INITIAL COMMENTS
|
This report is a result of an on-site licensure renewal inspection conducted on April 25-26, 2017 by staff from the Department of Drug and Alcohol Programs, Bureau of Quality Assurance for Prevention and Treatment, Program Licensure Division. Based on the findings of the on-site inspection, The Consortium 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
|
704.11(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
Based on a review of personnel records, the facility failed to ensure that employee #13 received the minimum of 6 hours of HIV/AIDS training and 4 hours of TB/STD training within the regulatory timeframe. Employee #13 was hired as counselor on 11/02/15 and was due to have HIV/AIDS training and TB/STD training no later than 11/02/16. There was no documentation of the completion of the HIV/AIDS and TB/STD trainings as of the date of the inspection.
The findings were discussed with facility staff during the licensing process.
|
Plan of Correction
Employee #13 will have the required HIV/AIDS and TB/STD training by 7/30/17.
Responsible Party(s):
The Supervisors are responsible for ensuring that all direct reports receive a minimum of 6 hours of HIV/AIDS training and at least 4 hours of TB/STD and other health related topics training within the regulatory timeframe.
Ongoing Monitoring: The Supervisors will schedule all new staff for the HIV/AIDS and TB/STD required training within 365 days of hire.
|
704.11(c)(3) & (4) LICENSURE Training types and amounts
704.11. Staff development program.
(c) General training requirements.
(3) At least one-half of all training in this section shall be provided by trainers not directly employed by the project unless the project employs staff persons specifically to provide training for its organization and staff.
(4) An individual who holds more than one position in a facility shall meet the training requirement hours set forth for the individual's primary position. Subject areas shall be selected according to the individual's training plan. Primary position is defined as that position for which an individual was hired.
|
Observations
Based on a review of personnel records, the facility failed to ensure that 2 employees received at least one-half of training provided by an external trainer, for the project ' s 1/1/2016 through 12/31/2016 training year. The project does not employ staff members specifically for training.
Employee # 4 was hired as a counselor. This employee only received 10.5 external hours. They were required to receive at least 12.5 hours.
Employee # 12 was hired as a counselor. This employee only received 10.25 external hours. They were required to receive at least 12.5 hours.
The findings were discussed with facility staff during the licensing process.
|
Plan of Correction
All staff will be scheduled for external training for at least one half of their annual required training hours.
Responsible Party:
Supervisors will be responsible for ensuring that their respective staff attend at least one half of their annual training hours by an external provider.
Ongoing Monitoring:
Each supervisor will monitor their respective staff's training hours each month to ensure they are receiving training from outside sources. This will be reviewed in monthly supervision.
|
704.11(d)(2) LICENSURE Annual Training Requirements
704.11. Staff development program.
(d) Training requirements for project directors and facility directors.
(2) A project director and facility director shall complete at least 12 clock hours of training annually in areas such as:
(i) Fiscal policy.
(ii) Administration.
(iii) Program planning.
(iv) Quality assurance.
(v) Grantsmanship.
(vi) Program licensure.
(vii) Personnel management.
(viii) Confidentiality.
(ix) Ethics.
(x) Substance abuse trends.
(xi) Developmental psychology.
(xii) Interaction of addiction and mental illness.
(xiii) Cultural awareness.
(xiv) Sexual harassment.
(xv) Relapse prevention.
(xvi) Disease of addiction.
(xvii) Principles of Alcoholics Anonymous and Narcotics Anonymous.
|
Observations
Based on a review of the personnel records, the facility failed to document the completion of 12 clock hours of annual training required for the project director as of the date of the inspection.
Employee #1 was hired as the project director on 12/3/01 and was still in that position at the time of inspection. The facility's training year that was reviewed was from 01/01/16 through 12/31/16. The record for employee #1 only included documentation of 9 hours of annual training for the training year reviewed.
These findings were reviewed with facility staff during the licensing process
|
Plan of Correction
The Project Director will ensure attendance in training to meet the annual training requirement of 12 hours.
Responsible Party: The Project Director is responsible for ensuring that he receives at least 12 clock hours of training by December 31st of each year.
