INITIAL COMMENTS
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This report is a result of an on-site licensure renewal and methadone monitoring inspection conducted on August 23, 2022 - August 24, 2022, by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, Dolminis 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 a review of three counselor assistants, the facility failed to ensure they only counseled clients under the required level of supervision appropriate to their education in all three records reviewed.Employee #7 was hired as a counselor assistant on July 5, 2022 and was current in that position at the time of the inspection. Employee #7 has a bachelor ' s degree and is required to have six months of close supervision. Close supervision is defined by regulation as follows: " Formal documented case review and an additional hour of direct observation by a supervising counselor or a clinical supervisor once a week " . Employee #7 only had documented weekly supervision on July 5, 2022, and July 13, 2022, and neither documented formal case reviews or direct observation.Employee #8 was hired as a counselor assistant on June 15, 2022 and was current in that position at the time of the inspection. Employee #8 has a bachelor ' s degree and is required to have six months of close supervision. Close supervision is defined by regulation as follows: " Formal documented case review and an additional hour of direct observation by a supervising counselor or a clinical supervisor once a week " . Employee #8 only had documented weekly supervision on June 16, 2022, June 23, 2022, June 29, 2022, July 7, 2022, and July 12, 2022. There was no documented formal case reviews or direct observation during those supervision sessions.Employee #9 was hired as a counselor assistant on January 3, 2022 and was current in that position at the time of the inspection. Employee #9 has a bachelor ' s degree and is required to have six months of close supervision. Close supervision is defined by regulation as follows: " Formal documented case review and an additional hour of direct observation by a supervising counselor or a clinical supervisor once a week " . Employee #9 had documented weekly supervision from January 6, 2022 - May 26, 2022, there were two documented formal case reviews and only forty minutes of documented direct observation. These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
An excel spreadsheet has been developed to track supervision of counselor assistants. The spreadsheet includes the initials of the clients discussed/formal case reviews, the date and the length of time the direct observation took place. The clinical supervisor will add this information to the clinical supervision note that is completed weekly.
Executive director will review the supervision spreadsheet bi-weekly and the supervision notes monthly to ensure that 60 minutes of direct observation is completed weekly and case reviews are being discussed during this time.
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705.23 (3) LICENSURE Counseling or activity areas and office space
705.23. Counseling or activity areas and office space.
The nonresidential facility shall:
(3) Ensure privacy so that counseling sessions cannot be seen or heard outside the counseling room. Counseling room walls shall extend from the floor to the ceiling.
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Observations
Based on a physical plant inspection on August 24, 2022, the facility failed to ensure privacy so that counseling sessions cannot be seen or heard outside the counseling room. There was a camera located in group room #6 on the outpatient side of the facility.These findings were reviewed with facility staff during the licensing process. This is a repeat citation from an inspection conducted on July 20, 2021.
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Plan of Correction
A maintenance ticket has been submitted to remove the non-operative camera in the front group room.
Director will monitor to ensure non-operative camera is removed by 9/16/22.
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705.24 (5) LICENSURE Bathrooms.
705.24. Bathrooms.
The nonresidential facility shall:
(5) Ventilate bathrooms by exhaust fan or window.
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Observations
Based on a physical plant inspection on August 24, 2022, the facility failed to ventilate bathrooms by exhaust fan or window.The fan inside the bathroom located in the CRS office hallway did not have a working exhaust fan.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
A maintenance ticket has been submitted to repair or replace the exhaust fan in the employee restroom.
Director will monitor to ensure fan is in operative condition by 9/16/22. Director will monitor monthly during the facility walk-thru to ensure all restroom exhaust fans are operative.
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705.28 (d) (4) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(4) Maintain a written fire drill record including the date, time, the amount of time it took for evacuation, the exit route used, the number of persons in the facility at the time of the drill, problems encountered and whether the fire alarm or smoke detector was operative.
