INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on August 7-8, 2013 by staff from the Division of Drug and Alcohol Program Licensure. 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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704.5(b) LICENSURE Clinical Supervisor
704.5. Qualifications for the positions of project director and facility director.
(b) If the facility does not have a clinical supervisor on staff, clinical responsibilities shall be addressed in one of the following ways:
(1) A facility director who has direct responsibility for clinical services shall meet the qualifications in at least one of the paragraphs of 704.7 (b) (relating to qualifications for the position of counselor).
(2) If the facility director does not meet counselor qualifications and the facility employs less than eight counselors, a lead counselor or part-time clinical supervisor shall be appointed.
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Observations
Based on a review of personnel records, the facility failed to ensure that clinical responsibilities were addressed by a facility director or clinical supervisor who met the qualifications for that position.
The findings include:
The personnel records were reviewed on August 7-8, 2013. One employee was listed as the facility director / clinical supervisor and was required to meet the qualifications for those positions. Employee #2 did not meet the qualifications for facility director or clinical supervisor.
Employee #2 was hired as a facility director / clinical supervisor on February 1, 2013. There was no degree certificate or official transcripts in employee #2's personnel record. The resume for employee #2 does not include any experience in a human service agency; therefore, employee #2 does not meet the qualifications for facility director and clinical supervisor.
An interview with the project director and facility director / clinical supervisor was conducted on August 8, 2013 at which time the aforementioned information was confirmed.
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Plan of Correction
A new facility director has been hired by the facility who meets requirements of facility director.
Employee file #2 has been updated with necessary documents.
Facility Director will review personnel charts on a quarterly basis to ensure all personnel files are up to date.
In the future, the board of directors will review candidates for facility director to ensure qualifications are met for the position.
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704.5(c) LICENSURE Qualifications for Proj/Fac Dir
704.5. Qualifications for the positions of project director and facility director.
(c) The project director and the facility director shall meet the qualifications in at least one of the following paragraphs:
(1) A Master's Degree or above from an accredited college with a major in medicine, chemical dependency, psychology, social work, counseling, nursing (with a specialty in nursing/health administration, nursing/counseling education or a clinical specialty in the human services), public administration, business management or other related field and 2 years of experience in a human service agency, preferably in a drug and alcohol setting, which includes supervision of others, direct service and program planning.
(2) A Bachelor's Degree from an accredited college with a major in chemical dependency, psychology, social work, counseling, nursing (with a specialty in nursing/health administration, nursing/counseling education or a clinical specialty in the human services), public administration, business management or other related field and 3 years of experience in a human service agency, preferably in a drug and alcohol setting, which includes supervision of others, direct service and program planning.
(3) An Associate Degree from an accredited college with a major in chemical dependency, psychology, social work, counseling, nursing (with a specialty in nursing/health administration, nursing/counseling education or a clinical specialty in the human services), public administration, business management or other related field and 4 years of experience in a human service agency, preferably in a drug and alcohol setting, which includes supervision of others, direct service and program planning.
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Observations
Based on a review of personnel records, the facility failed to document that the facility director met the qualifications for the position.
The findings include:
The personnel records were reviewed on August 7-8, 2013. One employee was listed as the facility director and was required to meet the qualifications for that position. Employee #2 did not meet the qualifications for facility director.
Employee #2 was hired as a facility director / clinical supervisor on February 1, 2013. There was no degree certificate or official transcripts in employee #2's personnel record. The resume for employee #2 does not include any experience in a human service agency; therefore, employee #2 does not meet the qualifications for facility director.
An interview with the project director and facility director / clinical supervisor was conducted on August 8, 2013 at which time the aforementioned information was confirmed.
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Plan of Correction
A new facility director has been hired by the facility who meets requirements of facility director.
Employee file #2 has been updated with necessary documents.
Facility Director will review personnel charts on a quarterly basis to ensure all personnel files are up to date.