Ongoing Monitoring: The Training Director will register the Project Director for at least one training per month.
|
704.11(f)(2) LICENSURE Trng Hours Req-Coun
704.11. Staff development program.
(f) Training requirements for counselors.
(2) Each counselor shall complete at least 25 clock hours of training annually in areas such as:
(i) Client recordkeeping.
(ii) Confidentiality.
(iii) Pharmacology.
(iv) Treatment planning.
(v) Counseling techniques.
(vi) Drug and alcohol assessment.
(vii) Codependency.
(viii) Adult Children of Alcoholics (ACOA) issues.
(ix) Disease of addiction.
(x) Aftercare planning.
(xi) Principles of Alcoholics Anonymous and Narcotics Anonymous.
(xii) Ethics.
(xiii) Substance abuse trends.
(xiv) Interaction of addiction and mental illness.
(xv) Cultural awareness.
(xvi) Sexual harassment.
(xvii) Developmental psychology.
(xviii) Relapse prevention.
(3) If a counselor has been designated as lead counselor supervising other counselors, the training shall include courses appropriate to the functions of this position and a Department approved core curriculum or comparable training in supervision.
|
Observations
Based on a review of the personnel records, the facility failed to document the completion of 25 clock hours of annual training required for 3 employees for the training year 01/01/16 through 12/31/16.
Employee #6 was hired as a counselor on 3/4/01 and was still in that position at the time of inspection. The record for employee #6 only included documentation of 20.5 hours of annual training for the training year reviewed.
Employee #14 was hired as a counselor on 3/12//01 and was still in that position at the time of inspection. The record for employee #14 only included documentation of 18.5 hours of annual training for the training year reviewed.
Employee #15 was hired as a counselor on 8/22/11 and was still in that position at the time of inspection. The record for employee #15 only included documentation of 13.5 hours of annual training for the training year reviewed.
These findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
Each counselor will attend at least 2 hours of training each month in an attempt to meet the annual requirement of 25 clock hours.
Responsible Party: The Clinical Supervisor is responsible for ensuring that all counselors receive 25 hours of training per year.
Ongoing Monitoring: The Clinical Supervisors will review the status of each of their respective counselors while in supervision each month.
|
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.
|
Observations
Based on the physical plant inspection that was conducted on April 26, 2017 at approximately 9:30 am, the facility failed to ensure that the facility's client entrance door (near the reception area) was maintained in a functioning manner as the door was not able to be properly opened and closed with ease. The entrance door appeared to not fit its frame properly.
These findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
The facility's client entrance door
(near the reception area, which did not properly and easily open and close, will be repaired by 6/15/17. Additionally, the frame will be repaired by 6/15/17.
Responsible Party(s: The Facilities Department is responsible for ensuring that the grounds of the facility are maintained in a clean, safe, and sanitary manner, including the assurance that all doors work properly.
Ongoing Monitoring: Facilities Staff will monitor grounds and document daily rounds to ensure all issues are addressed in a timely manner
|
705.24 (7) LICENSURE Bathrooms.
705.24. Bathrooms.
The nonresidential facility shall:
(7) Maintain each bathroom in a functional, clean and sanitary manner at all times.
|
Observations
Based on the physical plant inspection that was conducted on April 26, 2017 at approximately 9:30 am, the facility failed to ensure that the bathroom near the dosing area, where clients provide urine samples, was maintained in a functioning manner as the door was not able to be properly opened and closed with ease. The door appeared to not fit its frame properly.
These findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
The door of the bathroom near the dosing area, where clients provide urine samples, which was found to have a door that did not open and close with ease will be repaired by 6/15/17. Additionally,the door frame will be repaired by 6/15/17.
Responsible Party:
The Facilities Department is responsible for maintaining each bathroom in a functional, clean and sanitary manner at all times and for ensuring that all bathroom doors work properly.
Ongoing Monitoring:
Facilities Staff will ensure that all bathroom doors open and close with ease as part of their daily rounds.
|
705.26 (2) LICENSURE Heating and cooling.
