INITIAL COMMENTS
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This report is a result of an on-site licensure renewal and methadone monitoring inspection conducted on June 7-8, 2023 by staff from the Department of Drug and Alcohol Programs, Bureau of 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 the Staffing Requirements Facility Summary Report and personnel records, the facility failed to document the completion of 25 clock hours of annual training required for counselors.
Employee #5 was hired as a counselor on July 6, 2010 and was still in the position as of the date of the inspection. The facility's training year that was reviewed was from July 1, 2021 through June 30, 2022. Employee # 5's record only document 22.5 hours of annual training for the training year reviewed.
This finding was reviewed with facility staff during the licensing inspection.
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Plan of Correction
The CEO has reviewed the citation with the management team. The Clinical Director reinforced the training hour requirement in group supervision with all clinical staff, and the clinical supervisor addressed the matter with the subject staff person during individual supervision. A new process has been implemented whereby staff upload training certificates into a shared drive. The CEO's administrative assistant reconciles the training hours monthly and informs the Clinical Director and staff of total hours completed to date and hours needed for compliance. During the last 60 days of the training year alerts are sent by the administrative assistant to non-compliant staff on a weekly basis. The Clinical Director is copied on the emails to ensure that staff are scheduled for trainings to obtain the necessary hours. |
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 facility failed to document an annual physical examination within the regulatory timeframe in one out of four applicable records.
Patient #9 was admitted on May 3, 2022 and was still active at the time of the inspection. The annual physical examination was due no later than May 3, 2023; however, it was not completed until May 18, 2023.
This finding was reviewed with facility staff during the licensing process.
This is a repeat citation from the June 30, 2022 licensing inspection.
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Plan of Correction
The CEO has reviewed the citation with Nursing and Clinical supervisors. Clarification was provided as to the regulatory requirement to complete the annual physical exam within 365 days, and not within the same month each year. Nursing and Clinical supervisors indicated their understanding of the clarification, and the current tracking system will be modified by the Director of Nursing to ensure the all annual exams are rescheduled within 365 days. The Chief Nursing Officer will conduct monthly audits of the records to further ensure compliance. |
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 clinical evaluation within the regulatory timeframe in one out of four applicable records.
Patient #4 was admitted on August 16, 2019 and was still active at the time of the inspection. The annual clinical evaluation was due no later than August 16, 2022; however, it was not completed until October 13, 2022.
This finding was reviewed with facility staff during the licensing inspection.
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Plan of Correction
The CEO has reviewed the matter with the Clinical Director, who in turn, reinforced compliance with the regulation during clinical group supervision. A new EHR has been implemented as of October, 2022 with enhanced tracking capabilities for various matters including annual evaluations. Clinical supervisors will review compliance during individual supervision by accessing the particular therapists' caseload on the EHR. As due dates approach the therapist will be alerted for the need to complete the annual evaluation, and will confirm that the task has been completed in the following supervision session. |
709.92(a) LICENSURE Treatment and rehabilitation services
709.92. Treatment and rehabilitation services.
(a) An individual treatment and rehabilitation plan shall be developed with a client. This plan shall include, but not be limited to, written documentation of:
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Observations
Based on a review of client records, the facility failed to document a comprehensive treatment plan within guidelines established by the facility's policy and procedures manual in one out of three applicable records reviewed. The facility's policy and procedures manual states the comprehensive treatment plan must be completed between within 30 days following admission.
Client #7 was admitted on November 7, 2022 and was discharged on April 13, 2023. A comprehensive treatment plan was due no later than December 7, 2022; however, it was not completed until March 22, 2023.
This finding was reviewed with facility staff during the licensing inspection.
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Plan of Correction
The CEO has reviewed the matter with the Clinical Director, who in turn, reinforced compliance with the regulation during clinical group supervision. A new EHR has been implemented as of October, 2022 with enhanced tracking capabilities for various matters including treatment plan updates. Clinical supervisors will review compliance during individual supervision by accessing the particular therapists' caseload on the EHR. As due dates approach the therapist will be alerted for the need to complete the comprehensive treatment plan, and will confirm that the task has been completed in the following supervision session. |
709.93(a)(9) 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:
(9) Aftercare plan, if applicable.
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Observations
Based on a review of client records, the facility failed to provide a complete client record, which is to include an aftercare plan in one out of three discharged records reviewed.
Client #8 was admitted on June 14, 2014 and discharged on October 20, 2022.
This finding was reviewed with facility staff during the licensing inspection.
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Plan of Correction
The CEO has reviewed the citation with the Clinical Director and Clinical Supervisors. The matter was then addressed by the Clinical Director in group clinical supervision. Clinical Supervisors will review compliance during individual supervision by accessing the therapists' records. When a client is discharged the matter will be addressed in supervision to ensure that the aftercare plan has been completed. The Clinical Supervisor conducting chart audits will also verify that an aftercare plan is in place and the client record is complete. |
709.93(a)(10) 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:
(10) Discharge summary.
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Observations
Based on a review of client records, the facility failed to document a discharge summary within guidelines established by the facility's policy and procedures manual in two out of three applicable records reviewed. The facility's policy and procedures manual states the discharge summary must be completed between within 7 days following discharge.
Client #2 was admitted on May 11, 2020 and was discharged on February 7, 2023. A discharge summary was due no later than February 14, 2023; however, the discharge summary was not completed until March 30, 2023.
Client #7 was admitted on November 7, 2022 and was discharged on April 13, 2023. A discharge summary was due no later than April 20, 2023; however, the discharge summary was not completed until June 6, 2023.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The CEO has reviewed the citation with the management team. After discussion it was determined that the policy should be changed to require a completed discharge summary within 30 days instead of 7. The policy has subsequently been changed. The Clinical Director and Clinical Supervisors addressed the matter in group supervision and will ensure compliance by a review of records during individual supervision. The supervisor in charge of chart audits will also ensure compliance as part of this process. |
709.93(a)(11) 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:
(11) Follow-up information.
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Observations
Based on a review of client records, the facility failed to provide a complete client record, which is to include follow-up information in two out of three discharged records reviewed.
Client #2 was admitted on May 11, 2020 and was discharged on February 7, 2023.
Client #8 was admitted on June 14, 2014 and was discharged on October 20, 2022.
These findings were reviewed with facility staff during the licensing process.
This is a repeat citation from the June 30, 2022 licensing inspection.
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Plan of Correction
The CEO has reviewed the citation with the Clinical Director and Clinical Supervisors. The policy has subsequently amended to increase the follow-up time-period to 30 days. The Clinical Director addressed the matter in group supervision and the Clinical Supervisors will ensure compliance during individual supervision by reviewing records of discharged clients. The supervisor in charge of chart audits will also track the issuance of a follow-up letter in the EHR. |