INITIAL COMMENTS
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This report is a result of an on-site provisional license follow-up inspection conducted on May 19-20, 2021 by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, Discovery House HA 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(c) LICENSURE Core Curriculum - Supervisor Training
704.6. Qualifications for the position of clinical supervisor.
(c) Clinical supervisors and lead counselors who have not functioned for 2 years as supervisors in the provision of clinical services shall complete a core curriculum in clinical supervision. Training not provided by the Department shall receive prior approval from the Department.
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Observations
Based on a review of personnel records, the facility failed to document completion of core curriculum in clinical supervision training by the Clinical Director. The Clinical Director was promoted to the position on May 1, 2020 and as
of the date of the inspection, had not completed the required training. The clinical supervisor is scheduled to complete the training on May 24-28, 2021.
The findings were reviewed with facility staff during the licensing process. This is a repeat citation from the December 23, 2020 licensing inspection.
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Plan of Correction
Clinical Supervisor completed 30 hours of PA DDAP Clinical Supervisor Training 5/24/21-5/28/21. |
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.
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Observations
Based on a review of personnel files, the facility failed to document that each counselor met the experiential qualifications for the position.
Employee #5 was hired as a counselor on April 28, 2021 and was still in that position at the time of the inspection. The employee does not have the one-year clinical experience required with a qualifying bachelor ' s degree.
Employee #6 was hired as a counselor on May 3, 2021 and was still in that position at the time of the inspection. The employee does not have the one-year clinical experience required with a qualifying bachelor ' s degree.
The findings were reviewed with facility staff during the licensing inspection. This is a repeat
citation from the January 30, 2020 and December 23, 2020 licensing inspections.
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Plan of Correction
Plan of Correction:
Counselor #5's position will be reduced to a Counselors Assistant Position. Counselor will obtain 1 year of clinical experience (a minimum of 1,820 hours) in a drug and alcohol setting before eligibility to qualify for a full counselor position. The individual's written training plan shall specifically address a plan to achieve counseling competency in chemical dependency issues and work towards obtaining a CADC.
Counselor #6's position will be reduced to a Counselors Assistant Position. Counselor will obtain 1 year of clinical experience (a minimum of 1,820 hours) in a drug and alcohol setting before eligibility to qualify for a full counselor position. The individual's written training plan shall specifically address a plan to achieve counseling competency in chemical dependency issues and work towards obtaining a CADC.
Clinical Director will assure all clinical positions meet qualifications for a counselor position before the hiring process. Clinical Director will refer to the Department of Drug and Alcohol Program' counselor for clarity of qualifications.
Regional Director submitted exception request to staff requirements. Identified staff and CD assist with training.
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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 personnel records, the facility failed to show supervision for a counselor assistant based upon their qualifying education.
Employee #8 was hired on September 1, 2020 as a counselor and was reassigned to a counselor assistant position on January 11, 2021. The employee's bachelor's degree is non-qualifying therefore they must receive supervision as an employee with a high school diploma. There was no documentation, at the time of the inspection, that the clinical supervisor provided any direct or close supervision since the date of the position reassignment.
These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
Plan of Correction:
Counselor #8's position will remain Counselors Assistant Position. Clinical Director will assure all clinical positions meet qualifications for a counselor position before the hiring process. Clinical Director will refer to the Department of Drug and Alcohol Program' counselor for clarity of qualifications.
Staff members identified will retain the position of a counselor assistant. Counselors will continue to work towards obtainment of 1 year of clinical experience (a minimum of 1,820 hours) along with continued outside DDAP facilitated and/or approved trainings. Clinical Supervisor, Clinic Director, and Regional Director will ensure all such supervision, both direct and indirect is appropriately documented and available for review. All staff members individual written training plan will specifically address a plan to achieve counseling competency in chemical dependency issues and work towards obtaining a CADC and such will also be readily available for future review. Clinic Director, Clinical Supervisor, and Regional Director will ensure all clinical positions meet qualifications. Each counselor assistant will receive direct supervision for 3 months followed by 9 months of close supervision during group and/or individual sessions by either a trained counselor, clinical supervisor, clinical director, or regional director. Each counselor will have documentation showing supervision and observations hours. Clinic Director and Regional Director will monitor weekly to ensure supervision is being completed.
Regional Director submitted exception request to staff requirements. Identified staff and CD assist with training.
