INITIAL COMMENTS
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This report is a result of an on-site licensure renewal and methadone monitoring inspection conducted on February 22, 2023 by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, RHJ Medical Center, 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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704.9(c) LICENSURE Supervised Period
704.9. Supervision of counselor assistant.
(c) Supervised period.
(1) A counselor assistant with a Master's Degree as set forth in 704.8 (a)(1) (relating to qualifications for the position of counselor assistant) may counsel clients only under the close supervision of a trained counselor or clinical supervisor for at least the first 3 months of employment.
(2) A counselor assistant with a Bachelor's Degree as set forth in 704.8 (a)(2) may counsel clients only under the close supervision of a trained counselor or clinical supervisor for at least the first 6 months of employment.
(3) A registered nurse as set forth in 704.8 (a)(3) may counsel clients only under the close supervision of a trained counselor or clinical supervisor for at least the first 6 months of employment.
(4) A counselor assistant with an Associate Degree as set forth in 704.8 (a)(4) may counsel clients only under the close supervision of a trained counselor or clinical supervisor for at least the first 9 months of employment.
(5) A counselor assistant with a high school diploma or GED equivalent as set forth in 704.8 (a)(5) may counsel clients only under the direct observation of a trained counselor or clinical supervisor for the first 3 months of employment. For the next 9 months, the counselor assistant may counsel clients only under the close supervision of a lead counselor or a clinical supervisor.
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Observations
Based on two applicable employee personnel records reviewed, the facility failed to provide documentation of supervision to include one hour of direct observation for a counselor assistant in employee records # 8 and # 9.
Employee # 8 was hired as a counselor assistant on September 12, 2022 and was still in this position at the time of the inspection. Based on a review of employee # 8's personal record there was no documentation of supervision that included one hour of direct observation with a master's degree.
Employee # 9 was hired as a counselor assistant on January 23, 2023 and was still in this position at the time of the inspection. Based on a review of employee # 9's personal record there was no documentation of supervision that included one hour of direct observation with an associate degree.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The leadership team will review and discuss the counselor training and supervision requirements and documentation and will update to include more specific documentation of the direct observation of staff. The staff charts will be reviewed at the end of the training period for each new hire to ensure that the training and documentation are complete and accurate. The facility director and clinical supervisor are responsible to ensure compliance with this regulation. |
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 two of five applicable employee personnel records reviewed, the facility failed to provide documentation of at least 25 clock hours of annual training required for a counselor for the training year January-December 2022 in employee records # 3 and # 7.
Employee # 3 was hired as a counselor on March 8, 2021 and was still in this position at the time of the inspection. After a review of employee # 3's personnel record, there were no training hours documented.
Employee # 7 was hired as a counselor on August 3, 2020 and was still in this position at the time of the inspection. After a review of employee # 7's personnel record, there were no training hours documented.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The leadership and training team reviewed the staff training documentation. It was determined that the trainings were noted but no training certificates were provided for some of the trainings. The training protocol was updated to include training certificates for all trainings beginning the 2023 training period. All staff were notified of this update. The clinical supervisor is responsible to ensure compliance with this regulation. |
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.
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Observations
Based on review of The Staffing Requirements Facility Summary Report, the FTE counselor caseload for counselor # 8 in the outpatient program exceeded 35 active clients.
Employee # 8 was hired as a counselor assistant on September 12, 2022 and was still in this position at the time of the inspection. Employee #8 was reported to have 16 hours per week devoted to their 16 clients on their caseload.
The FTE counselor's caseload calculation is as follows: 16/40 = .4 (FTE); 16/.4 = 40, which equals to a client/counselor ratio of 40:1.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The leadership team reviewed the citation and the counselor caseload cited. The leadership team updated the counselor caseload to ensure compliance with this regulation. All future non-full time staff ratios will be calculated prior to assignment of a caseload. The clinical supervisor is responsible to ensure compliance with this regulation. |
715.17(c)(1)(i-vi)) LICENSURE Medication control
(c) A narcotic treatment program shall develop and implement written policies and procedures regarding the medications used by patients which shall include, at a minimum:
(1) Administration of medication.