In the future, the board of directors will review candidates for facility director to ensure qualifications are met for the position
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704.6(b) LICENSURE Qualification Groups
704.6. Qualifications for the position of clinical supervisor.
(b) A clinical supervisor shall meet at least one of the following groups of qualifications:
(1) A Master's Degree or above from an accredited college with a major in medicine, chemical dependency, psychology, social work, counseling, nursing (with a clinical specialty in administration or the human services) or other related field and 2 years of clinical experience in a health or human service agency which includes 1 year of working directly with the chemically dependent.
(2) A Bachelor's Degree from an accredited college with a major in chemical dependency, psychology, social work, counseling, nursing (with a clinical specialty in administration or the human services) or other related field and 3 years of clinical experience in a health or human service agency which includes 1 year of working directly with the chemically dependent person.
(3) An Associate Degree from an accredited college with a major in chemical dependency, psychology, social work, counseling, nursing (with a clinical specialty in administration or the human services) or other related field and 4 years of clinical experience in a health or human service agency which includes 1 year of working directly with the chemically dependent person.
(4) Full certification as an addictions counselor by a statewide certification body which is a member of a National certification body or certification by another state government's substance abuse counseling certification board and 3 years of clinical experience in a health or human service agency which includes 1 year of working directly with the chemically dependent person. The individual shall also complete a Department approved core curriculum training which includes a component on clinical supervision skills.
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Observations
Based on a review of personnel records, the facility failed to document that the clinical supervisor met the qualifications for the position.
The findings include:
The personnel records were reviewed on August 7-8, 2013. One employee was listed as the clinical supervisor and was required to meet the qualifications for that position. Employee #2 did not meet the qualifications for clinical supervisor.
Employee #2 was hired as a facility director / clinical supervisor on February 1, 2013. There was no degree certificate or official transcripts in employee #2's personnel record. The resume for employee #2 does not include any experience in a human service agency; therefore, employee #2 does not meet the qualifications for clinical supervisor.
An interview with the project director and facility director / clinical supervisor was conducted on August 8, 2013 at which time the aforementioned information was confirmed.
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Plan of Correction
A new facility director has been hired by the facility who meets requirements of facility director.
At this time, Axiom will not employ a clinical supervisor due to current staffing.
Employee #2 personnel charts have been updated with required information. Facility Director will audit personnel charts on a quarterly basis to ensure all necessary documents are included in personnel charts.
In the future, the board of directors will review qualifications of facility director and clinical supervisor to ensure person meets qualification for the positions before hire. |
704.6(c) LICENSURE Core Curriculum - Supervisor Training
704.6. Qualifications for the position of clinical supervisor.
(c) Clinical supervisors and lead counselors who have not functioned for 2 years as supervisors in the provision of clinical services shall complete a core curriculum in clinical supervision. Training not provided by the Department shall receive prior approval from the Department.
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Observations
Based on a review of personnel records, the clinical supervisor failed to complete a core curriculum training in clinical supervision.
The findings include:
The personnel records were reviewed on August 7-8, 2013. Employee #2 was listed as the facility director / clinical supervisor. Employee #2 did not complete a core curriculum in clinical supervision.
Employee #2 was hired as the facility director / clinical supervisor on February 1, 2013. The resume for employee #2 did not include any experience in the provision of clinical services. As of the time of the inspection, employee #2 has not completed a core curriculum in clinical supervision.
An interview with the project director and clinical supervisor was conducted on August 8, 2013 at which time the aforementioned information was confirmed.
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Plan of Correction
Axiom will not employ a clinical supervisor at this time. Clinical responsibilities will addressed by the facility director.
When a clinical supervisor is hired in the future, the clinical supervisor will have six months to complete the clinical supervisor training.
Facility Director will review at date of hire with clinical supervisor expectations and scheduling of clinical supervisor training to ensure compliancy with regulations. |
704.7(b) LICENSURE Counselor Qualifications
704.7. Qualifications for the position of counselor.
(a) Drug and alcohol treatment projects shall be staffed by counselors proportionate to the staff/client and counselor/client ratios listed in 704.12 (relating to full-time equivalent (FTE) maximum client/staff and client/counselor ratios).
