INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on October 1-3, 2019 by staff from the Department of Drug and Alcohol Programs, Bureau of Quality Assurance for Prevention and Treatment. Based on the findings of the on-site inspection, Axiom Family Counseling 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(a)(3) LICENSURE Training Feedback
704.11. Staff development program.
(a) Components. The project director shall develop a comprehensive staff development program for agency personnel including policies and procedures for the program indicating who is responsible and the time frames for completion of the following components:
(3) A mechanism to collect feedback on completed training.
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Observations
During a licensing inspection conducted on October 30, 2019, the facility failed to a mechanism to collect feedback on completed trainings in three of six personnel records reviewed. Employee # 1 was hired for current position on August 20, 2011. Review of personnel records did not have a mechanism to collect feedback on completed trainings for the required 2018 training year.Employee # 2 was hired for current postilion on July 11, 2016. Review of personnel records did not have a mechanism to collect feedback on completed trainings for the required 2018 training year.Employee # 3 was hired for current position on March 12, 2015. Review of personnel records did not have a mechanism to collect feedback on completed trainings for the required 2018 training year.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The existing policy regarding completion of evaluation form upon completion of a training was amended to reflect Pennsylvania State regulations. In compliance with regulations, evaluations will be completed upon completion of in-house trainings only.
Compliance Officer will continue to provide evaluation forms to staff upon completing any trainings within the facility.
The evaluation form is required to be completed within 2 days of completing an in-house training and turned into the Compliance Officer.
Completion of evaluation forms will be monitored by Compliance Officer in audits of employee charts. |
709.28 (a) (2) LICENSURE Confidentiality
§ 709.28. Confidentiality.
(a) A written procedure shall be developed by the project director which shall comply with 4 Pa. Code § 255.5 (relating to projects and coordinating bodies: disclosure of client-oriented information). The procedure must include, but not be limited to:
(2) Identification of project staff having access to records, and the methods by which staff gain access.
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Observations
During a licensing inspection conducted on October 1-3, 2019, the facility's policy and procedure manual failed to include a written procedure identifying project staff having access to records, and the methods by which staff gain access.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The existing policy regarding access to client medical records were clarified to specify which staff have access to client records and for what purposes staff have access to client records.
The existing procedures regarding methods of access to client records were clarified to specify how both paper chart and electronic records are accessed and who will have access to them. |
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.
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Observations
During a licensing inspection conducted on October 2, 2019, the project failed to keep disclosures of client identifying information within the limits established by 4 Pa. Code 255.5 (b) for releases of information in client record # 7.Client # 7 was admitted on January 7, 2019 and was discharged on February 4, 2019. A voluntary and informed consent to disclose information form signed and dated August 20, 2018 to a funding agency allowed for the release of: type of treatment, progress notes, psychiatric evaluation, course of treatment, medications, and treatment plan.These findings were reviewed with project staff during the licensing process.
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Plan of Correction
A staff training was held reviewing PA Code 255.5 with all DA Staff. Clinical Supervisor reviewed with staff what information may be released under the code and what is in violation of the code.
Clinical Supervisor will audit for compliance with PA Code 255.5 in weekly chart audits and meet individually with any staff in violation of Code 255.5 for a coaching session. |
709.30 (4) LICENSURE Client rights
§ 709.30. Client rights.
The project shall develop written policies and procedures on client rights and document written acknowledgement by clients that they have been notified of those rights.
(4) Clients have the right to appeal a decision limiting access to their records to the director.
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Observations
During a licensing inspection conducted on October 1-3, 2019, the project ' s policy and procedure manual failed to include a written procedure identifying that clients have the right to appeal a decision limiting access to their records to the director.These findings were reviewed with project staff during the licensing process.
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Plan of Correction
The existing policy requiring all clients requesting an appeal to a decision limiting access to their records to follow appropriate procedure was clarified in the Policy and Procedure Manual to include specific process a client must complete to appeal said decision. The procedure previously outlined in Client Handbook is now outlined fully in the Policy and Procedure Manual.
The form utilized to complete an appeal to a decision limiting access to client records was incorporated into the EMR. That form will be provided to the client upon request by front office administration when the request is made.
The right to appeal a decision limiting access to client records remains within Client Handbook. The Client Handbook will continue to be reviewed in all intake/assessment sessions and provided to the client at time of intake/assessment. |
709.30 (5) LICENSURE Client rights
§ 709.30. Client rights.
The project shall develop written policies and procedures on client rights and document written acknowledgement by clients that they have been notified of those rights.
(5) Clients have the right to request the correction of inaccurate, irrelevant, outdated or incomplete information in their records.
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Observations
During a licensing inspection conducted on October 1-3, 2019, the project ' s policy and procedure manual failed to include a written procedure identifying that clients have the right to request the correction of inaccurate, irrelevant, outdated or incomplete information in their records. These findings were reviewed with project staff during the licensing process.