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Observations
Based on a review of fire drill logs from July 2021 to June 2022, the facility failed to maintain a written fire drill record including the exit route used on one fire drill log reviewed.The facility failed to include the exit used on the fire drill log dated October 22, 2021.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Beginning with the monthly fire drill in September 2022 all exit doors utilized during routine fire drills will be added to the Fire Drill Evaluation Form.
Executive director will review the Fire Drill Evaluation Form monthly to ensure that all means of egress utilized have been documented.
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705.28 (d) (6) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(6) Conduct fire drills on different days of the week, at different times of the day and on different staffing shifts.
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Observations
Based on a review of fire drill logs from July 2021 to June 2022, the facility failed to conduct fire drills on different staffing shifts.All documented fire drills were conducted during the first shift. The outpatient activity is open during the evening and no fire drills were conducted during those later hours. These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Beginning in September, the Facility Risk Leader will be responsible for conducting a fire drill bi-monthly during 2nd shift.
The Fire Drill Evaluation Form will be completed and monitored monthly by the facility risk leader and reviewed by the facility management team to ensure fire drills are being conducted during different shifts.
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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.
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Observations
Based on a review of fourteen client records, the facility failed to obtain an informed and voluntary consent from one client for the disclosure of information contained in the client record.Client #9 was admitted to the outpatient activity on September 23, 2021 and was current at the time of the inspection. Client #9 switched funding sources on December 22, 2021, however an informed and voluntary consent was not documented for the new funder until June 8, 2022. The facility staff acknowledged that billing was occurring during that time period. These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
On 9/22/22 clinical supervisor and executive director will review confidentiality regulations and the expectation concerning the completion of informed consents according to regulations. Billing specialist is now emailing counselors, administrative assistant and clinical supervisor with all funding changes to alert staff that a new consent needs to be obtained.
Clinical supervisor and lead counselors will monitor consents when signing off on the level of care assessment and during weekly/monthly chart reviews.
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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.
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Observations
Based on a review of seven narcotic treatment program patients, the facility failed to complete an annual physical examination by the narcotic treatment program that included an annual reevaluation by the narcotic treatment physician in one record reviewed. Patient #7 was admitted on October 17, 2017 and discharged on May 25, 2022. There was not documentation in the client record that the March 4, 2022 annual physical examination by the program that included an annual reevaluation by the narcotic treatment physician was completed.These findings were reviewed with facility staff during the licensing process. This is a repeat citation from an inspection conducted on July 20, 2021.
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Plan of Correction
Annual physicals are being tracked on the counselor caseload tracker to assist clinical staff in monitoring of annual physical due dates.
The CRNP who is responsible for completing annual evaluations will email the counselor and clinical supervisor daily a list of all clients who did not attend their scheduled annual appointment. This will assist in ensuring that the appointment gets re-scheduled and re-scheduled in a timely manner. Once the annual physical has been completed, the counselor will mark it as complete on the caseload grid.
Clinical supervisor and lead counselors will monitor for completion of annual physicals during monthly supervision and chart reviews.
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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.
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Observations
Based on a review of seven narcotic treatment program patient records, the facility failed to ensure that the patient's counselor completed an annual evaluation and included the areas of employment, legal standing, substance abuse, financial management abilities, physical and emotional health, fulfillment of treatment objectives, and family and community support in one record reviewed. Patient #7 was admitted on October 17, 2017 and discharged on May 25, 2022. The annual evaluation was due March 4, 2022 but was not documented in the record at the time of the inspection. These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Annual evaluations are being tracked on the counselor caseload tracker to assist clinical staff in monitoring of annual evaluation due dates.
Clinical supervisor and lead counselors will continue to monitor for timely completion of annual evaluations during monthly supervision and chart reviews.
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715.23(d)(2) LICENSURE Patient records
(d) A narcotic treatment program shall prepare a treatment plan that outlines realistic short and long-term treatment goals which are mutually acceptable to the patient and the narcotic treatment program.
(2) The narcotic treatment physician or the patient 's counselor shall review, reevaluate, modify and update each patient 's treatment plan as required by Chapters 157, 709 and 711 (relating to drug and alcohol services general provisions; standards for licensure of freestanding treatment activities; and standards for certification of treatment activities which are a part of a health care facility).