(b) Each counselor shall meet at least one of the following groups of qualifications:
(1) Current licensure in this Commonwealth as a physician.
(2) A Master's Degree or above from an accredited college with a major in chemical dependency, psychology, social work, counseling, nursing (with a clinical specialty in the human services) or other related field which includes a practicum in a health or human service agency, preferably in a drug and alcohol setting. If the practicum did not take place in a drug and alcohol setting, the individual's written training plan shall specifically address a plan to achieve counseling competency in chemical dependency issues.
(3) A Bachelor's Degree from an accredited college with a major in chemical dependency, psychology, social work, counseling, nursing (with a clinical specialty in the human services) or other related field and 1 year of clinical experience (a minimum of 1,820 hours) in a health or human service agency, preferably in a drug and alcohol setting. If a person's experience did not take place in a drug and alcohol setting, the individual's written training plan shall specifically address a plan to achieve counseling competency in chemical dependency issues.
(4) An Associate Degree from an accredited college with a major in chemical dependency, psychology, social work, counseling, nursing (with a clinical specialty in the human services) or other related field and 2 years of clinical experience (a minimum of 3,640 hours) in a health or human service agency, preferably in a drug and alcohol setting. If a person's experience was not in a drug and alcohol setting, the individual's written training plan shall specifically address a plan to achieve counseling competency in chemical dependency issues.
(5) Current licensure in this Commonwealth as a registered nurse and a degree from an accredited school of nursing and 1 year of counseling experience (a minimum of 1,820 hours) in a health or human service agency, preferably in a drug and alcohol setting. If a person's experience was not in a drug and alcohol setting, the individual's written training plan shall specifically address a plan to achieve counseling competency in chemical dependency issues.
(6) Full certification as an addictions counselor by a statewide certification body which is a member of a National certification body or certification by another state government's substance abuse counseling certification board.
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Observations
Based on a review of personnel records, the facility failed to ensure that each counselor met the qualifications for the position in three of four personnel records.
The findings include:
On August 7-8, 2013, six personnel records were reviewed. Four personnel records were required to have documentation of the qualifications for the position of counselor. The facility failed to provide documentation of counselor qualifications in personnel records # 4, 5 and 6.
Employee # 4 was hired as a counselor on June 29, 2013. Employee # 4 has a Bachelor of Arts in Psychology and a Master of Arts in Forensic Psychology. Employee #4 did not complete a practicum and does not have any clinical experience. Employee #4 does not meet the experience requirement for the position of counselor.
Employee # 5 was hired as a counselor on January 23, 2013. The personnel record for employee #5 did not include any degree certificates or official transcripts. The facility failed to document that employee #5 met the qualifications for the position of counselor.
Employee # 6 was hired as a counselor on March 9, 2013. Employee # 6 has a Bachelor of Science in Elementary Education. Employee #6 does not have any clinical experience. Employee #6 does not meet the experience requirement for the position of counselor.
An interview with the project director and facility director was held on August 8, 2013 at which time the aforementioned information was confirmed.
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Plan of Correction
The employees that do not meet the qualifications for the position of counselor will be demoted to counselor assistants and their training plan and supervision will be adjusted accordingly. In the future, the facility director will review qualifications of all perspective employees to assess their qualifications for positions within the organization. |
705.27 (5) LICENSURE General safety and emergency procedures.
705.27. General safety and emergency procedures.
The nonresidential facility shall:
(5) Notify the Department within 48 hours of a fire, other disaster or situation which affects the continuation of services.
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Observations
Based on a review of fire drill logs, the facility failed to notify the Department within 48 hours of a fire, other disaster or situation which affects the continuation of services.