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Plan of Correction
The existing policy requiring all clients requesting a correction of inaccurate, irrelevant, outdated, or incomplete information in their records to follow appropriate steps was clarified in the Policy and Procedure Manual to include specific process required to complete a correction of records. The procedure previously outlined in Client Handbook is now outlined in Policy and Procedure Manual.
The form utilized for all requested corrections of inaccurate, irrelevant, outdated, or incomplete information to a client's record was incorporated into the EMR. That form will be provided to the client upon request by front office administration when the request is made.
The right to request the correction of inaccurate, irrelevant, outdated, or incomplete information is identified within Client Handbook. The Client Handbook will continue to be reviewed in all intake/assessment sessions and provided to the client at time of intake/assessment |
709.30 (6) LICENSURE Client rights
§ 709.30. Client rights.
The project shall develop written policies and procedures on client rights and document written acknowledgement by clients that they have been notified of those rights.
(6) Clients have the right to submit rebuttal data or memoranda to their own records.
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Observations
During a licensing inspection conducted on October 1-3, 2019, the project ' s policy and procedure manual failed to include a written procedure identifying the clients have the right to submit rebuttal data or memoranda to their own records. These findings were reviewed with project staff during the licensing process.
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Plan of Correction
The existing policy requiring all clients requesting to submit rebuttal data to follow appropriate procedure was clarified in the Policy and Procedure Manual to include specific process a client must complete to submit rebuttal data or memoranda to their own records. The procedure previously outlined in Client Handbook is now outlined in Policy and Procedure Manual.
The form utilized in requesting to submit rebuttal data or memoranda to a client's own chart was incorporated into the EMR. That form will be provided to the client upon request by front office administration when the request is made.
The right to submit rebuttal data or memoranda to their own client record is identified within Client Handbook. The Client Handbook will continue to be reviewed in all intake/assessment sessions and provided to the client at time of intake/assessment |
709.32 (c) (2) LICENSURE Medication control
§ 709.32. Medication control.
(c) The project shall have and implement a written policy and procedures regarding all medications used by clients which shall include, but not be limited to:
(2) Drug storage areas including, but not limited to, the secure storage of controlled substances and other abusable drugs in accordance with State and Federal regulations and program requirements.
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Observations
During a licensing inspection conducted on October 1-3, 2019, the project failed to follow their policy and procedure in the storage of medications. The policy states Vivitrol will be ordered daily per patient use and returned the same day if not used. The project was observed storing Vivitrol onsite indefinitely.These findings were reviewed with project staff during the licensing process.
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Plan of Correction
The existing policy detailing the storage, ordering, and returning of Vivitrol medication was amended. Amendments were made regarding time of ordering, length of storage, and return of Vivitrol medication. Policy now allows for Vivitrol medication to be ordered upon need for the medication being determined by prescriber. The policy will be amended to not include time frame for removal of unused samples or prescriptions. |
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.
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Observations
During a licensing inspection conducted on October 2, 2019 the program failed to provide documentation of 2.5 hours of psychotherapy per month during the patient's first 2 years of treatment. Patient # 1 was admitted on January 31, 2019 and was still active at the time of the inspection. In June 2019, the patient had 1.5 hours of individual therapy and no group therapy. In July 2019, the patient had 1.45 hours of individual therapy and no group therapy. In August 2019, the patient had 2 hours of individual therapy and no group therapy. In September 2019, the patient had 1 hour of individual therapy and no group therapy.These findings were reviewed with program staff during the licensing process.
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Plan of Correction
Staff training was held with all program clinicians at which therapy requirements for all clients receiving buprenorphine were reviewed.
All clients receiving buprenorphine medication not meeting required 2.5 hours of psychotherapy in any given month within first 2 years of treatment will be placed on a one month probationary period in which they must meet 2.5 hours of psychotherapy.
Ongoing chart audits will be completed by Clinical Supervisor to ensure all clients receiving buprenorphine medication are completing a minimum of 2.5 hours of therapy. |
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
During a licensing inspection conducted on October 2, 2019, the facility failed to provide documentation of a complete client record to include follow-up information.Client # 5 was admitted on May 16, 2019 and discharged on July 18, 2019. The client record did not contain documentation of follow-up information.Client # 6 was admitted on December 26, 2018 and discharged on March 21, 2019. The client record did not contain documentation of follow-up information.Client # 7 was admitted on January 7, 2019 and discharged on February 4, 2019. The client record did not contain documentation of follow-up information. These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
A staff training was held reviewing discharge follow up process and policy. Clinical Supervisor reviewed with staff requirement of a follow up phone call within 7 days following a positive or negative discharge. Staff were instructed to document follow up phone call on termination letter upon its completion.
Clinical Supervisor will audit for follow up phone call in weekly chart audits. Clinical Supervisor will meet with clinicians for a coaching session who have not completed a follow up phone call within 7 days of a positive or negative discharge. |