INITIAL COMMENTS
|
This report is a result of an on-site licensure renewal inspection and NTP monitoring conducted on November 15, 2016 through November 16, 2016 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, The Healing Way was found not to be in compliance with the applicable chapters of 28 PA Code which pertain to the facility.
|
Plan of Correction
|
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 records on November 15-16, 2016, the facility failed to provide documentation of the required HIV/AIDS and TB/STD training in personnel record, #3.
Employee #3, a counselor was hired May 26, 2015. HIV/AIDS and TB/STD training was due to be completed no later than May 26, 2016.
These findings were reviewed with facility staff during the licensing inspection.
|
Plan of Correction
The findings were reviewed with the facility during the exit interview; The Healing Way has since taken drastic majors to insure that any new counselor coming in has been training or is schedule for all mandated training well within the allowed time frame. Upon reviewing and making state inspector aware of personnel record, #3 having her TB/STD certification. Since that time The Healing Way has also been proactive and researching training dates as well as outreaching to previous employer to obtain a copy of the Basic HIV certification for the staff member. The counselor has been registered with DDAP training management system to be able to search for upcoming trainings. The Counselor will register to attend the training being held on Friday March 10, 2017 from the DDAP training schedule unless they can locate a training soon then the date on the DDAP training management website. |
704.11(d)(1) LICENSURE Training Req-Proj/Fac Directors
704.11. Staff development program.
(d) Training requirements for project directors and facility directors.
(1) Subject areas for training shall be selected according to the training plan for each individual.
|
Observations
Based on a review of personnel records on November 15, 2016 and November 16, 2016. The facility failed to document 12 clock hours of annual training for employee #1. The facility's training year runs from January 1, 2015 through December 30, 2015.
Employee #1, Project Director/Facility Director was hired September of 2014. The facility documented 5 hours of training for the 2015 training year.
These findings were reviewed with facility staff during the licensing inspection.
|
Plan of Correction
The findings were reviewed with the facility during the exit interview; Program Director failed to comply with training requirements by only completing 5 of the 12 mandate training hours. As a plan for correction, The Healing Way has set up measures to register all new and existing staff for training throughout the year to be able to satisfy their training hours, including the Program Director Hours. The healing Way have sign up every staff member to the DDAP training website Training Management System to able to review upcoming training they might find interesting. To date The Healing Way has registered its staff of upcoming trainings in the coming months to be able to meet all mandated training hours within the training calendar year of December 31, 2017. |
709.25 LICENSURE Fiscal Management
§ 709.25. Fiscal management.
The project shall obtain the services of an independent certified public accountant for an annual financial audit of activities associated with the project ' s drug/alcohol abuse services, in accordance with generally accepted accounting principles which include reference to the drug and alcohol treatment activities.
|
Observations
Based on an administrative review on November 15, 2016 and November 16, 2016, the facility failed to document an annual audit for the facility's fiscal year January 2015 to December 2015.
This is a repeated citation from the December 2, 2015 licensing inspection.
These findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
Program Director will submit a letter to the State written by the Facility owners as a formal request of an exception from the requirements of 28 Pa. Code 709.25 (a). The letter for the request of an exception was created by the Owners and Program Director was able to provide said letter to the state inspector during the State Inspection to be submitted to the State Division of Drug and Alcohol Program Licensure. In the event that the exception is not granted, The Healing Way has been discussing with their accountant to devise a plan to be able to complete the Annual financial audit for The Healing Way if needed. The Hope is, the State would grant The Healing Way with the exception for the requirement of 28 Pa. Code 709.20 (a). However, The Healing Way accountants are aware if this request is denied the annual fiscal management audit would be due no later them before the start of the next fiscal year 1/1/2018. |
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
Based on a review of client records on November 15-16, 2016, the facility failed to document informed and voluntary consents in client record, #3.
Client #3 was admitted to treatment on August 25, 2016 and still active at the time of the inspection. An informed and voluntary consent was completed for a primary care physician on August 25, 2016, the facility failed to include the name of the primary care physician. Another informed and voluntary consent was completed for a laboratory on August 25, 2016, the facility failed to include what specific information is being release. Lastly, the facility provided client identifying information to a treatment provider on September 21, 2016. No consent on file for the treatment provider.
The findings were reviewed with the facility staff during the licensing process.
|
Plan of Correction
The Program failed to record the name of primary care doctor due to patients not having a primary care doctor at the time of their intake. Moving forward patients with no primary care doctor should not complete the primary care physician release of information. In addiction it should also be listed in the patient's treatment plan as a short-term goal to achieve while in treatment to seek and apply for a primary care physician. All the patients' charts have been check and that release has been removed from the patients chart.