The findings include:
The fire drill logs were reviewed on August 8, 2013. An entry dated January 3, 2013 included that the building was on lockdown for 2 hours and 18 minutes due to an alleged gunman being in the building. There was no documentation that this incident was reported to the Department within 48 hours of the event.
An interview with the project director took place on August 8, 2013 at which time the aforementioned information was confirmed.
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Plan of Correction
A training was held focusing on "Reporting of Unusual Incident". Project Director specifically discussed the importance of adhering to proper protocol as outlined in the Policy and Procedures manual.
Project Director discussed the proper utilization of the Unusual Incident report and the necessity of providing documentation of any incident to the Department of Health within 48 hours of the event.
Within the trainings, staff was instructed to provide Incident reports to Project Director immediately for review of proper utilization of report and documentation of notification of Department of Health.
As part of our ongoing quality management plan, Project Director will review and initial incident report binder and follow up with staff weekly to ensure any unusual incidences were not reported or communicated.
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705.28 (c) (4) LICENSURE Fire safety.
705.28. Fire safety.
(c) Fire extinguishers. The nonresidential facility shall:
(4) Instruct staff in the use of the fire extinguisher upon staff employment. This instruction shall be documented by the facility.
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Observations
Based on the review of personnel records, the facility failed to document fire extinguisher training upon staff employment in three of five personnel records.
The findings include:
Six personnel records were reviewed on August 7-8, 2013. Five personnel records were reviewed to verify that staff had been instructed in the use of a fire extinguisher upon employment.. The facility failed to document the completion of fire extinguisher training upon staff employment in personnel record # 2, 3 and 5.
Employee # 2 was hired on January 21, 2013. Fire extinguisher training was due upon hire. Employee #2 completed fire extinguisher training on March 12, 2013.
Employee # 3 was hired on February 13, 2013. Fire extinguisher training was due upon hire. Employee #3 completed fire extinguisher training on February 25, 2013.
Employee # 5 was hired on January 23, 2013. Fire extinguisher training was due upon hire. Employee #5 completed fire extinguisher training on February 28, 2013.
An interview with the facility director/clinical supervisor took place on August 8, 2013 at which time the aforementioned information was confirmed.
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Plan of Correction
Fire extinguisher training was added to the initial employee orientation completed the first day of employment at Axiom Family Counseling Center. Fire extinguisher training will be added to the personnel file checklist for assurance that the training was completed on first day of hire. |
705.28 (d) (3) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(3) Ensure that all personnel on all shifts are trained to perform assigned tasks during emergencies.
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Observations
Based on the review of personnel records, the facility failed to document that all personnel on all shifts are trained to perform assigned tasks during emergencies in three of five personnel records.
The findings include:
Six personnel records were reviewed on August 7-8, 2013. Five personnel records were reviewed to verify that staff had been trained to perform assigned tasks during emergencies.. The facility failed to document the completion of emergency training in personnel record # 2, 3 and 5.
Employee # 2 was hired on January 21, 2013. Emergency training was due upon hire. Employee #2 completed emergency training on March 11, 2013.
Employee # 3 was hired on February 13, 2013. Emergency training was due upon hire. Employee #3 completed emergency training on March 11, 2013.
Employee # 5 was hired on January 23, 2013. Emergency training was due upon hire. Employee #5 completed emergency training on March 11, 2013.
An interview with the facility director/clinical supervisor took place on August 8, 2013 at which time the aforementioned information was confirmed.
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Plan of Correction
Emergency training was added to the initial employee orientation completed the first day of employment at Axiom Family Counseling Center.
This will ensure all personnel on all shifts are trained to perform assigned tasks during an emergency.
Emergency training will be added to the personnel file checklist for assurance that the training was completed on first day of hire.
This will be reviewed and audited by the facility directory to ensure compliancy with required trainings on first date of hire. |
709.26(d)(3) LICENSURE Personnel Management
709.26. Personnel management.
(d) The personnel records shall include, but not be limited to:
(3) The verification of training experience and professional licensure or registration, where applicable.