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704.10 LICENSURE Counselor Asst Promotion
704.10. Promotion of counselor assistant.
(a) A counselor assistant who satisfactorily completes one of the sets of qualifications in 704.7 (relating to qualifications for the position of counselor) may be promoted to the position of counselor.
(b) A counselor assistant shall document to the facility director that he is working toward counselor status. This information shall be documented upon completion of each calendar year.
(c) A counselor assistant shall meet the requirements for counselor within 5 years of employment. A counselor assistant who has accumulated less than 7,500 hours of employment during the first 5 years of employment will have 2 additional years to meet the requirements for counselor.
(d) A counselor assistant who cannot meet the time requirements in subsection (c) may submit to the Department a written petition requesting an exception. The petition shall describe the circumstances that make compliance with subsection (c) impracticable and shall be approved by both the clinical supervisor or lead counselor and the project director. Granting of the petition will be within the discretion of the Department.
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Observations
Based on the review of personnel records, the facility failed to show documentation that a counselor assistant was working toward counselor status.
Employee #8was hired on September 1, 2020 as a counselor and reassigned as a counselor assistant on January 11, 2021.
These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
Plan of Correction:
Counselor #8's position will remain Counselors Assistant Position. Counselor will obtain 1 year of clinical experience (a minimum of 1,820 hours) in a drug and alcohol setting before eligibility to qualify for a full counselor position. The individual's written training plan shall specifically address a plan to achieve counseling competency in chemical dependency issues and work towards obtaining a CADC. The counselor assistant will provide a document to the facility stating they are working towards counselor status.
Clinical Supervisor will monitor to ensure all counselor assistants have the documentation needed to show they are working towards a counselor status.
Regional Director submitted exception request to staff requirements. Identified staff and CD assist with training.
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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 files and the facility's Staffing Requirement Facility Summary
Report form, the facility failed to ensure that employee's # 2 and 4 received the minimum
of six hours of HIV/AIDS training and at least four hours of TB/STD and other health related topics
within the regulatory timeframe.
Employee #2 was hired as a counselor on December 23, 2019 and was due to have the communicable
disease trainings no later than December 23, 2020. There was no documentation in the personnel file
of the completion of the HIV/AIDS training as of the date of the inspection.
Employee #4 was hired as a counselor on January 21, 2019 and was due to have the
communicable disease trainings no later than January 21, 2020. There was no documentation
in the personnel file of the completion of the HIV/AIDS training and the TB/STD training as of
the date of the inspection.
These findings were reviewed with facility staff during the licensing inspection. This is a repeat citation from the January 30, 2020 and December 23, 2020 licensing inspections.
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Plan of Correction
Clinical Supervisor will assure new counselors are scheduled and attend a minimum of 6 hours of HIV/AIDS training, minimum of 4 hours tuberculosis, sexually transmitted diseases and other health related topics training using a department approved curriculum within their first 90 days of employment. 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. Clinical Supervisor will be required to submit a sign off sheet from each new counselor indicating they have completed the required training to Clinic Director in allotted time required.
Employee # 2 completed training 6/16/21 ? 6/18/21.
Employee #4 completed HIV/STD 6/2/21 & 6/3/21 training.
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704.12(a)(6) LICENSURE OutPatient Caseload
704.12. Full-time equivalent (FTE) maximum client/staff and client/counselor ratios.
(a) General requirements. Projects shall be required to comply with the client/staff and client/counselor ratios in paragraphs (1)-(6) during primary care hours. These ratios refer to the total number of clients being treated including clients with diagnoses other than drug and alcohol addiction served in other facets of the project. Family units may be counted as one client.
(6) Outpatients. FTE counselor caseload for counseling in outpatient programs may not exceed 35 active clients.
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Observations
Based on a review of the Staffing Requirements Facility Summary Report, the facility failed to maintain counselor caseloads within the limits set by the regulation for employee #'s 3 and 9.
The counselor Full Time Equivalent (FTE) is determined by dividing the total number of hours the counselor devotes to their clients by the facility's work week. Then, in order to obtain the counselor ' s ratio, the total number of clients on
the counselor's caseload is divided by the FTE.
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Employee #3 was reported to have 40 hours per week devoted to their 52 clients on their caseload. The FTE caseload calculation is as follows: 40/40 = 1 (FTE); 52/1 = 52, which equals a client/counselor ratio of 52:1.