Furthermore; The Healing Way has decided to remove the Lab release from the Intake packet since it's truly not needed. The Healing Way currently work with Atlantic Diagnostic Laboratories who are accredited by the Center for Medicare and Medicaid Services (CMS) and The Healing Way Group currently has a QSOA with Atlantic Diagnostic Laboratories.
All staff will complete training on the PA 255.5, which will be conducted in house again that will be held on Friday January 20, 2017, that will address the importance of confidentiality and the State regulations of PA 255.5. Training is set for January 20, 2017 with all staff including the front desk. Additionally, Program Director will post PA code 255.5 throughout the staffing areas in the facility as a quick reference point for when completing consent forms or releases.
Furthermore; compliance with PA 255.5 will be monitored via the monthly quality record review by the program Director, as well as during supervision with counselors. The Program Director is in charge of making sure that the training gets completed as well as the staffs are applying the PA 255.5 code to their release of information. To date the old consent forms has been pulled from client's charts. New consent to release information will be completed no later them January 27, 2017. During the meeting Counselor will be instructed to place these individual on hold throughout the week to have them complete and sign these new treatment plans.
|
715.16(c) LICENSURE Take-home privileges
(c) A narcotic treatment program shall require a patient to come to the narcotic treatment program for observation daily or at least 6 days a week for comprehensive maintenance treatment, unless a patient is permitted to receive take-home medication as follows:
|
Observations
Based on a review of patient records on November 15 - 16, 2016, the facility failed to demonstrate that the patient demonstrated satisfactory adherence to narcotic treatment program rules for at least 2 years in patient #9.
Patient #9 was admitted on January 16, 2015. The patient was granted 3-day take home.
The findings were reviewed with the facility staff during the licensing process.
|
Plan of Correction
On November 29, 2016 Program Director and the Medical Director and the medical team were able to have a meeting upon the conclusion of the state inspection where we were able to address the Take-home privilege policy. Medical Director was able to make the necessary corrections to the take home Privileges and had the number of Take-home reflects the length of time each patient were in the program. To date, all of the current patients with 3 or more Take-Home that had not been in the clinic or treatment for two or more years have had a change to their take home schedule. As a precautionary measure, moving forward The Healing will continue to make sure that all eligible patient's meet the requirement of the length of time to have 3 consecutive take-home. Medical Director has also sent a memo to all patients' explaining the changes. |
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
Based on a review of patient records on November 15- 16, 2016, the facility failed to provide each patient an average of 2.5 hours of psychotherapy per month during the patient's first 2 years of treatment in records, #1, 2, 5, 13.
Patient #1 was admitted on September 23, 2014.
July 2016 - only received 2 group session 1 hrs. each and 1 individual session (30 min)
September 2016 - only received 1 group session 1 hr and 1 individual session (30 min)
Patient #2 was admitted on October 2, 2014. The patient received .5 hours of psychotherapy in August 2016 and .5 hours in July 2016.
July - only received 30 mins individual session.
August 2016 - only received 30 mins individual session.
Patient #5 was admitted on August 31, 2016. The patient received 2 indivdual sessions for the month of October lasting 30 min each and no group sessions.
Patient #13 was admitted on January 16, 2015. The patient received 0 hours of psychotherapy in June 2016.
The findings were reviewed with the facility staff during the licensing process.
|
Plan of Correction
The findings were reviewed with the facility during the exit interview; it was noted that one of the counselors had failed to comply with state regulation on numerous occasion to provide the significant hours of service to the clients in the treatment. On December 9, 2016 the Program Director was able to call an all staff meeting where he addresses the issue with the counselor's. Counselors were given a time table before the end of the year to meet with clients on case current load and ensure each patient had the required service hours of 2.5hours for the month. Furthermore; the counselor's will need to create and provide Program director a copy of their weekly schedule of pending appointments for current case load. In addition Program Director will meet with Counselor during Bi-weekly supervision to address reason patients are not being see for their average of 2.5 hours of psychotherapy per month.
Program Director encouraged the counselors to place patients on hold or also use the behavior contracts in order to be able to meet with the patients on a weekly basis. Counselor how continue to fail to provide the adequate therapeutic 2.5 hours of service weekly to the patients will face disciplinary actions as deemed fit by the Program director. Moving forward, it will be the counselor responsibility to make sure that all of their patients are being seen on a weekly basis or a note is present as to why that patient did not have a session for that week. Program Director will monitor weekly program reports and record of service reports each counselors case loads.
|
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.
|
Observations
Based on a review of patient records on November 15-16, 2016, the facility failed to document an annual evaluation that included documentation of the patient's employment, education and training in patient records, #7 and 9.