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Observations
Based on a review of personnel records, the facility failed to document the verification of training experience and professional licensure in two of six personnel records.
The findings include:
Six personnel records were reviewed on August 7-8, 2013. All six personnel records required the documentation of the verification of training experience and professional licensure. Personnel records # 2 and 5 did not include documentation of the verification of training experience and professional licensure.
Employee #2 was hired on January 21, 2013 and promoted on February 1, 2013. There was no degree certificate or official transcript documented in the personnel record of employee #1.
Employee #5 was hired on January 23, 2013. There was no degree certificate or official transcript documented in the personnel record of employee #5.
An interview with the project director and facility director was conducted on August 8, 2013 at which time the aforementioned information was confirmed.
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Plan of Correction
A "personnel checklist" will be utilized to ensure all personnel documents are in employee charts.
Facility/Project Director will audit and review personnel charts on an quarterly basis to ensure all necessary and required employee documents are in charts to ensure ongoing compliancy. |
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. The consent shall be in writing and include, but not be limited to:
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Observations
Based on the review of client records, the facility failed to ensure that the informed and voluntary consent to release information was within the limits imposed by 4 Pa. Code 255.5 (b) and the minimum amount of information necessary to fulfill the purpose of the release in three of six client records.
The findings included:
Six client records were reviewed August 7-8, 2013. Six records were reviewed regarding documentation for release of information . The facility failed to ensure that an informed and voluntary consent to release information was within the limits imposed by 4 Pa. Code 255.5 (b) and the minimum amount of information necessary to fulfill the purpose of the release in three of six records, # 2, 3 and 4.
Patient #2 was admitted on July 12, 2013 and releases of information were signed on July 12, 2013. The release of information signed for the insurance company included psychosocial evaluation, treatment plan, medical history, physical, treatment status and frequency of relapse. The information contained exceeded the limitations imposed by Pa Code 255.5 (b).
Patient #3 was admitted on July 12, 2013 and releases of information were signed on July 12, 2013. The release of information signed for the pharmacy included treatment plan, treatment status, nature of project and progress. The information contained in the release exceeds the information needed to fulfill the purpose of the release.
Patient #4 was admitted on July 13, 2013 and releases of information were signed on July 13, 2013. The release of information signed for the pharmacy included treatment status, prognosis, nature of project and progress. The information contained in the release exceeds the information needed to fulfill the purpose of the release.
An interview with the project director and facility director was conducted on August 8, 2013 at which time the aforementioned information was confirmed.
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Plan of Correction
A training was held by Project Director with all treatment staff to discuss confidentiality and release of information and 4 Pa Code 255.5.
The training conducted by the Project Director specifically discussed the purposes of disclosures, specific information to be disclosed, and not exceeding limitations needed to fulfill purpose of release in regards to PA Code 255.5.
As part of our ongoing quality management process, the Project Director will audit charts to ensure all information on releases is filled out appropriately with a purpose, specific information to be disclosed, and not exceeding limitations needed to fulfill purpose of release. |
709.28(c)(2) 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. The consent shall be in writing and include, but not be limited to:
(2) Specific information disclosed.
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Observations
Based on a review of the client records, the facility failed to document consents to release information which identified the specific information to be disclosed in five of six client records.
The findings include:
Six client records were reviewed on August 7-8, 2013. The consents to release information in record # 1, 3, 4, 5 and 6 did not indicate what specific information was to be released to the party whom the disclosure is being made.
The findings include:
Client # 1 was admitted to treatment on July 9, 2013. Release of information forms were signed on July 9, 2013 for a outside agency, laboratory and insurance company. None of the forms specified what information was to be released.
Client # 3 was admitted to treatment on July 12, 2013. A release of information form was signed on July 12, 2013 for an insurance company. The form did not specify what information was to be released.
Client # 4 was admitted to treatment on July 13, 2013. A release of information form was signed on July 13, 2013 for a laboratory. The form did not specify what information was to be released.
