INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection and complaint investigation conducted on November 15 - 16, 2021 by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. The allegations pertaining to the complaint investigation were unable to be substantiated. Based on the findings of the on-site licensure renewal inspection, Angel's Light Addiction Specialists 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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704.6(b) LICENSURE Qualification Groups
704.6. Qualifications for the position of clinical supervisor.
(b) A clinical supervisor shall meet at least one of the following groups of qualifications:
(1) A Master's Degree or above from an accredited college with a major in medicine, chemical dependency, psychology, social work, counseling, nursing (with a clinical specialty in administration or the human services) or other related field and 2 years of clinical experience in a health or human service agency which includes 1 year of working directly with the chemically dependent.
(2) A Bachelor's Degree from an accredited college with a major in chemical dependency, psychology, social work, counseling, nursing (with a clinical specialty in administration or the human services) or other related field and 3 years of clinical experience in a health or human service agency which includes 1 year of working directly with the chemically dependent person.
(3) An Associate Degree from an accredited college with a major in chemical dependency, psychology, social work, counseling, nursing (with a clinical specialty in administration or the human services) or other related field and 4 years of clinical experience in a health or human service agency which includes 1 year of working directly with the chemically dependent person.
(4) 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 and 3 years of clinical experience in a health or human service agency which includes 1 year of working directly with the chemically dependent person. The individual shall also complete a Department approved core curriculum training which includes a component on clinical supervision skills.
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Observations
Based on a review of personnel records, the facility failed to document the clinical supervisor met the qualifications for the position.
Employee # 2 was promoted to the position of clinical supervisor on January 1, 2021. At the time of the promotion, employee # 2 had an Associate degree in a related field but did not have the required four years of clinical experience. Employee # 2 only had three years of clinical experience documented.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
A standard resume/application has been developed that assesses candidates clinical experience prior to employment at Angels Light Addiction Specialists to ensure compliance with DDAP guidelines.
The Project Director is responsible for maintenance of HR files and compliance of position qualifications.
The project director will audit all employee files on a quarterly basis.
Employee #1 completed AAS degree in human services, however, did not have the time required for the title of Clinical Supervisor.
The degree with her experience now qualifies her to hold the position of Lead counselor, until she meets qualifications for the position of Clinical Supervisor in 1/2022.
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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.
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Observations
Based on a review of personnel records, the facility failed to document HIV/AIDS training in three of six personnel records.
HIV/AIDS training was not documented for the following employees:
Employee # 3 is a counselor and was hired February 1, 2020.
Employee # 4 is a counselor and was hired March 13, 2020.
Employee # 8 is support staff and was hired July 31, 2019.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Employees #3, #4, and #8 will be participating in an in-house training on 12-21-2021 that will be conducted by our MD. Once they complete this training, a copy of the certificate will be available in their personnel file. From 12/1/21 on, human resources have been checking employee files to make sure all other non-clinical staff completes the 6-hour Basic HIV training within their first two years of employment, and one year for the clinical staff. All future hires at Angels Light Addiction Specialists will receive all mandatory trainings in the required time frame as specified in DDAP regulations. |
704.11(c)(2) LICENSURE CPR CERTIFICATION
704.11. Staff development program.
(c) General training requirements.
(2) CPR certification and first aid training shall be provided to a sufficient number of staff persons, so that at least one person trained in these skills is onsite during the project's hours of operation.
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Observations
Based on a review of staff schedules and an interview with the project/facility director, the project failed to document first aid training for a sufficient number of staff persons, so that at least one person trained in these skills was available during the project's hours of operation.
The facility provides residential treatment twenty-four hours per day, seven days per week.