Employee #9 was reported to have 40 hours per week devoted to their 52 clients on their caseload. The FTE caseload calculation is as follows: 40/40 = 1 (FTE); 52/1 = 52, which equals a client/counselor ratio of 52:1.
These findings were reviewed with facility staff during the licensing inspection. This is a repeat citation from the December 23, 2020, January 30, 2020, November 21, 2018 and December 6, 2017 licensing inspections.
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Plan of Correction
Clinic Supervisor will redistribute clients to ensure each caseload is a 35:1 ratio for active patients to counselor.
Clinic Director will interview all qualified candidates, monitor, and maintain a qualified pool of potential counselors to assure facility maintains a 35:1 ratio.
The Clinic Director will continue to work with Human Resources Business Partner in the recruitment and hiring of appropriate staff for the project and to ensure that the FTE counselor caseload for counseling in an outpatient program does not exceed 35:1 active patients.
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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 client records, the facility failed to document an informed and voluntary consent to release information form prior to disclosing information in one out of eight records.
Client #10 was admitted on February 10, 2021 and was still active at the time of the inspection. There was no documentation of a consent form for information released to the funding source. Facility staff confirmed that billing had occurred.
These findings were reviewed with facility staff during the licensing inspection. This is a repeat citation from the December 23, 2020 and January 30, 2020 licensing inspections.
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Plan of Correction
The Regional Director presented a staff training on Confidentiality of Patient records 5/27/2021 to include obtaining an informed and voluntary consent from the client for the disclosure of information contained in the client record. The training will include consents must be in writing and include, but not be limited to: (3) Purpose of disclosure.
Clinical Supervisor will review consents daily for admissions and weekly during staff meetings.
Clinic Director will assure all staff attends the mandatory training. Clinical Director and Clinical Supervisor will review patient records weekly to assure compliance.
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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 failed to keep disclosure of client identifying information within the limited established by 4 Pa. Code 255.5(b) for releases of information in four out of eight client records.
Client #1 was admitted on March 26, 2021 and was discharged on May 4, 2021. Three consent to release forms, one dated April 21, 2021 to a government agency, and two additional forms both dated March 26, 2021 to two different funding sources allowed for the release of medical history.
Client #9 was admitted on March 31, 2021 and was still active at the time of the inspection. A consent to release form dated March 31, 2021 to a funding source allowed for the release of current dose level.
Client #11 was admitted on February 26, 2021 and was still active at the time of the inspection. A consent to release form dated February 26, 2021 to a funding source allowed for the release of treatment plans.
Client #12 was admitted on March 30, 2021 and was still active at the time of the inspection. A consent to release dated March 30, 2021 to a funding source allowed for the release of lab work results, benefits, discharge summary and medication. A second form dated March 30, 2021 to a different funding source allowed for the release of drug test results, lab work results, discharge summary and benefits.
These findings were reviewed with facility staff during the licensing inspection. This is a repeat citation from the December 23, 2020 and January 30, 2020 licensing inspections.
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Plan of Correction
Plan of Correction:
The Regional Director presented a staff training on Confidentiality of Patient records to include obtaining informed and voluntary consent from the client for the disclosure of information. The training will focus on assuring to stay in the boundaries set by 255.5(b). The active patients that are listed in this deficiency will sign a revised consent form.
Clinic Director will assure all staff attends the mandatory training. Clinical Director and Clinical Supervisor will review patient records weekly to assure compliance.
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709.28 (c) (6) 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:
(6) Date, event or condition upon which the consent will expire.
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Observations
Based on a review of client records, the facility failed to document a completed informed and voluntary consent to release information form that included an expiration date in two out of eight records reviewed.
Client #8 was admitted on March 3, 2021 and was still active at the time of the inspection. The form was dated March 3, 2021 to an emergency contact.
Client #11 was admitted on February 26, 2021 and was still active at the time of the inspection. The form was dated February 26, 2021 to an emergency contact.
These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
Plan of Correction:
The Regional Director presented a staff training on Confidentiality of Patient records to include obtaining informed and voluntary consent from the client for the disclosure of information. The training focused on consent to be in writing and include, but not limited to (6) date, event or condition upon which the consent will expire.
Clinic Director will assure all staff attends the mandatory training. Clinical Director and Clinical Supervisor will review patient records weekly to assure compliance.