705.26. Heating and cooling.
The nonresidential facility:
(2) May not permit in the facility heaters that are not permanently mounted or installed.
|
Observations
Based on the physical plant inspection on April 26, 2017 at approximately 9:30 A.M., the facility failed to ensure that all heaters in the facility were permanently mounted or installed. A space heater was found in nursing office room 109 and in room 5 in the basement.
The findings were reviewed with facility staff during the licensing inspection.
|
Plan of Correction
The two non-permanently mounted space heaters discovered in Rooms #5 and 109 have been removed as of 4/26/17.
Responsible Party:
The Facilities staff is responsible for removing space heaters observed on the interior facility grounds.
Managers are responsible for ensuring that all staff are aware that heaters that are not permanently mounted or installed are prohibited from being on the facilities grounds.
Ongoing Monitoring: The facilities Department will ensure daily checks for space heaters as part of daily rounds.
|
709.26 (b) (3) LICENSURE Personnel management.
§ 709.26. Personnel management.
(b) The personnel records must include, but are not limited to:
(3) Annual written individual staff performance evaluations, copies of which shall be reviewed and signed by the employee.
|
Observations
Based on a review of personnel records the facility failed to ensure that employee #1 ' s personnel record contained documentation of an annual written individual performance evaluation. Employee # 1 was hired as the Project Director on 12/3/01. The last documented evaluation was for the 2014-2015 year.
These findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
Employee #1's personnel record will contain documentation of an annual written individual performance evaluation by 5/31/17.
Responsible Party: The Board of Directors is responsible for ensuring that an annual evaluation is completed for employee #1.
Currently,the Board has approved that employee #1 have an evaluation completed every 2 years.
The Licensing Director will submit an exception to DDAP requesting a waiver for the evaluation to be completed every 2 years, instead every year. If its the case that the exception request is not approved by DDAP, the Board will be made aware that they must complete the evaluation annually for employee #1.
Additionally, the annual evaluation covering January 1, 2016 to December 31, 2016 will be completed by June 30, 2017.
The HR Department is responsible for ensuring that all employees have an annual performance plan completed as required.
Ongoing Monitoring: The HR Department will review receipt of all performance plans as indicated by the employee's evaluation schedule. |
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.
|
Observations
Based on a physical plant inspection conducted on April 26, 2017 at approximately 11:30 am, the facility failed to ensure that all hard copy patient records were kept in locked storage containers and that there was no ability of unauthorized persons to gain access to such records in Rooms 8 (located in the basement). This room was being utilized to store discharged patient charts that were going to be stored/destroyed by an outside agency; however, there were maintenance supplies also located in the rooms, which would allow unauthorized persons access to the records.
These findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
Room #8 will have all files removed and archived off site by 6/15/17. The program is requesting 30 days to ensure that the archiving process is in compliance for the pickup.
Responsible Party:
The Medical Records and Facilities Staff are responsible for ensuring that all records are stored in locked containers with no access to unauthorized persons.
Ongoing Monitoring: The Medical Records staff will ensure that all files are secured as required or archived off site as documented in the agency policy.
|
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
Based on the review of client records, the facility failed to document an informed and voluntary consent to release information form prior to the disclosure of information in 5 of 14 client records. Additionally, 2 of 14 client records had consent to release forms that were missing the specific information to be released, the purpose of the disclosure, and/or client signature.
Client #1 was admitted on 11/1/12 and was still an active client at the time of the inspection. There was documentation that urinalysis tests were conducted and the results were received and there was documentation that the facility was billing the funding source; however, there were no proper consent to release information forms signed by the client after 10/2015.
Client #2 was admitted on 3/9/17 and was still an active client at the time of the inspection. There was a consent to release form signed and dated on 2/23/17 to another treatment provider, but the consent failed to include the purpose of disclosure.
Client #3 was admitted on 1/18/17 and was still an active client at the time of the inspection. A facsimile was sent on 3/8/17 to the court system however, there was no proper consent to release information form signed by the client prior to disclosure.
