INITIAL COMMENTS
|
This report is a result of an on-site licensure renewal inspection and methadone monitoring conducted on June 1-2, 2023 by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, Aldie Foundation 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:
|
Plan of Correction
|
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.
|
Observations
Based on a review of personnel records, the facility failed to document that each counselor met both the education and experiential qualifications for the position.
Employee #4, who was hired as a counselor on September 16, 2022, did not meet the experience requirements to be a counselor. At the time of the hire, the employee did not have one year of clinical experience required to be a counselor with a bachelor's degree.
This finding was reviewed with facility staff during the licensing inspection.
|
Plan of Correction
The CEO has met with the hiring managers to review the education and experience requirements for the position of counselor. For future clinical hires, the Clinical Director will inform the CEO of the highest education level obtained as well as the years of experience. The CEO, in consultation with the Clinical Director, will properly document the findings. If the new hire does not qualify for the position of counselor, but qualifies for counselor assistant, they will be documented as such and thereafter supervised in accordance with the regulations. |
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.
|
Observations
Based on a review of the Staffing Requirements Facility Summary Report (SRFSR) and personnel records, the facility failed to provide close supervision by a trained counselor or clinical supervisor for the first 6 months of employment.
Employee #5 was hired on July 19, 2022 as a counselor asssistant and was still employed at the time of the inspection. She had no documentation one hour per week of direct observation.
This finding was reviewed with the facility staff during the licensing process
|
Plan of Correction
The CEO has reviewed the citation with the Clinical Director and Clinical Supervisor. For new individuals meeting the requirements for counselor assistant, the Clinical Director will provide one hour per week of direct supervision. If the Clinical Director is unable to meet this requirement the weekly direct supervision will be provided by a Clinical Supervisor. Progress will be reported to the CEO at monthly management meetings, and documented in supervision logs. |
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.
|
Observations
Based on a review of the Staffing Requirements Facility Summary Report (SRFSR) and personnel records, the facility failed to ensure that staff were instructed in the use of fire extinguishers upon employment.
Employee #7 was hired on October 3, 2022 as a counselor and was still in the position as of the date of the inspection. The training was due no later than October 10, 2022; however, it was not completed until October 31, 2022.
This finding was reviewed with the facility staff during the licensing process.
|
Plan of Correction
The CEO has restructured on-boarding and new staff orientation responsibilities. The administrative assistant to the CEO is charged with ensuring that the fire extinguisher training is completed within seven days of hire. The administrative assistant provides the CEO with a copy of a certificate of completion to document that the requirement has been met. The certificate is then placed in the individual's personnel chart. |
705.28 (d) (3) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(3) Ensure that all personnel on all shifts are trained to perform assigned tasks during emergencies.
|
Observations
Based on a review of the Staffing Requirements Facility Summary Report (SRFSR) and personnel records, the facility failed to ensure that all personnel on all shifts are trained to perform assigned task during emergencies.
Employee #7 was hired on October 3, 2022 as a counselor and was still in the position as of the date of the inspection. The training was due no later than October 10, 2022; however, it was not completed until October 31, 2022.
This finding was reviewed with the facility staff during the licensing process.
|
Plan of Correction
The CEO has restructured on-boarding and new staff orientation responsibilities. The administrative assistant to the CEO is charged with ensuring that the emergency training is completed within seven days of hire. The administrative assistant provides the CEO with a copy of a certificate of completion to document that the requirement has been met. The certificate is then placed in the individual's personnel chart. |
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.
|
Observations
Based on the review of client records, the facility failed to notify the client, in writing, of a decision to involuntarily terminate the client's treatment at the project in one out of one applicable client records.
Client #4 was admitted on June 13, 2022 and discharged on April 28, 2023.
This finding was reviewed with facility staff during the licensing inspection.