No staff with first aid training were onsite during the following dates and times:
August 29, September 11, September 12 and September 25, 2021 - 7 AM - 9 AM
August 30, September 3, September 13 and September 17, 2021 - 8 PM - 11 PM
August 31, September 5, September 14 and September 21, 2021 - 5 PM - 11 PM
September 1, September 11 and September 15, 2021 - 10 PM - 11 PM
September 5 and September 19, 2021 - 11 PM - 7 AM
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Following the survey, tech schedules were revised to ensure that all shifts currently have trained staff with CPR/First Aid credentials will accompany the staff that are awaiting training. Project Director and Clinical Supervisor will secure certified training for CPR/First Aid for all inpatient staff who are not currently trained in these areas. As new hires occur throughout the agency, additional training's will be scheduled to ensure that all appropriate staff have CPR/First Aid training within the first 90 days.
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705.10 (d) (1) LICENSURE Fire safety.
705.10. Fire safety.
(d) Fire drills. The residential facility shall:
(1) Conduct unannounced fire drills at least once a month.
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Observations
Based on a review of fire drill records, the facility failed to document a fire drill for September 2021.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Administrative Assistant and Project Director will ensure that the fire drills are being completed monthly with all fire drill reports and logs to verify times and dates of the random drills. These fire drills will be reviewed monthly by the Administrative Assistant and the Project Director. This has been in effect immediately after DDAP exit interview on 11/16/2021.
This binder is located in a central location of the facility for staff accessibility. (File room) |
705.10 (d) (4) LICENSURE Fire safety.
705.10. Fire safety.
(d) Fire drills. The residential 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 records, the facility failed to document the time of the drill, the exit route used and whether or not the fire alarm or smoke detector was operative.
The time of the drill was not documented for the drills conducted in the following months: March 2021 and October 2021.
The exit route used was not documented for the drills conducted in the following months: November 2020, December 2020 and March 2021.
The following fire drills did not include documentation of whether or not the fire alarm or smoke detector was operative: November 2020, December 2020 and March 2021.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Administrative Assistant and Project Director will ensure that the fire drills are being completed monthly with all fire drill reports and logs to verify times and dates of the random drills. These fire drills will be reviewed monthly by the Administrative Assistant and the Project Director. Included in the fire drill, there will be specific, and detailed information provided. Times, exit routes, and whether there was a smoke detector or fire alarm was operative at the time of the drill MUST be included in the report each month. |
709.28 (c) (2) 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. The consent must be in writing and include, but not be limited to:
(2) Specific information disclosed.
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Observations
Based on a review of client records, the facility exceeded the limitations imposed at 4 Pa. Code 255.5 when documenting the specific information disclosed to a government agency on the consent to release information form in one of seven client records.
Client # 1 was admitted October 28, 2021. A consent to release information form dated November 5, 2021 documented the following information would be released to a government agency exceeding 4 Pa. Code 255.5: third party payor/funding information and psychosocial/psychiatric evaluations.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
All Counselors have been met with by the Project Director and had a group meeting with Lead Counselor to review Confidentiality and Pa 255.55, and what all is permitted to be disclosed on the consent to release information. *(5 points).
All Clinical staff have been trained in Confidentiality but will be participating in an in-house Confidentiality training on 1-5-2022 to review materials.
Clinical Supervisor will be continuing to complete supervision and quality assurance that this will not occur in the future. She will also be conducting random chart audits to ensure compliance. Counselors will also complete quarterly peer chart reviews and discuss in clinical staff meetings. |
709.28 (d) LICENSURE Confidentiality
§ 709.28. Confidentiality.
(d) A copy of a client consent shall be offered to the client and a copy maintained in the client record.
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Observations
Based on a review of client records and client handbook/orientation materials, the facility failed to document a copy of the client consent was offered to the client in five of seven records.
Consents to release information were completed during the intake process and did not include documentation the client was offered a copy of these consents.
Client # 1 was admitted October 28, 2021.
Client # 2 was admitted November 9, 2021 and discharged November 11, 2021.
Client # 3 was admitted November 3, 2021.
Client # 4 was admitted September 14, 2021.
