INITIAL COMMENTS
|
This report is a result of an on-site licensure renewal inspection conducted on August 14-16, 2018 by staff from the Division of Drug and Alcohol Program Licensure, for the approval to use Methadone in the treatment of narcotic addiction. Based on the findings of the on-site inspection, Addiction Medicine and Health Advocate, Inc. was found not to be in compliance with the applicable chapters of 28 PA Code which pertain to the facility. The following deficiencies were identified during this inspection:
|
Plan of Correction
|
704.11(f)(2) LICENSURE Trng Hours Req-Coun
704.11. Staff development program.
(f) Training requirements for counselors.
(2) Each counselor shall complete at least 25 clock hours of training annually in areas such as:
(i) Client recordkeeping.
(ii) Confidentiality.
(iii) Pharmacology.
(iv) Treatment planning.
(v) Counseling techniques.
(vi) Drug and alcohol assessment.
(vii) Codependency.
(viii) Adult Children of Alcoholics (ACOA) issues.
(ix) Disease of addiction.
(x) Aftercare planning.
(xi) Principles of Alcoholics Anonymous and Narcotics Anonymous.
(xii) Ethics.
(xiii) Substance abuse trends.
(xiv) Interaction of addiction and mental illness.
(xv) Cultural awareness.
(xvi) Sexual harassment.
(xvii) Developmental psychology.
(xviii) Relapse prevention.
(3) If a counselor has been designated as lead counselor supervising other counselors, the training shall include courses appropriate to the functions of this position and a Department approved core curriculum or comparable training in supervision.
|
Observations
Seventeen personnel records were reviewed for the counselor position on August 14, 2018. The facility failed to document the completion of at least 25 annual training hours for employee # 20.
Employee # 20 was hired by the facility on March 2, 2009 as a full-time counselor and began employment as a part-time counselor on January 1, 2016. Annual training hours were reviewed for the facility training year of January 1, 2017 to December 31, 2017. Documentation for training hours completed during the reviewed training year was not found in the employee's record.
This finding was reviewed with facility staff during the licensing inspection.
|
Plan of Correction
A spreadsheet will be maintained to track all required training hours for staff. All counselors will complete 25 hours per calendar year. The employee identified in this citation only works 2 to 4 days per month in a clerk/staff support role on weekends doing crisis intervention when necessary. Her job description has been revised to reflect her duties. The Clinical Program Manager will be responsible for having the employee sign the new job description. The Program Director will manage the training spreadsheet to verify completed training hours as required. |
709.26 (b) (3) LICENSURE Personnel management.
§ 709.26. Personnel management.
(b) The personnel records must include, but are not limited to:
(3) Annual written individual staff performance evaluations, copies of which shall be reviewed and signed by the employee.
|
Observations
Twenty personnel records were reviewed on August 14, 2018. The facility failed to document a signed annual staff performance evaluation for employee record # 20.
Employee # 20 was hired by the facility on March 2, 2009 as a counselor. An annual staff performance evaluation was completed for the employee on April 8, 2018. However, the evaluation was not signed by the employee.
This finding was reviewed with facility staff during the licensing inspection.
|
Plan of Correction
The Clinical Program Manager will have the employee sign the annual evaluation after reviewing it with her. In the future, all evaluations will be completed timely, and reviewed and signed by the supervisor and employee at the time of the review. The Program Director will monitor completion of the annual evaluations. |
715.6(d) LICENSURE Physician Staffing
(d) A narcotic treatment program shall provide narcotic treatment physician services at least 1 hour per week onsite for every ten patients
|
Observations
Weekly physician time sheets and client census reports were reviewed on August 15-16, 2018, for the period of April 2, 2018 - July 29, 2018. Based on a review of this documentation, the facility failed to provide at least one hour of physician services per week onsite for each week within the reviewed time period.
For the week of April 2, 2018, the reported patient census was 481. The facility was required to provide at least 48.1 onsite physician hours. There were 11.25 onsite physician hours documented for this week.
For the week of April 9, 2018, the reported patient census was 482. The facility was required to provide at least 48.2 onsite physician hours. There were 8.25 onsite physician hours documented for this week.
For the week of April 16, 2018, the reported patient census was 483. The facility was required to provide at least 48.3 onsite physician hours. There were 8.25 onsite physician hours documented for this week.
For the week of April 23, 2018, the reported patient census was 487. The facility was required to provide at least 48.7 onsite physician hours. There were 34.75 onsite physician hours documented for this week.
For the week of April 30, 2018, the reported patient census was 494. The facility was required to provide at least 49.4 onsite physician hours. There were 11.50 onsite physician hours documented for this week.
For the week of May 7, 2018, the reported patient census was 494. The facility was required to provide at least 49.4 onsite physician hours. There were 33.75 onsite physician hours documented for this week.
