INITIAL COMMENTS
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This report is a result of an on-site licensure renewal and methadone monitoring inspection conducted on February 23, 2023 by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, RHJ Medical Center, Inc. / Vandergrift, LLC 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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704.7(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 one of eight employee personnel records reviewed, the facility failed to provide documentation of the qualification of counselors for employee # 8.
Employee # 8 was hired as a counselor assistant on April 4, 2022 and promoted to counselor on July 8, 2022 and was still in this position at the time of the inspection. Based on a review of employee # 8's personal record and resume, there was no documentation of at least one year of clinical experience with a bachelor's degree.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Project Director, Facility Director and Clinical supervisor reviewed and discussed the counselor documentation and determined that no counselor assistant would be promoted to counselor without proper and complete experience and documentation of necessary qualifications for the position of counselor. The clinical supervisor is the person responsible to ensure compliance with this regulation. |
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.
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Observations
Based two of seven applicable employee personnel records reviewed, the facility failed to provide documentation of at least 25 clock hours of annual training required for a counselor for the training year January-December 2022 in employee records # 3 and # 7.
Employee # 3 was hired as a counselor on November 2, 2011 and was still in this position at the time of the inspection. After a review of employee # 3's personnel record, there were only 16 training hours documented.
Employee # 7 was promoted to a counselor position on July 10, 2017 and was still in this position at the time of the inspection. After a review of employee # 7's personnel record, there were no training hours documented.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The leadership and training team reviewed the staff training documentation. It was determined that the trainings were noted but no training certificates were provided for some of the trainings. The training protocol was updated to include training certificates for all trainings beginning the 2023 training period. All staff were notified of this update. The clinical supervisor is responsible to ensure compliance with this regulation. |
715.20(3) LICENSURE Patient transfers
A narcotic treatment program shall develop written transfer policies and procedures which shall require that the narcotic treatment program transfer a patient to another narcotic treatment program for continued maintenance, detoxification or another treatment activity within 7 days of the request of the patient.
(3) The transferring narcotic treatment program shall document what materials were sent to the receiving narcotic treatment program.
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Observations
Based on one of one applicable patient record reviewed, the facility failed to include admission date, medical and psychosocial summaries, dosage level, urinalysis reports or summary, exception requests, and current status of the patient in the transfer paperwork provided to the receiving facility in patient record # 6.
Patient # 6 was admitted on June 10, 2022 and discharged on February 21, 2023. Patient # 6 was transferred to another facility and there was no documentation of the transfer paperwork documented in the patient record.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Leadership reviewed the record and documentation, updated the protocol to include copies of all documents sent to transferring facilities along with the fax transmittal together in the clinical chart. The leadership will hold a meeting with the clinical team to review the citation and resulting updates. To ensure future compliance chart audits will be conducted randomly to ensure inclusion of these documents. The clinical supervisor and facility director are responsible to ensure compliance with this regulation. |
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 one of three applicable patient records reviewed, the facility failed to provide documentation of an annual physical examination given by the narcotic treatment program which includes an annual reevaluation by the narcotic treatment physician.
Patient # 4 was admitted on March 30, 2012 and was still active at the time of the inspection. There was no documentation of an annual physical examination for the year 2022 documented in the patient record.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Leadership reviewed the current protocol for scheduling and completion of the patients annual physical. The protocol will be reviewed with clinical, front desk, and medical staff to ensure understanding and compliance with this regualtion. Random chart audits will be conducted to ensure compliance with this regulation. The clinical supervisor is responsible for compliance with this requirement. |
709.93(a)(9) LICENSURE Client records
709.93. Client records.
(a) There shall be a complete client record on an individual which includes information relative to the client's involvement with the project. This shall include, but not be limited to, the following:
(9) Aftercare plan, if applicable.
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Observations
Based on one of one applicable client records reviewed, the facility failed to provide an aftercare plan upon successful discharge in client record # 7.
Client # 7 was admitted on December 13, 2019 and was discharged on June 7, 2022.
There was no aftercare plan available in the client record.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The leadership team reviewed this citation and the current protocol. The Leadership team will meet with the clinical team to review patient discharge protocols and procedures, which include discharge planning, so that they understand the aftercare plan guidelines. The clinical supervisor is responsible to ensure that all discharge procedures are completed. Chart reviews of patient charts following discharge will be completed to ensure compliance with this regulation. |