Patient #7 was admitted on January 11, 2015. The annual evaluation was documented on January 5, 2016.
Patient #9 was admitted on January 16, 2015. The annual evaluation was documented on January 16, 2016.
The findings were reviewed with the facility staff during the licensing inspection.
|
Plan of Correction
The findings were reviewed with the facility during the exit interview; as a plan of correction, the Facility has discuss the issue with their programmer and has implement the 7 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 in their electronic system to ensure that all of the necessary areas are met and address by the counselors with the clients during each annual evaluation. The Healing Way has already taken steps toward correcting the problem by working with Tower System to implement the changes in the software; the Techs are currently working on the improvement and Program Director expects to have the updates to be completed no later than January 27, 2017 if not sooner. |
715.23(d) LICENSURE Patient records
(d) A narcotic treatment program shall prepare a treatment plan that outlines realistic short and long-term treatment goals which are mutually acceptable to the patient and the narcotic treatment program.
|
Observations
Based on a review of patient records on November 15-16, 2016, the facility failed to document a comprehensive treatment plan which should include short/long-term goals with action steps and support services in records 3, 4, 5 and 6.
Patient #3 admitted on August 25, 2016. The comprehensive treatment plan was completed on September 26, 2016.
Patient #4 admitted on August 30, 2016. The comprehensive treatment plan was completed on September 8, 2016.
Patient #5 admitted on August 31, 2016. The comprehensive treatment plan was completed on September 29, 2016.
Patient #6 admitted on March 7, 2016. The comprehensive treatment plan was completed on April 4, 2016.
The findings were reviewed with the facility staff during the licensing process.
|
Plan of Correction
Since the exit interview after the State inspection, The Program Director during regular bi-weekly clinical supervision have been and will continue to work with the counselor on how to create a clinically sound treatment plan that reflects the patients short and long term goals, that are measurable and that meet the standards of clinically sound treatment. Program Director also was able to order "The Practice Planners" The Addiction Treatment Planner" for each counselor to use as a tool guide in assisting in completing clinically sound treatment plan for their patients as well as providing copies of sample clinically sound treatment plans that address of a patients short and long term goals. Program Director help an all Staff meeting on December 9, 2016 where all these issues were address and the counselors were able to express their challenges with completing these treatment plans
The comprehensive Treatment plan should be completed within the first 5 days of the patient admission in the program and will reflect a time frame as well as list of patients Strengths. Counselor will have a time table of 30 days of their initial treatment plan and 60 days for every comprehensive Plans their after. Counselor will insure to include their action-steps to assist the client achieve success, as well as the clients action step that he will be working on while in the community to improve their recovery process.
|
709.91(b)(6) LICENSURE Intake and admission
709.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(6) Psychosocial evaluation.
|
Observations
Based on a review of patients records on November 15-16, 2016. The facility failed to document a psychosocial evaluation in patients records, # 3, 4, 5 and 6. The psychosocial evaluations documented were more historical or just documented what the client stated.
Patient #3 was admitted on August 25, 2016. Psychosocial was documented on September 26, 2016.
Patient #4 was admitted on August 30, 2016. Psychosocial was documented on August 29, 2016.
Patient #5 was admitted on August 31, 2016. Psychosocial was documented on August 31, 2016.
Patient #6 was admitted on March 7, 2016. Psychosocial was documented on March 4, 2016.
The findings were reviewed with the facility staff during the licensing process.
|
Plan of Correction
The Program Director will conduct an in-house training on January 20, 2017 to make sure anyone who is completing intake process is able to complete a clinically sound assessment evaluation of the Biopsychosocial, in addition to sending staff to take the clinical assessment training once it become available in our area. The counselor will make sure that they include all the information that is needed in the Biopsychosocial evaluation of each patient. However, after the exit interview, the Program Director was able to meet with staff as well as the tower system programmers to discuss what are needed in the psychosocial evaluation moving forward and they are to be implemented in the next intake. Program Director will conduct internal audit of each patient chats to ensure that the information need are added to each client charts. Effective immediately, and moving forward, all staff that complete an intake will ensure the all Biopsychosocial are more of the counselors' assessment of the individual seeking treatment and not a reporting of the client's history. Program Director will also review the BIO of these patients and will make the necessary corrections by January 27, 2017. |