INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection and methadone monitoring conducted on August 25, 2021 through August 26, 2021 by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. 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.
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Plan of Correction
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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 the review of the Staffing Facility Requirements Summary Report and personnel records, the facility failed to ensure that all counselors received the minimum of six hours of HIV/AIDS training and four hours of TB/STD training within the first year of employment in three of three applicable personnel records reviewed.
Employee # 11 was hired as a counselor on September 9, 2019 and was due to have both trainings completed no later than September 9, 2020. The emloyee completed the HIV/AIDS training within the first year of employment; however, there was no documentation that the TB/STD training was completed as of the date of the inspection.
Employee # 12 was hired as a counselor on December 16, 2019 and was due to have both trainings completed no later than December 16, 2020. The employee completed the HIV/AIDS training within the first year of employment; however, there was no documentation that the TB/STD training was completed as of the date of the inspection.
The employee # 14 was hired as a counselor on March 2, 2020 and was due to have both trainings completed no later than March 2, 2021. The employee completed the HIV/AIDS training within the first year of employment; however, there was no documentation that the TB/STD training was completed as of the date of the inspection.
The findings were discussed with facility staff during the licensing process.
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Plan of Correction
Each of these employees was originally scheduled for the TB/STD training early in the pandemic and it was cancelled. There was difficulty securing a new training slot but all three are scheduled for 9/20/21. Our Training Coordinator keeps a spreadsheet for all employees with their hire date and required trainings. Moving forward, we will schedule the mandatory DDAP trainings early in their employment so as to allow for cancellations/re-schedules while still completing the trainings within the first year of employment. The Training Coordinator will be responsible for ensuring that they are completed within this time frame. |
709.28 (d) LICENSURE Confidentiality
§ 709.28. Confidentiality.
(d) A copy of a client consent shall be offered to the client and a copy maintained in the client record.
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Observations
Based on a review of client records, the facility failed to assure that a copy of all consent to release information forms were offered to the client in one of nine client records reviewed.
Client # 7 was admitted on April 16, 2021 and discharged on August 4, 2021. A release of information form to a government agency was signed and dated by the client on April 16, 2021; however, there was no documentation in the record that a copy of the form was offered to the client.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Staff were informed of this citation and the need to offer a copy of a signed release of information form to the patient and document their acceptance or refusal on the form. We will hold a staff meeting to review the needed elements of a consent to release information form. Appropriate completion of consent forms will be monitored by our Clinical Program Manager and will be reviewed during Quality Record Reviews as part our Performance Improvement Committee. |
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 a review of patient records, the narcotic treatment program failed to document the results of an annual physical examination given by the program and is to include an annual reevaluation by the narcotic treatment physician in two of nine patient records reviewed.
Patient #2 was admitted on August 22, 2014 and was active at the time of inspection. The last documented annual physical exam was completed on August 28, 2019.
Patient # 8 was admitted on August 27, 2017 and was discharged on April 12, 2021. The last documented annual physical exam was completed on August 27, 2019.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Intake/Administrative Nurse will review the current patient list to identify all patients who may be overdue for an annual physical exam as well as those who are due each month moving forward. Patients will be scheduled for their physical exam and notified via appointment card. Patients who miss their appointment or need to re-schedule will need to do so within the appropriate time-frame related to their anniversary date of last physical. The Intake/Administrative Nurse is responsible for managing this process and keeping the Clinical Program Manager aware of any issues with completing annual physicals in a timely manner. |