(i) A narcotic treatment physician shall determine the patient 's initial and subsequent dose and schedule. The physician shall communicate the initial and subsequent dose and schedule to the person responsible for the administration of medication. Each medication order and dosage change shall be written and signed by the narcotic treatment physician.
(ii) An agent shall be administered or dispensed only by a practitioner licensed under the appropriate Federal and State laws to dispense agents to patients.
(iii) Only authorized staff and patients who are receiving medication shall be permitted in the dispensing area.
(iv) There shall be only one patient permitted at a dispensing station at any given time.
(v) Each patient shall be observed when ingesting the agent.
(vi) Administering and dispensing shall be conducted in a manner that protects the patient from disruption or annoyance from other individuals.
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Observations
Based on one of four patient records reviewed, the facility failed to have a narcotic treatment physician determine the patient 's initial dose and schedule in patient record # 1.
Patient # 1 was admitted on January 12, 2023 and was still active at the time of the inspection. An initial dose order was documented in the patient record.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The leadership team reviewed the intake protocols, procedures, and documentation. The project director will meet with the medical staff to review the protocols, procedures, and documentation to ensure that documents are not omitted or incomplete. Upon completion of the patient intake, charts will be reviewed to ensure that all intake documentation is complete and accurate. The medical director and clinical supervisor are responsible to ensure compliance with this regulation. |
715.20(3) 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.
(3) The transferring narcotic treatment program shall document what materials were sent to the receiving narcotic treatment program.
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Observations
Based on one of one applicable patient record reviewed, the facility failed to include admission date, medical and psychosocial summaries, dosage level, urinalysis reports or summary, exception requests, and current status of the patient in the transfer paperwork provided to the receiving facility in patient record # 6.
Patient # 6 was admitted on May 11, 2022 and discharged on July 13, 2022. Patient # 6 was transferred to another facility and there was no documentation of the transfer paperwork documented in the patient record.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Leadership reviewed the record and documentation, updated the protocol to include copies of all documents sent to transferring facilities along with the fax transmittal together in the clinical chart. The leadership will hold a meeting with the clinical team to review the citation and resulting updates. To ensure future compliance chart audits will be conducted randomly to ensure inclusion of these documents. The clinical supervisor and facility director are responsible to ensure compliance with this regualtion. |
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.
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Observations
Based on one of two applicable patient records reviewed, the facility failed to provide, in writing, documentation 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.
Patient # 3 was admitted on June 7, 2022 and was still active at the time of the inspection. There was no documentation in the patient record of the initial dose given to the patient by the receiving treatment program.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Leadership reviewed the protocols, policies, and procedures for patient transfer into the facility. Leadership will meet with staff to review the protocols, policies, and procedures specific to patient transfer into the facility. Intake charts will be audited upon completion of intake to ensure compliance with this regulation. The clinical supervisor is responsible to ensure compliance with this requirement. |
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 one of four applicable patient records reviewed, the facility failed to provide documentation of an annual physical examination given by the narcotic treatment program which includes an annual reevaluation by the narcotic treatment physician.
Patient # 5 was admitted on February 29, 2013 and was discharged April 25, 2022. There was no documentation of an annual physical examination for the year 2022 documented in the patient record.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Leadership reviewed the current protocol for scheduling and completion of the patient's annual physical. The protocol will be reviewed with the clinical, front desk, and medical staff to ensure understanding and compliance with this regulation. Random chart audits will be conducted to ensure compliance with this regulation. The clinical supervisor is responsible for compliance with this requirement. |
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 one of one applicable client records reviewed, the facility failed to provide an aftercare plan upon successful discharge in client record # 5.
Client # 5 was admitted on February 29, 2013 and was discharged on April 25, 2022.
There was no aftercare plan available in the client record.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Leadership team reviewed this citation and the current protocol. The leadership team will meet with the clinical team to review patient discharge protocols and procedures, which include discharge planning, so that they understand the aftercare plan guidelines. The clinical supervisor is responsible to ensure that all discharge procedures are completed. Chart reviews of patient charts following discharge will be completed to ensure compliance with this regulation. |