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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, the facility failed to ensure that there was appropriate documentation of written acknowledgment by the client that the client had been made aware of their rights in three out of seven records reviewed.
Client #8 was admitted on March 3, 2021 and was still active at the time of the inspection.
Client #10 was admitted on February 10, 2021 and was still active at the time of the inspection.
Client #14 was admitted on February 23, 2021 and was still active at the time of the inspection.
These findings were reviewed with facility staff during the licensing inspection. This is a repeat citation from the December 23, 2021 and January 30, 2020 licensing inspections.
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Plan of Correction
Plan of Correction:
The Regional Director presented a staff training on Clients Rights and document written acknowledgement 5/27/2021.
All patients listed in this deficiency will sign a patients' rights acknowledgement. All patients will complete an intake packet for all services.
Clinic Director will assure all staff attends the mandatory training. Clinical Director and Clinical Supervisor will review patient records monthly to assure compliance.
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715.9(a)(2) 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:
(2) Verify the individual 's identity, including name, address, date of birth, emergency contact and other identifying data.
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Observations
Based on a review of client records, the facility failed to verify the patient's identity and/or obtain an emergency contact in three out of nine records reviewed.
Client #10 was admitted on February 10, 2021 and was still active at the time of the inspection. There was no documentation of individual ' s identity being verified and no emergency contact.
Client #13 was admitted on September 23, 2020 and discharged on April 27, 2021. There was no emergency contact in the record.
Client #14 was admitted on February 23, 2021 and was still active at the time of the inspection. There was no emergency contact in the record.
These findings were reviewed with facility staff during the licensing inspection. This is a repeat citation from the December 23, 2020 and January 30, 2020 licensing inspections.
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Plan of Correction
Plan of Correction:
The Clinical Supervisor will complete a training on verification on the patients individual identity, including name, address, date of birth, emergency contact and other identifying data prior to administration of an agent 5/21/2021. All information from patients in deficiency will be obtained. All patients will complete an intake packet for all services.
The Clinic Supervisor will monitor weekly for new admissions. The Clinic Director will monitor quarterly to assure compliance.
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715.13(a) LICENSURE Patient identification
(a) A narcotic treatment program shall use a system for patient identification for the purpose of verifying the correct identity of a patient prior to administration of an agent.
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Observations
Based on observation of methadone medication dispensing, the facility failed to follow their policy and procedures manual for identifying of a patient prior to administration of an agency. The policy and procedure manual section 6.1.1 (7)(d) states "Patients will present at the dispensing window without hats or sunglasses". During observation, one patient was not asked to remove their hats prior to dosing.
These findings were reviewed with facility staff during the licensing inspection. This is a repeat citation from the December 23, 2020 licensing inspection.
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Plan of Correction
The Nurse Supervisor will complete a training on Policy 6.1 "Dispensing of Medication" on 05/24/2021. The Nurse Supervisor will observe dispensing daily to ensure compliance in this area and address non-compliance during individual supervision.
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715.13(b) LICENSURE Patient identification
(b) A narcotic treatment program shall maintain onsite a photograph of each patient which includes the patient 's name and birth date. The narcotic treatment program shall update the photograph every 3 years.
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Observations
Based on a review of client records, the facility failed to maintain an onsite photograph of each patient in two out of fourteen records reviewed.
Client #10 was admitted on February 10, 2021 and was still active at the time of the inspection.
Client #11 was admitted on February 2, 2021 and was still active at the time of the inspection.
These findings were reviewed with facility staff during the licensing inspection. This is a repeat citation from the December 23, 2020 licensing inspection.
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Plan of Correction
Clinical Supervisor shall maintain onsite photographs of each patient which includes the patient's name and birth date as part of the admission process. The narcotic treatment program shall update the photograph every 3 years.
All patients' pictures have been verified. All new intakes will be required to have a checklist completed by staff before admission.
Clinic Director will monitor admission process weekly to assure patient photographs are present in charts.
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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.
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Observations
Based on a review of patient records, the facility failed to provide each patient an average of 2.5 hours of psychotherapy per month in two out of five records reviewed.
Client #13 was admitted on September 23, 2020 and discharged on April 27, 2021. The patient received no counseling in January 2021, 60 minutes of group therapy with no individual sessions in February 2021, and 120 minutes of group therapy with no individual sessions in March 2021.
