INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection, and an inspection conducted for the approval to use a narcotic agent, specifically methadone and buprenorphine in the treatment of narcotic addition. This inspection was conducted on July 1 - 2, 2015 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Aldie Counseling Center 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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704.11(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 on a review of personnel records, the facility failed to ensure that each counselor completed at least 25 clock hours of annual training.
The findings include:
One employee record was reviewed on July 1, 2015, for documentation of counselor training hours. The facility failed to ensure that employee #5, a counselor who was hired August 28, 2012, completed at least 25 clock hours of annual training for the facility's training year, July 1, 2013 through June 30, 2014. Employee #5's training file only included documentation of 19.5 training hours.
In addition, the facility documented on the Staffing Requirements Facility Summary Report form which was completed by the facility on July 1, 2015, that employee # 5 received 19.5 hours of training.
The findings were reviewed with facility staff during the licensing process
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Plan of Correction
The executive director, in consultation with the program managers will develop an agency-wide training plan by July 31, 2015. The Office Manager will keep a spreadsheet of all staff and their training requirements. The spreadsheet will be updated monthly. Results will be communicated via email to all applicable staff and their supervisors. The supervisors will review the information as part of clinical supervision on a not less than monthly basis. Supervisors will assist with the customization of any training plan to ensure that the required number of hours are scheduled over the course of the year. The executive director will reinforce the importance of compliance at monthly staff meetings. The spreadsheet will be in place by August 3, 2015. |
705.28 (d) (1) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(1) Conduct unannounced fire drills at least once a month.
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Observations
Based on a review of the facility's fire drill log, the facility failed to conduct unannounced fire drills at least once a month and the fire drill logs were missing documentation of required components.
The findings include:
The facility's fire drill log was reviewed on July 1, 2015, covering the period of June 29, 2015 through August 28, 2014. The facility failed to conduct an unannounced fire drill during the month of November 2014.
In addition, the facility failed to include the required components on all logs for the time period reviewed. The facility failed to document 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
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The executive director restructured staff and responsibilities in 2015. Since that time all fire drills have been conducted as required and the appropriate documentation is in place. The executive director will continue to monitor compliance on a not less than monthly basis during supervision with the employee given the new responsibilities. |
715.23(b)(23) LICENSURE Patient records
(b) Each patient file shall include the following information:
(23) Discharge summary.
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Observations
Based on a review of patient records, the facility failed to document a discharge summary in two of two patient records reviewed.
The findings include:
Two patient records requiring documentation of a discharge summary were reviewed on July 2, 2015. The facility failed to document a discharge summary in patient records, #4 and 5.
Patient # 4 was admitted to the facility on January 7, 2012 and discharged on June 22, 2015. The facility failed to document a discharge summary in patient record #4, at the time of inspection.
Patient # 5 was admitted to the facility on March 29, 2014 and discharged on June 15, 2015. The facility failed to document a discharge summary in patient record #5, at the time of inspection.
The findings were reviewed with facility staff during the monitoring inspection.
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Plan of Correction
The program supervisor will develop a tracking system to alert clinicians when a discharge summary needs to be completed. The clinicians will then compete the form and return it to the program supervisor for approval. The supervisor will turn in the completed discharge summary to the administrative assistant who will then mark the electronic health record that the patient is discharged and a follow-up survey will be sent. The program supervisor will review compliance on a not less than monthly basis during clinical supervision. The tracking system will be in place by August 15, 2015. |
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 patient records, the facility failed to document an annual evaluation in two of two patient records reviewed.
The findings include:
Two patient records requiring documentation of an annual evaluation were reviewed on July 2, 2015. The facility failed to document an annual evaluation in patient records, #4 and 5.
Patient # 4 was admitted to the facility on January 7, 2012 and discharged on June 22, 2015. The facility failed to document an annual evaluation in patient record #4 which was to start on the date of the patient's admission to the narcotic treatment program on or by January 7, 2015.
Patient # 5 was admitted to the facility on March 29, 2014 and discharged on June 15, 2015. The facility failed to document an annual evaluation in patient record #5 which was to start on the date of the patient's admission to the narcotic treatment program on or by March 29, 2015.
The findings were reviewed with facility staff during the monitoring inspection.
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Plan of Correction
As of August 15, 2015 an administrative assistant will be added to the program and devote approximately 10 hours per week to various support duties and tasks. One of the first assignments will be the creation of a tracking spreadsheet for all active clients. The administrative assistant will inform the clinicians via email by the 15th day of each month the annual evaluations needed for the upcoming month. The supervisor will be copies on all emails.The clinicians will complete the form and submit it to the supervisor for approval. The completed form will be returned to the administrative assistant to mark the spreadsheet as completed. If not completed within 30 days the administrative assistant will inform the supervisor so that corrective action can be taken. The new procedure will be fully implemented by September 1, 2015. |