This is a repeat citation from the June 23, 2022 licensing inspection.
|
Plan of Correction
The CEO has reviewed the citation with the Management Team. The Clinical Director and Clinical Supervisor have devised a process to ensure that clients are notified in writing when involuntarily terminated from the program. When a client is involuntarily terminated the Clinical Director will provide the client with written notification of the decision. The client will be requested to sign the letter acknowledging the decision. The letter will be uploaded into the EHR with the client's acknowledgment or a notation the the client "refused to sign". The Clinical Director will check the EHR at least five days prior to the due date to ensure that the requirement has been met to comply with the current facility policy. |
715.19(1) LICENSURE Psychotherapy services
A narcotic treatment program shall provide individualized psychotherapy services and shall meet the following requirements:
(1) A narcotic treatment program shall provide each patient an average of 2.5 hours of psychotherapy per month during the patient 's first 2 years, 1 hour of which shall be individual psychotherapy. Additional psychotherapy shall be provided as dictated by ongoing assessment of the patient.
|
Observations
Based on a review of patient records, the facility failed to provide patients with 2.5 hours of psychotherapy per month during the patient's first two years of treatment, one hour of which shall be individual psychotherapy, in one out of four applicable records reviewed.
Patient #4 was admitted on June 13, 2022 and discharged on April 28, 2023. In January 2023, the patient did not receive any psychotherapy sessions.
This finding was reviewed with facility staff during the licensing inspection.
|
Plan of Correction
The CEO has reviewed the citation with the management team including the Clinical Director. The Clinical Director and Clinical Supervisor will monitor the active client caseloads on the EHR on a weekly basis, as well as in group and individual supervision, to ensure that the counseling requirement is met. For clients that are not engaging in counseling, the Clinical Director will authorize treatment contracts and medication holds to further encourage attendance at counseling sessions. Failure to comply will result in discharge from treatment. |
715.23(b)(5) LICENSURE Patient records
(b) Each patient file shall include the following information:
(5) The results of all annual physical examinations given by the narcotic treatment program which includes an annual reevaluation by the narcotic treatment physician.
|
Observations
Based on a review of patient records, the facility failed to document an annual physical examination within the regulatory timeframe in three out of three applicable records.
Patient #3 was admitted on July 28, 2017 and was discharged on January 30, 2023. The annual physical examination was due July 28, 2022; however, it was completed on August 5, 2022.
Patient #5 was admitted on February 5, 2020 and was still active at the time of the inspection. The annual physical examination was due February 5, 2023; however, it was not completed as of the date of the inspection.
Patient #6 was admitted on November 21, 2016 and was still active at the time of the inspection. The annual physical examination was due November 21, 2022; however, it was not completed as of the date of the inspection.
These findings were reviewed with facility staff during the licensing inspection.
|
Plan of Correction
The CEO has reviewed the citation with the management team. The Chief Nursing Officer will tract, via the EHR, the date when all client annual physical exams are due. The Chief Nursing Officer will coordinate with Clinical Director, and administrative assistant in charge of scheduling to ensure that all clients are scheduled to receive an annual physical exam in advance of the due date. Clients will be scheduled a minimum of two weeks prior to the due date. If an appointment is missed, the client will be rescheduled within five days. Dose holds will be implemented if the client is resistant. Results will be documented in the client record. |
715.23(c)(1-7) LICENSURE Patient records
(c) An annual evaluation of each patient 's status shall be completed by the patient 's counselor and shall be reviewed, dated and signed by the medical director. The annual evaluation period shall start on the date of the patient 's admission to a narcotic treatment program and shall address the following areas:
(1) Employment, education and training.
(2) Legal standing.
(3) Substance abuse.
(4) Financial management abilities.
(5) Physical and emotional health.
(6) Fulfillment of treatment objectives.
(7) Family and community supports.
|
Observations
Based on a review of patient records, the facility failed to document an annual clinical evaluation within the regulatory timeframe in two out of three applicable records.
Patient #5 was admitted on February 5, 2020 and was still active at the time of the inspection. The annual clinical evaluation was due February 5, 2023; however, it was not completed until February 28, 2023
Patient #6 was admitted on November 21, 2016 and was still active at the time of the inspection. The annual clinical evaluation was due November 21, 2022; however, it was not completed as of the date of the inspection.