Client #14 was admitted on February 23, 2021 and was still active at the time of the inspection. The patient received no counseling in March 2021 and 120 minutes of group therapy with no individual sessions in April 2021.
These findings were reviewed with facility staff during the licensing inspection. This is a repeat citation from the December 23, 2020 and January 30, 2020 licensing inspections.
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Plan of Correction
Plan of Correction:
The Clinical Supervisor and Lead Counselor will make every effort to ensure each patient are provided with 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 and/or additional psychotherapy shall be provided as dictated by ongoing assessment of the patient by conducting monthly ongoing monitoring during quality record reviews.
The Clinical Services Coordinator will conduct a meeting with Clinical Supervisor bi-weekly to ensure patients are receiving the appropriate psychotherapy per month requirements.
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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 the review of client records, the facility failed to document an annual physical examination in two out of three records reviewed.
Client #6 was admitted on April 22, 2016 and was still active at the time of the inspection. The annual physical examination was due no later than April 22, 2021; however, it was completed on April 29, 2021.
Client #7 was admitted on May 8, 2012 and was still active at the time of the inspection. The annual physical examination was due no later than May 8, 2021; however, there was no documentation of the exam being completed at the time of the inspection.
These findings were reviewed with facility staff during the licensing inspection. This is a repeat citation from the December 23, 2020 licensing inspection.
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Plan of Correction
The Nurse Manager will collaborate with the Clinical Supervisor to ensure the Medical Director is aware of upcoming patient physical examinations to review, date, and sign at the beginning of each month.
The Clinic Director will meet with the Nurse Manager and Clinical Supervisor weekly to assure this procedure is being maintained.
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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 the review of client records, the facility failed to document an annual clinical evaluation in two out of three records reviewed.
Client # 5 was admitted on February 17, 2015 and was still active at the time of the inspection. The annual clinical evaluation was due no later than February 17, 2021; however, it was completed on February 27, 2021.
Client #6 was admitted on April 22, 2016 and was still active at the time of the inspection. The annual clinical evaluation was due no later than April 22, 2021; however, it was completed on May 18, 2021.
The findings were reviewed with facility staff. This is a repeat citation from the December 23, 2020 licensing inspection.
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Plan of Correction
The Clinical Supervisor will ensure the clinical staff will complete an annual clinical evaluation on all patients. The Clinical Supervisor will review, annual evaluations with clinical staff weekly to ensure they are being compliant.
The Clinic Director will meet with the Clinical Supervisor biweekly to assure this procedure is being maintained
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709.91(b)(4) LICENSURE Intake and admission
709.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(4) Consent to treatment.
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Observations
Based on a review of client records, the facility failed to document a consent to treat with buprenorphine in two out of four records.
Client # 10 was admitted on February 10, 2021 and was still active at the time of the inspection.
Client #14 was admitted on February 23, 2021 and was still active at the time of the inspection.
These findings were reviewed with facility staff during the licensing inspection. This is a repeat citation from the December 23, 2020 licensing inspection.
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Plan of Correction
The Clinical Supervisor will do a training/review on intake and admission process. The Clinical Supervisor will conduct peer reviews as well as quarterly checks to ensure procedures are being maintained.
The Clinic Supervisor will update the Clinic Director weekly on intake and admission process.
. "Ongoing compliance will be monitored during quality record reviews. The Clinical Supervisor will address non-compliance in this area during individual supervision. Continued non-compliance will be addressed via the EIP process."
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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 client records, the facility failed to complete an individual treatment plan, document the treatment plan was developed with the client and/or complete the individual treatment plan within the thirty day timeframe outlined in the facility's policy and procedure manual in eight out of ten records reviewed.
Client #1 was admitted on March 26, 2021 and discharged on May 4, 2021. There was no documentation of a treatment plan in the client ' s record.
Client #8 was admitted on March 3, 2021 and was still active at the time of the inspection. There was no documentation of a treatment plan in the client ' s record.
Client #9 was admitted on March 31, 2021 and was still active at the time of the inspection. There was no documentation of a treatment plan in the client ' s record.
Client #10 was admitted on February 10, 2021 and was still active at the time of the inspection. The comprehensive treatment plan was due no later than March 10, 2021; however, it was not completed until March 24, 2021.
Client #11 was admitted on February 26, 2021 and was still active at the time of the inspection. There was no documentation of a treatment plan in the client ' s record.
