INITIAL COMMENTS
|
This report is a result of an onsite licensure renewal and methadone monitoring inspection. The inspection was conducted on December 14-15, 2017 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the onsite inspection, Parkside Recovery 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 the inspection:
|
Plan of Correction
|
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.
|
Observations
Based on a review of personnel records on December 12, 2017, the facility failed to ensure that each counselor met the qualifications for the position in one of nine new counselor hires personnel records.
Employee #12 was hired as a Counselor on February 13, 2017. The employee met the education requirement with a bachelor degree in Psychology. The employee's resume did not document that the employee had the one year of clinical experience required.
These findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
-Project Director and Facility Director will now review the resumes of all prospective candidates in order to ensure that candidates have the required clinical experience so that this deficiency does not reoccur. |
704.11(b)(1) LICENSURE Individual training plan.
704.11. Staff development program.
(b) Individual training plan.
(1) A written individual training plan for each employee, appropriate to that employee's skill level, shall be developed annually with input from both the employee and the supervisor.
|
Observations
Based on a review of personnel records, the facility failed to provide documentation of individual training plans in two of thirty-three personnel/training records reviewed.
Employee #30 was hired as Security on August 19, 2013 and the there was no individual training plan documented for the July 1, 2017 to June 30, 2018 training year.
Employee #33 was hired as Security on on April 15, 2013 and there was no individual training plan documented for the July 1, 2017 to June 30, 2018 training year.
These findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
-Administrative Assistant will collect copies of all Individual Training Plans for all staff; record date Training plan was received on the Training spreadsheet and enter those plans into staff training files.
Supervisors will be responsible for ensuring that Individual training plans are completed and implemented for their staff as required for the current training year in order to ensure that this deficiency does not reoccur. |
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.
|
Observations
Based on a review of personnel/training records on December 12, 2017, the facility failed to ensure that staff received a minimum of 6 hours of HIV/AIDS and/or 4 hours of TB/STD training within the required time frame in five of thirty-three personnel/training records reviewed. The facility training year was from July 1, 2016 through June 30, 2017.
Employee #19 was hired as a Counselor on June 13, 2016. The employee was required to obtain 4 hours of STD/TB training by June 13, 2017. Employee #19 failed to obtain the training as of the date of inspection.
Employee #20 was hired as a Counselor on January 25, 2016. The employee was required to obtain six hours of HIV/AIDS training by January 25, 2017. Employee #20 failed to obtain the training as of the date of inspection.
Employee #31 was hired as an Intake Worker on February 10, 2014. The employee was required to obtain 6 hours of HIV/AIDS training and four hours of TB/STD training by February 10, 2016. Employee #31 failed to obtain the training as of the date of inspection.
Employee #32 was hired as Security on July 5, 2014. The employee was required to obtain 6 hours of HIV/AIDS training and four hours of TB/STD training by July 5, 2016. Employee #32 failed to obtain the training as of the date of inspection.
Employee #33 was hired as Security on April 15, 2013. The employee was required to obtain 6 hours of HIV/AIDS training and four hours of TB/STD training by April 15, 2015. Employee #33 failed to obtain the training as of the date of inspection.
These findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
-Administrative Assistant will now register all Counselors for trainings as scheduled. AA will collect copies of Training Certificates and record hours on the Training spreadsheet.
Supervisors will be responsible to review all training needs including accumulated hours with their staff during Weekly Supervision and/or during Team meetings in order to ensure that staff receive the appropriate trainings in the required time frame which will prevent this deficiency from reoccurring. |
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
Based on a review of personnel/training records and a review of the Staffing Requirements Facility Summary Report on December 12th, the facility failed to document the completion of 25 clock hours of annual training required for counselors in eleven of thirteen counselor personnel records.
Employee #19 was hired on June 13, 2016 as a counselor and only 22 clock hours of training were documented for the July 1, 2016 to June 30, 2017 training year.
Employee #20 was hired on January 25, 2016 as a counselor and there were no training hours documented for the July 1, 2016 to June 30, 2017 training year.
Employee #21 was hired on May 210, 2013 as a counselor and only 14 clock hours of training were documented for the July 1, 2016 to June 30, 2017 training year.
Employee #22 was hired on November 5, 2007 as a counselor and only 23.5 clock hours of training were documented for the July 1, 2016 to June 30, 2017 training year.
Employee #23 was hired on April 13, 2009 as a counselor and only 16 clock hours of training were documented for the July 1, 2016 to June 30, 2017 training year.