Client #5 was admitted on 10/10/14 and was still an active client at the time of the inspection. A facsimile was sent on 3/16/17 to a hospital however, there was no proper consent to release information form signed by the client prior to disclosure.
Client #6 was admitted on 3/6/13 and was still an active client at the time of the inspection. There was a consent to release form signed and dated on 2/22/17 to another treatment provider, but the consent failed to include the client signature. Additionally, there was a consent to release form signed and dated on 1/10/17 that had " other " checked but did not include specific information to be disclosed.
Client #7 was admitted on 3/12/04 and was still an active client at the time of the inspection. All consent to release forms documented in the record expired 4/6/16. No updated consent to release forms were documented at the time of the inspection.
Client #10 was admitted on 10/22/12 and was discharged on 2/23/17. All consent to release forms documented in the record expired 10/14/16. No updated consent to release forms were documented at the time of the inspection.
The findings were reviewed with facility staff during the licensing inspection.
|
Plan of Correction
Staff will be retrained on the documentation of informed and voluntary consent to release information form prior to the disclosure of information by 6/15/17.
Consents for chart #1,2,3,5,6,7, and 10 will be updated by 5/30/17.
Responsible Party(s): Counselors are responsible for ensuring that all consents are updated within the required time frames.
Supervisors are responsible for ensuring that all consents are completely and accurately filled out.
Medical records will be responsible for faxing out documentation and will ensure an active release is in place prior to sending out to external parties.
Ongoing Monitoring: Supervisors will increase monitoring of deadlines for all releases of information.
Additionally supervisors will increase review of all consents submitted to them to ensure all elements are completely filled out. |
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 the review of the physician timesheets for the months of January through April, the facility failed to provide at least one hour of physician time a week, on site for every ten patients during the months of January and February.
During the week of January 15, 2017, the patient census was 292. The facility was required to provide at least 29.2 physician hours. There were 23 physician hours documented.
During the week of February 5, 2017, the patient census was 291. The facility was required to provide at least 29.1 physician hours. There were 25 physician hours documented.
During the week of February 19, 2017, the patient census was 283. The facility was required to provide at least 28.3 physician hours. There were 27.5 physician hours documented.
These findings were reviewed with facility staff during the licensing inspection.
|
Plan of Correction
The Medical Director will ensure that time scheduled off or out, is covered by another physician.
Responsible Party: The Medical Director is responsible for ensuring that there are sufficient physician hours to maintain at least 1 hour per week onsite for every ten patients in relation to the weekly census.
Ongoing Monitoring: The Chief Medical Officer will supply a schedule monthly to account for absences and scheduled off time to maintain adequate coverage
|
715.11 LICENSURE Confidentiality of patient records
A narcotic treatment program shall physically secure and maintain the confidentiality of all patient records in accordance with 42 CFR 2.22 (relating to notice to patients of Federal confidentiality requirements) and § 709.28 (relating to confidentiality).
|
Observations
During a physical plant inspection on April 26, 2017 at approximately 9:30 A.M., it was observed that Client-identifying information was easily accessible in Room 233 (2nd floor staff printer room), as 10 individual client ' s group notes were sitting on the table with the door open and no one present.
These findings were reviewed with facility staff during the licensing inspection.
|
Plan of Correction
The door for room 203 will be locked at all times to ensure that all information in the copy room is secured and is not accessible by unauthorized staff and/or clients. Authorized staff will be provided with a key to enter the room.
Responsible Party: All staff is responsible for ensuring that the door to room 233 is securely locked at all times.
Ongoing Monitoring: The Facilities staff will check that the door to room 233 is locked at all times as a part of their daily rounds.
|
715.28(c)(1-5) LICENSURE Unusual incidents
(c) A narcotic treatment program shall file a written Unusual Incident Report with the Department within 48 hours following an unusual incident including the following:
(1) Complaints of patient abuse (physical, verbal, sexual and emotional).
(2) Death or serious injury due to trauma, suicide, medication error or unusual circumstances.
(3) Significant disruption of services due to a disaster such as a fire, storm, flood or other occurrence.