Client # 5 was admitted to treatment on August 1, 2013. Release of information forms were signed on August 1, 2013 for a OB/GYN, PCP, laboratory, pharmacy, and insurance company. None of the forms specified what information was to be released.
Client # 6 was admitted to treatment on July 13, 2013. Release of information forms were signed on July 13, 2013 for a doctor, laboratory, pharmacy, and insurance company. None of the forms specified what information was to be released.
An interview with the project director and facility director on August 8, 2013 at which time the aforementioned information was confirmed.
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Plan of Correction
A training was held by Project Director with all treatment staff to discuss confidentiality and release of information and 4 Pa Code 255.5.
The training conducted by the Project Director specifically discussed the purposes of disclosures, specific information to be disclosed, and not exceeding limitations needed to fulfill purpose of release in regards to PA Code 255.5.
As part of our ongoing quality management process, the Project Director will audit charts to ensure all information on releases is filled out appropriately with a purpose, specific information to be disclosed, and not exceeding limitations needed to fulfill purpose of release. |
709.28(c)(3) 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. The consent shall be in writing and include, but not be limited to:
(3) Purpose of disclosure.
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Observations
Based on a review of the client records, the facility failed to document consents to release information which identified the purpose of disclosure in three of six client records.
The findings include:
Six client records were reviewed on August 7-8, 2013. The consents to release information in record # 1, 5 and 6 did not indicate the purpose of disclosure.
The findings include:
Client # 1 was admitted to treatment on July 9, 2013. A release of information form was signed on July 9, 2013 for a outside agency and it did not include a purpose for the disclosure.
Client # 5 was admitted to treatment on August 1, 2013. Release of information forms were signed on August 1, 2013 for a OB/GYN, PCP, pharmacy, and insurance company. None of the forms specified the purpose of the disclosure.
Client # 6 was admitted to treatment on July 13, 2013. Release of information forms were signed on July 13, 2013 for a doctor, pharmacy, and insurance company. None of the forms specified the purpose of the disclosure.
An interview with the project director and facility director on August 8, 2013 at which time the aforementioned information was confirmed.
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Plan of Correction
A training was held by Project Director with all treatment staff to discuss confidentiality and release of information and 4 Pa Code 255.5.
The training conducted by the Project Director specifically discussed the purposes of disclosures, specific information to be disclosed, and not exceeding limitations needed to fulfill purpose of release in regards to PA Code 255.5.
As part of our ongoing quality management process, the Project Director will audit charts to ensure all information on releases is filled out appropriately with a purpose, specific information to be disclosed, and not exceeding limitations needed to fulfill purpose of release. |
709.30 LICENSURE Client Rights
709.30. Client rights.
The project director shall develop written policies and procedures on client rights and shall demonstrate efforts toward informing clients of the following:
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Observations
Based on a review of client records and the client handbook, the facility failed to demonstrate efforts toward informing clients of their rights specific to drug and alcohol treatment.
The findings include:
The client handbook, which contains the client rights, was reviewed on August 7-8, 2013. None of the required D/A client rights were included in the handbook, in the client records or posted anywhere in the facility.
An interview with the project director and facility director was conducted on August 8, 2013 at which time the aforementioned information was confirmed.
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Plan of Correction
The Drug and Alcohol Client Handbook has been updated with specific client rights related to drug and alcohol treatment.
The Project Director will complete reviews and monitor drug and alcohol client handbook on a quarterly basis to ensure all information is current and up to date.
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715.6(a) LICENSURE Physician staffing
(a) A narcotic treatment program shall designate a medical director to assume responsibility for administering all medical services performed by the narcotic treatment program
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Observations
Based on a review of the Staffing Requirements Facility Summary Report and personnel records, the facility failed to designate a medical director to assume responsibility for administering all medical services performed by the narcotic treatment program.