For the week of May 14, 2018, the reported patient census was 497. The facility was required to provide at least 49.7 onsite physician hours. There were 11.50 onsite physician hours documented for this week.
For the week of May 21, 2018, the reported patient census was 495. The facility was required to provide at least 49.5 onsite physician hours. There were 31.75 onsite physician hours documented for this week.
For the week of May 28, 2018, the reported patient census was 500. The facility was required to provide at least 50 onsite physician hours. There were 13 onsite physician hours documented for this week.
For the week of June 4, 2018, the reported patient census was 500. The facility was required to provide at least 50 onsite physician hours. There were 26.75 onsite physician hours documented for this week.
For the week June 11, 2018, the reported patient census was 500. The facility was required to provide at least 50 onsite physician hours. There were 8.75 onsite physician hours documented for this week.
For the week of June 18, 2018, the reported patient census was 500. The facility was required to provide at least 50 onsite physician hours. There were 31.50 onsite physician hours documented for this week.
For the week of June 25, 2018, the reported patient census was 497. The facility was required to provide at least 49.7 onsite physician hours. There were 10 onsite physician hours documented for this week.
For the week of July 2, 2018, the reported patient census was 500. The facility was required to provide at least 50 onsite physician hours. There were 10.75 onsite physician hours documented for this week.
For the week of July 9, 2018, the reported patient census was 492. The facility was required to provide at least 49.2 onsite physician hours. There were 26.50 onsite physician hours documented for this week.
For the week of July 16, 2018, the reported patient census was 493. The facility was required to provide at least 49.3 onsite physician hours. There were 21.75 onsite physician hours documented for this week.
For the week of July 23, 2018, the reported patient census was 498. The facility was required to provide at least 49.8 onsite physician hours. There were 34.5 onsite physician hours documented for this week.
These findings were reviewed with facility staff during the licensing inspection.
This is a repeat citation, as the facility was cited for non-compliance of this standard during the previous inspection conducted on August 10-11, 2017.
|
Plan of Correction
AMHA has added onsite doctor time by hiring another narcotic treatment physician and utilizing a staffing agency to supplement the Medical Director's time. The Program Director will monitor the patient census each week to verify that there is sufficient doctor time to meet the regulatory requirements. |
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.
|
Observations
Eight client records were reviewed on August 15-16, 2018. For client record # 2, the facility failed to ensure that monthly psychotherapy hours provided to the client included at least 1 hour of individual psychotherapy per month.
Client # 2 was admitted into treatment on October 24, 2017 and was still active in treatment. Documentation in the client's record indicated that the client received less than 1 hour of individual psychotherapy for the following months: February 2018, March 2018, April 2018, May 2018, June 2018, and July 2018.
This finding was reviewed with facility staff during the licensing inspection.
|
Plan of Correction
A meeting was held on 8/24/18 with the clinical supervisors to review the mandatory psychotherapy requirements for active patients. Supervisors will provide additional training to their supervisees regarding these requirements and monitor adherence to such. Additionally, during our monthly chart review as part of the Performance Improvement Program, our chart reviewer will monitor compliance with the mandatory psychotherapy hours and report findings in the monthly PI meeting. The Clinical Program Manager will be responsible for monitoring the overall process and providing additional supervision and training for any clinician who may require it. |
715.28(c)(1-5) LICENSURE Unusual incidents
(c) A narcotic treatment program shall file a written Unusual Incident Report with the Department within 48 hours following an unusual incident including the following:
(1) Complaints of patient abuse (physical, verbal, sexual and emotional).
(2) Death or serious injury due to trauma, suicide, medication error or unusual circumstances.
(3) Significant disruption of services due to a disaster such as a fire, storm, flood or other occurrence.
(4) Incidents with potential for negative community reaction or which the facility director believes may lead to community concern.
(5) Drug related hospitalization of a patient.
|
Observations
The facility's incident report log was reviewed on August 15-16, 2018. Based on a review of this documentation, the facility failed to report to the Department an incident that had the potential to cause a negative community reaction or lead to a community concern.
Documentation in the incident report log indicated that on February 23, 2018, facility personnel observed a client selling drugs to another client in the immediate vicinity of the facility. Facility staff confirmed that a written Unusual Incident Report for this event was not submitted to the Department.
This finding was reviewed with facility staff during the licensing inspection.
|
Plan of Correction
During the licensing inspection we were provided with clarification regarding what events could be viewed as "an incident that had the potential to cause negative community reaction or lead to a community concern". Moving forward, AMHA will submit an Unusual Incident Report to DDAP within 48 hours when one of these incidents occurs. The Clinical Program Manager will be responsible for making sure the form has been completed and submitted. The documentation will be maintained in our Health and Safety Manual. |