed to document the basis for determining current and one year history of dependency in three of three records reviewed.
The findings include:
Three records requiring documentation of eligibility for admission, including a physical examination, were reviewed on January 25, 2013. The physician failed to document the basis for determining current and one year history of dependency, to include a physical examination in three of three records, specifically client records # 8, 9, and 10.
Client # 8 was admitted into treatment on 11/1/12 and was still an active client at the time of the inspection. At the time of inspection, the client file did not contain documentation of a physical prior to the initial dosing.
Client # 9 was admitted into treatment on 11/8/12 and was still an active client at the time of the inspection. At the time of inspection, the client file did not contain documentation of a physical prior to the initial dosing.
Client # 10 was admitted into treatment on 11/6/12 and was still an active client at the time of the inspection. At the time of inspection, the client file did not contain documentation of a physical prior to the initial dosing.
The Facility Director confirmed the findings.
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Plan of Correction
Prior to the administration of an agent within our narcotic treatment program, the treatment provider's physician will meet with each individual face to face to determine whether an individual is currently physiologically dependent on an Opioid for at least one year. The program physician will document in the client record the basis for determining the level of dependency and evidence of the one-year history. All new clients entering the program will have a physical completed by our program physician prior to the initial dosing.
The program will ensure that all current clients receiving a narcotic agent within the program have a physical within 30 days or by March 10, 2013. Client #8, #9, #10 will all have the program doctor complete a physical by March 10, 2013.
The facilit director will review all charts to ensure compliance. Program will be in full compliance with all existing clients' physicals by March 10, 2013. Program will be in full compliance with all new clients entering into the narcotic treatment program effective 2/13/13. Facility director will continue to review all client records monthly to ensure compliance. |