INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection and buprenorphine monitoring inspection conducted on December 2 - 4, 2014 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Penn Foundation for Mental Health, 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:
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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 a review of personnel records, the facility failed to ensure that each counselor met the qualifications for the position of counselor in one out of thirteen personnel records reviewed.
The findings include:
Thirteen personnel records were reviewed for documentation of the qualifications for the position of counselor. The facility failed to ensure that employee # 13 met the experiential qualifications for the position of counselor.
Employee # 13 was hired as a counselor on October 1, 2014. Employee # 13 has a Bachelor's Degree with a qualifying major. However, personnel record # 13 did not include documentation of the required clinical experience.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Employee #13 will be demoted to a counselor assistant. This employee will sign a new counselor assistant job description completed by the outpatient clinical supervisor by POC due date 1/02/2015. Facility director will ensure this task is completed. Counselor assistant supervision requirements will be instituted immediately by outpatient clinical supervisor. Moving forward clinical supervisors will be educated on the direct requirements of a counselor. If the clinical supervisor has a question in regards to this or a individual does not clearly meet the regulation of a counselor this must be approved by the facility director. It will be the responsibility of the facility director to oversee this POC and to ensure that when a new counselor is hired, he/she meets the qualifications of counselor. |
715.14(a) LICENSURE Urine testing
(a) A narcotic treatment program shall complete an initial drug-screening urinalysis for each prospective patient and a random urinalysis at least monthly thereafter.
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Observations
Based on a review of patient records, the facility failed to provide documentation of a random drug-screen urinalysis for each patient at least monthly in three of three patient records reviewed.
The findings include:
Three patient records requiring documentation of random monthly drug-screen urinalysis were reviewed from December 2, 2014 to December 4, 2014. The facility failed to provide documentation of random drug-screen urinalysis in patient records # 7, 12, and 13.
Patient # 7 was admitted May 14, 2014 as a detox patient and was stepped down to out-patient on 5/30/14. Patient # 7 was still an active patient as of 12/4/14. Patient # 7 started Suboxone on 6/11/14 and was required to have random monthly drug-screen urinalysis. However, the only monthly drug-screen urinalysis documented in patient record # 7 was for 8/14/14 as of December 4, 2014.
Patient # 12 was admitted February 20, 2014 as an inpatient non-hospital patient and was stepped down to out-patient on 4/19/14. Patient # 12 was discharged on 9/10/14. Patient # 12 started Suboxone on 4/17/14 and was required to have random monthly drug-screen urinalysis. However, patient record # 12 did not include documentation of monthly drug-screen urinalysis from April 2014 to August 2014 as of December 4, 2014.
Patient # 13 was admitted August 2, 2010 as an out-patient Suboxone patient and was discharged on 5/16/14. Patient # 13 was required to have random monthly drug-screen urinalysis. However, patient record # 13 did not include documentation of monthly drug-screen urinalysis from February 2014 to April 2014 as of December 4, 2014.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Outpatient clinical supervisor reviewed drug screen policies with staff at team meeting 1/02/2015. To ensure ongoing compliance, administrative assistant will keep a list of buprenorphine clients and the date of their last UDS. By the 3rd week of the month, supervisor will review the list and identify any clients who have not had a monthly UDS. Counselor will outreach to client to have them come in for monthly UDS. Clients who are not compliant with monthly urines will not be eligible for ongoing buprenorphine treatment. Clients were all made aware of this new process. Patient #7 will receive random monthly UDS according to the above plan, Outpatient Clinical Supervisor will be responsible for ensuring patient #7 is in full compliance with this regulation. Outpatient Clinical Supervisor will be responsible for overseeing this POC and ensuring ongoing compliance. |
709.53(a) LICENSURE Complete Client Record
709.53. 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:
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Observations
Based on a review of client records, the facility failed to document a complete client record that included a record of services, discharge summary, and/or aftercare plan in four of eight records reviewed.
The findings include:
Eight client records requiring documentation of a complete client record were reviewed from December 2, 2014 to December 4, 2014. The facility failed to document an aftercare plan in client records # 8 and 11, the discharge summary in client records # 8 and 9, and a record of services in client record # 12.
Client # 8 was admitted September 26, 2014 as an inpatient client and was discharged October 22, 2014. The aftercare plan was due October 22, 2014 and the discharge summary was due October 29, 2014. However, client record # 8 did not include documentation of an aftercare plan and discharge summary as of December 4, 2014.
Client # 9 was admitted September 10, 2014 as an inpatient client and was discharged October 10, 2014. The discharge summary was due October 10, 2014. However, client record # 9 did not include documentation of a discharge summary as of December 4, 2014.
Client # 11 was admitted April 11, 2014 as an inpatient client and was discharged May 1, 2014. The aftercare plan was due May 1, 2014. However, client record # 11 did not include documentation of an aftercare plan as of December 4, 2014.
Client # 12 was admitted February 20, 2014 as an inpatient client, was stepped down to out-patient 4/19/14, and discharged 5/1/14. As of December 4, 2014, the record of service was missing from 3/3/14 until the client was stepped down to out-patient on 4/19/14.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Facility Director will review the discharge process policy with the inpatient and outpatient staff to ensure staff complete the discharge summary and aftercare plan for all clients leaving the facility. Facility director will ensure closure process includes discharge summary completed within 7 days of discharge. Facility Director will be responsible for ensuring a discharge summary is completed on clients #8 and 9 and placed in the record. Facility Director will be responsible for completing the record of service for client #12 and placing it in the chart. This will be implemented by 1/26/2015. Random closure audits will be completed by the clinical supervisor to ensure compliance with this regulation. Facility Director will be responsible for implementation and oversight of this POC. |
709.93(a) 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:
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Observations
Based on a review of client records, the facility failed to document a complete client record that included a record of services in two of four client records reviewed.
The findings include:
Four client records requiring documentation of a complete client record were reviewed from December 2, 2014 to December 4, 2014. The facility failed to document a record of services in client records # 6 and 12.
Client # 6 was admitted June 2, 2014 and was still an active client as of 12/4/14. Client record # 6 did not include documentation of record of services as of December 4, 2014.
Client # 12 was admitted February 20, 2014 as an inpatient client, was stepped down to out-patient on 4/19/14, and was discharged on 9/10/14. Client record # 12 did not include documentation of record of services while the client was in out-patient from April 2014 to September 2014 as of 12/4/14.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
It was discovered during the site visit that the Record of Services was not consistently located in the clinical file. Record of services will no longer be computerized. We will return to our former method of a handwritten record of services that will be used to document all services provided. Administrative Assistant will place Record of Services log in all open client records and will be responsible for ensuring the service received is documented prior to the chart returning to the file cabinet. Record of services for client record #6 will be placed into the clinical record by the administrative assistant. Outpatient Clinical supervisor will oversee this POC for ongoing compliance with this regulation. |