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Observations
Based on a review of seven narcotic treatment program patient records, the facility failed to prepare a treatment plan that outlines realistic short and long-term treatment goals which are mutually acceptable to the patient and the narcotic treatment program in one record reviewed.Patient #1 was admitted on July 15, 2022 and was current at the time of the inspection. According to facility policy patient #1 was due to have a comprehensive treatment plan within fourteen calendar days of arrival. There was no documentation of a treatment plan in the patient record at the time of the inspection. These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
During treatment team on 9/22/22 clinical supervisor and director will review importance of documenting when clients do not show for or cancel scheduled appointments causing the treatment plan to be late. Staff will also be reminded to document when the treatment plan was completed with client via telehealth and then sent to client for signature and not returned. Implementation of motivational contracts, completion of call logs when engagement attempts are made and adding information regarding lack of engagement to clients treatment plan will also be reviewed.
Clinical supervisor and lead counselors will monitor for timely completion of treatment plans and/or documentation of missed appointments and attempts at client engagement during monthly supervision and chart reviews.
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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:
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Observations
Based on a review of seven outpatient client records, the facility failed to develop individual treatment and rehabilitation plans with a client at all and two within the facility ' s policy time frame of fourteen days within admission, in three records reviewed. Client #11 was admitted on May 12, 2022 and discharged June 27, 2022. Client #11 did not have an individual treatment and rehabilitation plan developed during their time as a client at the facility.Client #12 was admitted on November 29, 2021 and discharged on February 14, 2022. Client #12 was to have an individual treatment and rehabilitation plan developed by December 13, 2021; however, it was not developed until December 15, 2021.Client #14 was admitted on December 30, 2021 and discharged March 10, 2022. Client #14 was to have an individual treatment and rehabilitation plan developed by January 13, 2022; however, one was not developed until January 19, 2022. These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
During treatment team on 9/22/22 clinical supervisor and director will review importance of documenting when clients do not show for or cancel scheduled appointments causing the treatment plan to be late. Staff will also be reminded to document when the treatment plan was completed with client via telehealth and then sent to client for signature and not returned. Implementation of motivational contracts, completion of call logs when engagement attempts are made and adding information regarding lack of engagement to clients treatment plan will also be reviewed.
Clinical supervisor and lead counselors will monitor for documentation of missed appointments and attempts at client engagement during monthly supervision and chart reviews.
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709.92(c) LICENSURE Treatment and rehabilitation services
709.92. Treatment and rehabilitation services.
(c) The project shall assure that counseling services are provided according to the individual treatment and rehabilitation plan.
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Observations
Based on a review of seven outpatient client records, the facility failed to assure that counseling services are provided according to the individual treatment and rehabilitation plan in three records reviewed.Client #10 was admitted on July 20, 2022 and was still current at the time of the inspection. Client #10 ' s individual treatment and rehabilitation plan dated July 22, 2022, indicated the client should receive three group sessions a week and two individual sessions a week. Client #10 did not have any documented individual sessions for the week of July 31, 2022 - August 6, 2022.Client #13 was admitted on June 6, 2022 and was discharged on July 11, 2022. Client #13 ' s individual treatment and rehabilitation plan dated June 14, 2022, indicated the client should receive one group session weekly and individual sessions biweekly. Client #13 did not have any documented individual sessions for the week of June 26, 2022 - July 2, 2022.Client #14 was admitted on December 30, 2021 and discharged March 10, 2022. Client #14 ' s individual treatment and rehabilitation plan dated January 19, 2022, indicated three group sessions a week and individual sessions biweekly. Client #14 did not have any documented individual sessions for the week of February 13, 2022 - February 19, 2022. These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
During treatment team on 9/22/22 clinical supervisor and director will review the importance of documenting when clients do not show for or cancel scheduled appointments and the importance of completing call logs when engagement attempts are made.
Clinical supervisor and lead counselors will monitor for documentation of missed appointments and attempts at client engagement during monthly supervision and chart reviews.
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