Employee #24 was hired on September 18, 1989 as a counselor and only 23 clock hours of training were documented for the July 1, 2016 to June 30, 2017 training year.
Employee #25 was hired on July 6, 2009 as a counselor and only 21 clock hours of training were documented for the July 1, 2016 to June 30, 2017 training year.
Employee #26 was hired on October 6, 20013 as a counselor and only 14 clock hours of training were documented for the July 1, 2016 to June 30, 2017 training year.
Employee #27 was hired on April 10, 1989 as a counselor and only 24 clock hours of training were documented for the July 1, 2016 to June 30, 2017 training year.
Employee #28 was hired on February 9, 2004 as a counselor and only 14.8 clock hours of training were documented for the July 1, 2016 to June 30, 2017 training year.
These findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
-Supervisors will be responsible to review all training needs including accumulated hours with their staff during Weekly Supervision and/or during Bi-Weekly Team meetings in order to ensure that staff receive the appropriate trainings in the required time frame which will prevent this deficiency from reoccurring.
-Administrative Assistant will be responsible for collecting copies of Counselor's Training Certificates and will then enter those certificates in Counselor's training files in order to document the completion of 25 clock hours of required annual training. Those hours will be entered on the Training spreadsheet in order to ensure that this deficiency does not reoccur. |
704.12(a)(6) LICENSURE OutPatient Caseload
704.12. Full-time equivalent (FTE) maximum client/staff and client/counselor ratios.
(a) General requirements. Projects shall be required to comply with the client/staff and client/counselor ratios in paragraphs (1)-(6) during primary care hours. These ratios refer to the total number of clients being treated including clients with diagnoses other than drug and alcohol addiction served in other facets of the project. Family units may be counted as one client.
(6) Outpatients. FTE counselor caseload for counseling in outpatient programs may not exceed 35 active clients.
|
Observations
A licensing renewal inspection was conducted on December 14 - 15, 2017. Based on a review of the Staffing Requirements Facility Summary Report completed by the facility during the licensing process, the facility failed to ensure that all staff caseloads remained at or under 35:1.
Based on the total number of hours per week devoted to clients, and 35 hours, employee # 16 exceeded the allowable maximum 35:1 caseload.
The actual client caseload is determined by dividing the Full Time Equivalent (FTE) into the actual number of clients. The FTE is determined by dividing the number of hours devoted to the clients' treatment by the standard work week of 35 hours.
As reported on the Staffing Requirements Facility Summary Report, the number of hours per week devoted to outpatient treatment services by employee # 16 was 12 hours per week. The employee had 16 active client as of 12/15/17.
- Employee # 16 (12/35 = .3428 FTE *** 16 clients/.3428 = 47/1 caseload)
This finding was reviewed with facility staff during the licensing process.
|
Plan of Correction
Clinical Supervisors will routinely monitor Counselor's caseloads during their Weekly Supervision in order to ensure that they do not exceed the 35:1 Client/Counselor ratio so that this deficiency does not reoccur. |
705.28 (c) (4) LICENSURE Fire safety.
705.28. Fire safety.
(c) Fire extinguishers. The nonresidential facility shall:
(4) Instruct staff in the use of the fire extinguisher upon staff employment. This instruction shall be documented by the facility.
|
Observations
Based on the review of personnel/training records on December 12, 2017, the facility failed to instruct staff in the use of the fire extinguisher upon employment in one of thirty-three records reviewed.
Employee #14 was hired as a Counselor on September 14, 2017.
These findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
-Administrative Assistant and/or Executive Administrative Assistant will obtain verification of Pre-service Fire extinguisher trainings from new hires on their first day of employment. If AA/Exec AA is unable to obtain verification on their first day of employment, Supervisors will print Certificate from the LMS Learning Portal and submit to AA so that the training is filed and recorded on the Training spreadsheet in order to ensure this deficiency does not reoccur. |
705.28 (d) (3) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(3) Ensure that all personnel on all shifts are trained to perform assigned tasks during emergencies.
|
Observations
Based on the review of personnel/training records on December 12, 2017, the facility failed to ensure that all personnel on all shifts are trained to perform assigned tasks during emergencies in one of thirty-three records reviewed.
Employee #14 was hired as a Counselor on September 14, 2017.
These findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
-Administrative Assistant will keep track of the number of staff on each shift who are required to be trained to respond to emergencies. AA will register staff to complete these trainings and/or renew these trainings as they expire in order to ensure that this deficiency does reoccur. |
709.28 (c) LICENSURE Confidentiality
§ 709.28. Confidentiality.
