INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on July 5, 2018 through July 6, 2018 by staff from the Department of Drug and Alcohol Programs, Bureau of Quality Assurance for Prevention and Treatment, Program Licensure Division. 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(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.
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Observations
The facility failed to ensure that five staff persons received the required communicable disease trainings within the regulatory timeframe.
Employee #2 was hired as a counselor within the project on November 11, 2015 and was promoted to Clinical Supervisor on March 11, 2018. The employee file did not contain documentation of the TB/STD training at the time of the inspection.
Employee #9 was hired as a counselor on December 5, 2016. The employee file did not contain documentation of the TB/STD training at the time of the inspection.
Employee #10 was hired as a counselor on September 26, 2016. The employee file did not contain documentation of the HIV/AIDS training at the time of the inspection.
Employee #13 was hired as a counselor on August 17, 2015. The employee file did not contain documentation of the TB/STD training at the time of the inspection.
Employee #15 was hired as a counselor on July 5, 2016. The employee file did not contain documentation of the TB/STD training at the time of the inspection.
The findings were discussed with facility staff during the licensing process.
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Plan of Correction
Aldie has a program and staff person that are DDAP approved to provide both TB/STD and HIV/AIDS training. The trainings will be scheduled by the CEO for the for all affected individuals. All of the staff in need of the trainings will be mandated by the CEO to attend. The process will be completed by 9/15/18 and the training records will be updated by the Operations Manager. |
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
The facility failed to document the completion of 25 clock hours of annual training required for counselors for the facility's July 1, 2017 through June 30, 2018 training year in five employee files.
Employee #9's employee file documented 14.5 hours of annual training.
Employee #10's employee file documented 6.5 hours of annual training.
Employee #12's employee file documented 21 hours of annual training.
Employee #13's employee file documented 10.5 hours of annual training.
Employee #14's employee file documented 14.5 hours of annual training.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Effective July 26, 2018 Aldie has promoted an individual to Director of Clinical Programming. This individual will also serve as Facility Director for DDAP licensing purposes once the required paperwork is completed. The requirement to meet the minimum training hours will be communicated to therapists at staff meetings and individual and group supervision. The Operations Manager will keep a spreadsheet and post the same to a shared computer drive so that progress can be tracked throughout the year. The Facility Director will monitor and ensure compliance is obtained for all staff. |
705.28 (d) (1) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(1) Conduct unannounced fire drills at least once a month.
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Observations
The facility failed to conduct an unannounced fire drill for the month of April 2018 and the facility also failed to conduct fire drills during different times of the day and on different staffing shifts as every drill conducted during the reviewed timeframe was completed at 1:00 p.m. This was discovered based on the review of the August 2017 through June 2018 fire drill logs.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The CEO has appointed the Operations Manager to assume responsibilities for conducting monthly fire drills and keeping necessary records.This individual has extensive experience in this area and has not ever received a deficiency. The monthly log will also be reviewed at the end of each month by the Facility Director to further ensure compliance. |
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
The facility failed to obtain an informed and voluntary consent to release information form prior to the disclosure of information in one of ten patient records reviewed.
Patient #2 was admitted into the outpatient maintenance level of care on January 16, 2017 and was still active at the time of the inspection. There was a facsimile sent to another treatment provider on September 7, 2017; however, there was no consent to release information documented in the record prior to the disclosure.
The findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
A staff training will be held not later than August 21, 2018 on confidentiality and practical applications. The appointment of the Director of Clinical Programming will also add a management presence to the Langhorne facility. This individual will reinforce confidentiality protocols in supervision and team meetings. Documentation pertaining to confidentiality is also reviewed as part of monthly chart audits. |
715.28(c)(1-5) LICENSURE Unusual incidents
(c) A narcotic treatment program shall file a written Unusual Incident Report with the Department within 48 hours following an unusual incident including the following:
(1) Complaints of patient abuse (physical, verbal, sexual and emotional).
(2) Death or serious injury due to trauma, suicide, medication error or unusual circumstances.
(3) Significant disruption of services due to a disaster such as a fire, storm, flood or other occurrence.
(4) Incidents with potential for negative community reaction or which the facility director believes may lead to community concern.
(5) Drug related hospitalization of a patient.
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Observations
The facility failed to notify the Department within 48 hours of the death of an active patient. After the review of the facility's unusual incidents, the facility was notified of the off-site death of an active patient (admitted on September 21, 2017) on June 18, 2018; however, it was not reported to the Department until the day of the inspection-July 5, 2018.
These findings were reviewed with project and facility staff during the licensing process.
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Plan of Correction
A staff training on the proper completion and submission of Incident Reports was held in June, 2018. The recent appointment of the Director of Clinical Programming will add a management presence to the facility and offer an opportunity for further instruction in this area as well as assistance in completing the reports. |
709.92(b) LICENSURE Treatment and rehabilitation services
709.92. Treatment and rehabilitation services.
(b) Treatment and rehabilitation plans shall be reviewed and updated at least every 60 days.
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Observations
The facility failed to provide treatment plan updates within the regulatory timeframe in four of ten client records reviewed.
Client #2 was admitted on January 16, 2017 and was active at the time of inspection. A treatment plan update was completed on November 14, 2017 and the next update was due no later than January 14, 2018. However, the update was not completed until February 5, 2018.
Client #4 was admitted on June 15, 2010 and was discharged on June 25, 2018. A treatment plan update was completed on March 8, 2018 and the next update was due no later than May 8, 2018. However, the update was not completed prior to discharge.
Client #6 was admitted on October 3, 2017 and was discharged on May 24, 2018. A treatment plan update was completed on February 5, 2018 and the next update was due no later than April 5, 2018. However, the update was not completed prior to discharge.
Client #7 was admitted on September 13, 2017 and was discharged on December 8, 2017. The comprehensive treatment plan was completed on September 27, 2017 and the first update was due no later than November 27, 2017. However, the update was not completed prior to discharge.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
A Director of Clinical Programming was recently appointed. This individual has the responsibility for the oversight of all clinical services and compliance requirements. The Director of Clinical Programming will assist the Program Directors in reinforcing the requirement to provide timely treatment plan updates. This requirement will be also discussed at a staff meeting to be held on August 7th. Any barriers presented to compliance will be address by the Director. Monthly chart audits will also assist in ensuring compliance. |