Client # 7 was admitted May 21, 2021 and discharged June 9, 2021.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Program director and Clinical Supervisor have revised the client consent. The consent will be offered to the client, and whether they refused or accepted it, and a copy maintained in the client record. Effective immediately. This will be reviewed in the clinical staff meeting.
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709.30 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.
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Observations
Based on a review of client records and the client handbook/orientation materials, the facility failed to document clients had been notified of all of their rights in seven of seven client records.
There was no documentation that clients had been notified of the following rights:
client receiving care or treatment under section 7 of the act (71 P. S. 1690.107) shall retain civil rights and liberties except as provided by statute. No client may be deprived of a civil right solely by reason of treatment.
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.
project, facility or clinical director may temporarily remove portions of the records prior to the inspection by the client if the director determines that the information may be detrimental if presented to the client. Reasons for removing sections shall be documented in the record.
have the right to appeal a decision limiting access to their records to the director.
have the right to request the correction of inaccurate, irrelevant, outdated or incomplete information in their records.
have the right to submit rebuttal data or memoranda to their own records.
Client # 1 was admitted October 28, 2021.
Client # 2 was admitted November 9, 2021 and discharged November 11, 2021.
Client # 3 was admitted November 3, 2021.
Client # 4 was admitted September 14, 2021.
Client # 5 was admitted December 19, 2020 and discharged January 1, 2021.
Client # 6 was admitted February 23, 2021 and discharged April 12, 2021.
Client # 7 was admitted May 21, 2021 and discharged June 9, 2021.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Angels Light Addiction Specialists now provides a hard copy of the client rights document that contains all required elements to all patients at admission. The patient signs receipt of the client rights document. Staff have been instructed to review this document with all patients at admission. In addition, ALAS has posted the client rights document in the common area. Patient files are reviewed weekly by the Clinical Supervisor who monitor for compliance. The Project Director is responsible for implementation of the Client Rights procedure. |
709.32 (c) (4) (i) - (ii) LICENSURE Medication control
§ 709.32. Medication control.
(4) Methods for control and accountability of drugs, including, but not limited to:
(i) Who is authorized to remove drug.
(ii) The program ' s system for recording drugs, which includes the name of the drug, the dosage, the staff person, the time and the date.
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Observations
Based on a review of client records and medication administration records, the facility failed to document the dates and times medications were self-administered or refused by the client in two of six records.
Client # 4 was admitted September 14, 2021.
Client # 4 was prescribed Trazadone 100 mg at bedtime. The medication administration record did not indicate whether the medication was self-administered or refused by the client for the following dates: October 10 - October 13, 2021, October 15 - 18, 2021, October 22 - 24, 2021, October 25 - 28, 2021 and October 30, 2021.
Client # 4 was also prescribed Topiramate 50 mg twice per day. The medication administration record did not indicate whether the medication was self-administered or refused by the client for the following dates and times:
8 AM - October 12 - 13, 2021 and October 22 - 31, 2021.
8 PM - October 12 - 31, 2021.
Client # 6 was admitted February 23, 2021 and discharged April 12, 2021.
Client # 6 was prescribed buprenorphine 8 mg/2 mg two times per day. The medication administration record did not indicate whether the medication was self-administered or refused by the client for the following dates and times:
8 AM - April 8, 2021.
8 PM - March 1 - 2, 2021, March 13 - 21, 2021, March 23 - 27, 2021, March 29 - 31, 2021 and April 1 - 11, 2021.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Since the audit, Angel's Light has implemented utilizing only one MAR sheet from admission; duplicated MARS were removed from the med room to not duplicate medications and to ensure staff signatures were on the most recent/correct MAR.
A training will be held on 12/22/21 by the Project Director with those who observe med pass to address the blank spots on MAR sheets from the inspection charts. It will be reiterated to staff to ensure that when an individual refuses a medication that the staff marks the date with an R and circles it to show that the individual refused the medication, the importance of writing this in will be addressed during this meeting to follow DDAP regulations and suggestions from the inspection and Angel's Light policy regarding medications. |