(c) The project shall obtain an informed and voluntary consent from the client for the disclosure of information contained in the client record.
|
Observations
Eight client records were reviewed on December 14-15, 2017. The facility failed to obtain a valid informed and voluntary consent to release information in client records, # 1 and 5.
Client # 1 was admitted into treatment on 12/27/16 and was still active in treatment. The client's record contained a consent to release to a county children and youth services agency, signed and dated by the client on 11/30/17. The dated signature of a witness was not documented on this consent form. Documentation in the client's record indicated that the facility forwarded a letter to the county agency on 12/9/17, reporting the client's presence in treatment and prognosis.
Client # 5 was admitted into treatment on 8/31/17 and was still active in treatment. A consent to release to a medical assistance provider, signed and dated by the client on 8/29/17, did not document the dated signature of a witness.
These findings were reviewed with facility staff during the licensing inspection.
|
Plan of Correction
Facility Director re-trained staff on the proper procedure for completing Consents to Release Information on 1/11/18. Supervisors will complete monthly chart audits and review this process during Weekly supervisions and/or Team meetings to ensure that consents are completed properly which will prevent this deficiency from reoccurring.
The following deficiencies for client records #1 and #5 have been corrected as they remain active in our program. |
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
Five client records were reviewed for the outpatient methadone maintenance activity on November 14-15, 2017. The facility failed to document the provision of 2.5 total hours of psychotherapy per month and/or the provision of at least 1 hour of individual psychotherapy per month for client records # 4 and 5.
Client # 4 was admitted into treatment on 7/16/15 and was discharged on 8/25/17. Documentation in the client's record indicated that the client received less than 2.5 hours of combined psychotherapy for the following months: January 2017, February 2017, March 2017, April 2017, May 2017, and June 2017. In addition, the client received less than 1 hour of individual psychotherapy for the month of June 2017.
Client # 5 was admitted into treatment on 8/31/17 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 month of November 2017.
These findings were reviewed with facility staff during the licensing inspection.
|
Plan of Correction
Facility Director will conduct an in-service training on January 11th to review the monthly service requirements for program participants. Clinical Supervisors will then review Counselor's treatment schedule for their client's during their Weekly supervision in order to ensure that this deficiency does not reoccur. |
715.20(1) 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.
(1) The transferring narcotic treatment program shall transfer patient files which include admission date, medical and psychosocial summaries, dosage level, urinalysis reports or summary, exception requests, and current status of the patient, and shall contain the written consent of the patient.
|
Observations
Five client records were reviewed for the outpatient methadone maintenance activity on November 14-15, 2017. As a referring narcotic treatment program, the facility failed to document the transfer of required patient files to a receiving narcotic treatment program for client record # 4.
Client # 4 was admitted into treatment on 7/16/15 and was discharged on 8/25/17. Documentation in the client's record indicated that the client transferred to another narcotic treatment program, with treatment services beginning there on 8/24/17. The client's record did not contain documentation verifying the transfer of required patient files to the receiving narcotic treatment program.
This finding was reviewed with facility staff during the licensing inspection.
|
Plan of Correction
Facility Director re-trained staff on the correct process for completing external participant transfers on 1/11/18. Clinical Supervisors will be responsible for ensuring that participant documentation and/or files are sent to the receiving program as required to complete participant's transfer. Clinical Supervisors will enter documentation of those completed transfers into participant's file as part of their record in order to ensure that this deficiency does not reoccur. |
715.20(4) 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.
(4) The receiving narcotic treatment program shall document in writing that it notified the transferring narcotic treatment program of the admission of the patient and the date of the initial dose given to the patient by the receiving narcotic treatment program.
|
Observations
Five client records were reviewed for the outpatient methadone maintenance activity on November 14-15, 2017. As a receiving narcotic treatment program, the facility failed to document having notified the referring narcotic treatment program of the client's admission and date of the initial dose for client record # 5.
Client # 5 was admitted into treatment on 8/31/17, as a transfer, and was still active in treatment.
This finding was reviewed with facility staff during the licensing inspection.
|
Plan of Correction
The Intake Specialist will be responsible for providing verification of admission and date of initial dose to the referring narcotic treatment program via fax once a client is admitted to our program. The Intake Specialist will obtain fax confirmation and enter verification into the client's chart.
Clinical Supervisors will audit the charts of all new admissions assigned to their caseloads in order to confirm that the documentation is present and to ensure that this deficiency does not reoccur.
Training for this standard will be completed for all Clinical Staff by 3/5/18. |