(4) Incidents with potential for negative community reaction or which the facility director believes may lead to community concern.
(5) Drug related hospitalization of a patient.
|
Observations
Based on the review of the facility's unusual incident reports on April 25-27, 2017, the facility failed to notify the Department within 3 business days following the unusual incidents below, which were discovered during the licensing process.
The incident dates and incident reason are:
January 27, 2017 - Ambulance presence requested
February 17, 2017 - Ambulance presence requested
February 27, 2017 - Police presence requested
March 13, 2017 - Disruption of service
March 24, 2017 - Police presence requested
April 6, 2017 - Ambulance and police presence requested (3 separate incidents)
April 7, 2017 - Ambulance presence requested
April 27, 2017 - Patient's (offsite) death
These findings were reviewed with project and facility staff during the licensing process.
|
Plan of Correction
All unusual incidents will be faxed to the Department within 3 days of the incident by the Administrative Supervisors.
Responsible Party: All staff is responsible for documenting unusual incidents occurring that they are a witness to.
Staff is responsible to submit the incident report to the Administrative Supervisor within 24 hours.
The administrative supervisor, or designee is responsible for ensuring that the department receives a faxed copy of the incident within 48 hours of the incident.
Ongoing Monitoring: The Division Director will be notified via email or phone of all incidents and ensure that the Administrative Supervisor submits them to the Department within 48 hours of the incident
|
709.91(b)(6) LICENSURE Intake and admission
709.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(6) Psychosocial evaluation.
|
Observations
Based on a review of client records, the facility failed to document a psychosocial evaluation in 2 of 4 client records.
Client #2 was admitted on 3/9/17 and was still an active client at the time of the inspection.
Client #12 was admitted on 09/15/16 and was discharged 3/15/17.
These findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
Client chart #2 will be reviewed by 5/19/17. If psycho social evaluation is still deficient, it will be completed by 5/19/17.
Responsible Party: Clinical Supervisor is responsible for ensuring that psycho social evaluations are completed within 30 days of admission of each client.
Ongoing Monitoring: Supervisor will ensure that they utilize the internal documentation tracking system to track timelines. Timelines will be discussed in monthly supervision.
|
709.17(a)(3) LICENSURE Subchapter B.Licensing Procedures.Refusal/rev
709.17. Refusal or revocation of license.
(a) The Department may revoke or refuse to issue a license for any of the following reasons:
(3) Failure to comply with a plan of correction approved by the Department, unless the Department approves an extension or modification of the plan of correction.
|
Observations
Based on the physical plant inspection that was conducted on April 26, 2017 at approximately 9:30 am and a review of areas of noncompliance identified during this licensing inspection that had previously been cited, the facility failed to comply with prior plans of correction approved by the Department, as evidenced by not ensuring that the roof of the facility would be in good repair at all times.
1.There were active water leaks in the facility, which were coming from different sections of the facility's roof that haven't been completely replaced/repaired as of the date of the inspection. This was verbally confirmed by maintenance personnel during the physical plant inspection. Because of the roof leaks, water was actively leaking into a closet (near room 232) and room 207 (both on the second floor).
As a result of the leak in the closet, there was missing ceiling tiles exposing the studs in the ceiling, and the water was observed to be dripping into a large trash container. As a result of the leak in room 207, there was a wet and stained ceiling tile. The water leaking through the roof to the second-floor ceilings creates the possibly of causing an electrical fire among the various wiring located within the ceilings/floors of the facility.
This is a repeat citation from prior licensing renewal inspections.
These findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
Active water leaks caused by the facility's roof will be repaired by 6/30/17. Once completed all ceiling tiles will be placed over open areas where ceiling tile is currently missing. All water damaged ceiling tiles will be replaced as well. All roofing and ceiling tile work will be completed by 6/30/17.
Responsible Party: The Facilities Staff is responsible for ensuring that the roof is repaired as needed.
Ongoing Monitoring:
The Facilities Staff will ensure that the roof and ceiling tiles are assessed as a part of their daily rounds.
|