These findings were reviewed with facility staff during the licensing inspection.
|
Plan of Correction
The CEO reviewed the finding with the Clinical Director. The Facility recently implemented a new EHR which should assist in tracking due dates for clinical documentation including the annual evaluation. The Clinical Director and Clinical Supervisor will monitor the EHR on a not less than weekly basis to determine documentation requirements. The data will be reviewed with the counselors in group and individual supervisor. Within 30 days from the due date that counselors will need to verify that the annual evaluation will be completed. The clinical record will be marked in the EHR when completed. |
709.92(a) LICENSURE Treatment and rehabilitation services
709.92. Treatment and rehabilitation services.
(a) An individual treatment and rehabilitation plan shall be developed with a client. This plan shall include, but not be limited to, written documentation of:
|
Observations
Based on a review of client records, the facility failed to document that the comprehensive treatment plan was completed with the patient in two out of four applicable records reviewed.
Client #2 was admitted on September 28, 2022 and was discharged on May 16, 2023. A comprehensive treatment plan completed on October 12, 2022 was not signed by the patient.
Client #8 was admitted on January 18, 2023 and was still active at the time of the inspection. A comprehensive treatment plan completed on January 31, 2023 was not signed by the patient.
These findings were reviewed with facility staff during the licensing inspection.
|
Plan of Correction
The CEO reviewed the citation with the Clinical Director. The Clinical Director has, in turn, instructed all clinical staff of the requirement to have clients sign the comprehensive treatment plan. The Clinical Director and Clinical Supervision will monitor compliance by reviewing records in individual supervisor and reinforcing compliance with the requirement in group supervision. |
709.92(b) LICENSURE Treatment and rehabilitation services
709.92. Treatment and rehabilitation services.
(b) Treatment and rehabilitation plans shall be reviewed and updated at least every 60 days.
|
Observations
Based on a review of clients records, the facility failed to document treatment plan updates within the regulatory timeframe in six out of seven applicable records reviewed.
Client #2 was admitted on September 28, 2022 and was discharged on May 16, 2023. A comprehensive treatment plan was completed on October 12, 2022 and an update was due no later than December 12, 2022; however, the update was completed on December 29, 2022.
Client #4 was admitted on June 13, 2022 and discharged on April 28, 2023. A treatment plan update was completed on October 15, 2022 and the next update was due no later than December 15, 2022; however, it was completed on December 28, 2022.
Client #5 was admitted on February 5, 2020 and was still active at the time of the inspection. A treatment plan update was completed on March 2, 2023 and the next update was due no later than May 2, 2023; however, it was not completed until May 12, 2023.
Client #6 was admitted on November 21, 2016 and discharged was still active at the time of the inspection. A treatment plan update was completed on October 20, 2022 and the next update was due no later than December 20, 2022; however, no update has been completed.
Client #7 was admitted on June 11, 2021 and was still active at the time of the inspection. A treatment plan update was completed on July 28, 2022 and the next update was due no later than September 18, 2022; however, it was not completed until October 4, 2022.
Client #8 was admitted on January 18, 2023 and was still active at the time of the inspection. A comprehensive treatment plan was completed on January 31, 2023 and the next update was due no later than March 31, 2023; however, it was not completed until May 24, 2023.
These findings were reviewed with facility staff during the licensing inspection.
|
Plan of Correction
The CEO reviewed the citation with the Clinical Director. The Clinical Director has, in turn, instructed all clinical staff of the requirement to have all comprehensive treatment plan updates completed within 60 days. The Clinical Director and Clinical Supervision will monitor compliance by reviewing records in individual supervisor and reinforcing compliance with the requirement in group supervision. The EHR will be used as a tool to alert counselors and supervisors as to upcoming due dates. |
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.
|
Observations
Based on a review of client records, the facility failed to provide a complete patient record, which is to include follow-up information in three out of three discharged records reviewed.
Client #2 was admitted on September 28, 2022 and was discharged on May 16, 2023.
Client #3 was admitted on July 28, 2017 and was discharged on January 30, 2023.
Client #4 was admitted on June 13, 2022 and was discharged on April 28, 2023
These findings were reviewed with facility staff during the licensing process.
This is a repeat citation from the June 23, 2022 licensing inspection.
|
Plan of Correction
The CEO has reviewed the citation with the management team. A new process has been established whereby the counselors will notify the administrative assistant to the CEO when a client has completed treatment. The administrative assistant will generate and mail a letter to the client informing them that follow-up services are available and contact information will be provided. The letter will be uploaded into the client record. The CEO will meet with the administrative assistant on a not less than monthly basis to ensure the requirement is being met. |