Client #12 was admitted on March 30, 2021 and was still active at the time of the inspection. The comprehensive treatment plan was due no later than April 30, 2021; however, it was not completed until May 7, 2021.
Client #13 was admitted on September 23, 2020 and discharged on April 27, 2021. The comprehensive treatment plan was due no later than October 23, 2020; however, it was not completed until February 24, 2021 and did not include a dated client signature.
Client #14 was admitted on February 23, 2021 and was still active at the time of the inspection. The comprehensive treatment plan was due no later than March 23, 2021; however, it was not completed until April 27, 2021.
These findings were reviewed with facility staff during the licensing inspection. This is a repeat inspection from the December 23, 2020 licensing inspection.
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Plan of Correction
Plan of Correction:
The Clinical Supervisor will do a training/review on individual treatment plans to include what written documentation is needed within the treatment plan, how frequent a patient should obtain services, and what type of service is required.
The Clinical Supervisor will conduct peer reviews as well as quarterly checks to ensure procedures are being maintained. The Clinic Supervisor will update the Clinic Director weekly on treatment plan compliance.
. "Ongoing compliance will be monitored during quality record reviews. The Clinical Supervisor will address non-compliance in this area during individual supervision. Continued non-compliance will be addressed via the EIP process."
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709.92(a)(2) 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:
(2) Type and frequency of treatment and rehabilitation services.
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Observations
Based on a review of client records, the facility failed to document type and frequency of treatment services in the treatment plan in three out of four records reviewed.
Client #10 was admitted on February 10, 2021 and was still active at the time of the inspection. A comprehensive treatment plan dated March 24, 2021 did not specify frequency for specific types of counseling.
Client #12 was admitted on March 30, 2021 and was still active at the time of the inspection. A comprehensive treatment plan dated May 7, 2021 did not specify type and frequency for counseling.
Client #13 was admitted on September 23, 2020 and discharged on April 27, 2021. A comprehensive treatment plan dated February 24, 2021 did not specify frequency for individual counseling sessions.
These findings were reviewed with facility staff during the licensing inspection. This is a repeat citation from the December 23, 2020, January 30, 2020 and November 28, 2018 licensing inspections.
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Plan of Correction
Plan of Correction:
The Clinical Supervisor will do a training/review on individual treatment plans to include what written documentation is needed within the treatment plan, how frequent a patient should obtain services, and what type of service is required.
The Clinical Supervisor will conduct peer reviews as well as weekly checks to ensure procedures are being maintained.
The Clinic Supervisor will update the Clinic Director weekly on treatment plan compliance.
"Ongoing compliance will be monitored during quality record reviews. The Clinical Supervisor will address non-compliance in this area during individual supervision. Continued non-compliance will be addressed via the EIP process."
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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.
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Observations
Based on a review of client records, the facility failed to document treatment plan updated within the regulatory timeframe in three out of five records. The facility's policy and procedure manual require a treatment plan update to be completed at a minimum of every sixty days.
Client #5 was admitted on February 17, 2015 and was still active at the time of the inspection. A treatment plan update was completed on September 14, 2020 and the next update was due no later than November 14, 2020; however, the next one was completed on February 22, 2021.
Client #6 was admitted on April 22, 2016 and was still active at the time of the inspection. A treatment plan update was completed on February 16, 2021 and the next update was due no later than April 16, 2021; however, there was no update documented in the record at the time of the inspection.
Client #13 was admitted on September 23, 2020 and discharged on April 27, 2021. A comprehensive treatment plan was completed on February 24, 2021 and the update was due no later than April 24, 2021; however, there was no update documented in the record at the time of the inspection.
These findings were reviewed with facility staff during the licensing inspection. This is a repeat citation from the December 23, 2020 and January 30, 2020 licensing inspections.
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Plan of Correction
The Clinical Supervisor will do a training/review on individual treatment plans to include what written documentation is needed within the treatment plan, how frequent a patient should obtain services, and what type of service is required. Treatment plans will be updated every 60 days.
The Clinical Supervisor will conduct peer reviews as well as weekly checks to ensure procedures are being maintained.
The Clinic Supervisor will update the Clinic Director weekly on treatment plan compliance.
"Ongoing compliance will be monitored during quality record reviews. The Clinical Supervisor will address non-compliance in this area during individual supervision. |