The findings include:
A review of the Staffing Requirements Facility Summary Report and personnel records and was conducted on August 7-8, 2013. The facility failed to document a medical director on the Staffing Requirements Facility Summary Report and there was no signed job description for medical director in the physician's personnel record. The facility has approval to provide buprenorphine services. In order to provide these services, a facility must have a medical director.
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Plan of Correction
The Medical Director's job description has been signed. Facility Director will complete personnel chart audits on a monthly basis to ensure all information is up to date and to ensure deficiency does not occur again.
Facility Director will also list Medical Director on Facility Summary Staffing Requirements and this summary will be reviewed by both Facility Director and Project Director. |
715.9(a)(2) LICENSURE Intake
(a) Prior to administration of an agent, a narcotic treatment program shall screen each individual to determine eligibility for admission. The narcotic treatment program shall:
(2) Verify the individual 's identity, including name, address, date of birth, emergency contact and other identifying data.
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Observations
Based on the review of patient records, the facility failed to verify the patient's emergency contact prior to the administration of an agent in two of five patient records.
The findings include:
Six patient records were reviewed on August 7-8, 2013. Five of the patient records reviewed required the documentation of an emergency contact. An emergency contact was not documented in patient records #4 and 6.
Patient #4 was admitted on July 13, 2013 and was provided a prescription for buprenorphine on July 15, 2013. There was no documentation of an emergency contact in patient record #4.
Patient #6 was admitted on July 12, 2013 and was provided a prescription for buprenorphine on July 18, 2013. There was no documentation of an emergency contact in patient record #6.
An interview with the project director and facility director was conducted on August 8, 2013 at which time the aforementioned information was confirmed.
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Plan of Correction
The audit form utilized by the project director for quality management/internal audit purposes was updated to include the emergency contact form. Audits will be conducted regularly to ensure emergency contact forms are completed in chart by Project Director and Administrative staff.
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715.9(a)(4) LICENSURE Intake
(a) Prior to administration of an agent, a narcotic treatment program shall screen each individual to determine eligibility for admission. The narcotic treatment program shall:
(4) Have a narcotic treatment physician make a face-to-face determination of whether an individual is currently physiologically dependent upon a narcotic drug and has been physiologically dependent for at least 1 year prior to admission for maintenance treatment. The narcotic treatment physician shall document in the patient 's record the basis for the determination of current dependency and evidence of a 1 year history of addiction.
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Observations
Based on a review of patient records, the facility failed to document a physical examination in five of five patient records.
The findings include:
Six patient records were reviewed on August 7-8, 2013. Five of the patients reviewed required the completion of a physical examination prior to admission to narcotic, specifically buprenorphine, services.. Patient records #1, 2, 3, 4 and 6 did not include documentation of a physical examination.
Patient #1 was admitted on July 9, 2013. There was no documentation of a physical examination in patient record #1.
Patient #2 was admitted on July 12, 2013. There was no documentation of a physical examination in patient record #2.
Patient #3 was admitted on July 12, 2013. There was no documentation of a physical examination in patient record #3.
Patient #4 was admitted on July 13, 2013. There was no documentation of a physical examination in patient record #4.
Patient #6 was admitted on July 12, 2013. A physical was completed by an off-site physician; however, there was no documentation of a consultation between the narcotic treatment physician and the off-site physician who completed the physical.
An interview with the project director and facility director took place on August 8, 2013 at which time the aforementioned information was confirmed. All identified patients participated in buprenorphine treatment.
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Plan of Correction
A Certified Registered Nurse Practitioner has been hired to complete physicals for patients requiring a physical.
The narcotic treating physician will review all physicals and information collected by the CRNP.
To ensure a physical review has occurred for every patient receiving the physical by the CRNP, the narcotic treating physician will also sign all physical forms.
Facility Director will complete chart audits to ensure all patients requiring a physical have one completed before treatment begins and to ensure all physicals were reviewed by the narcotic treating physician.
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715.28(a)(1-10) LICENSURE Unusual incidents
(a) A narcotic treatment program shall develop and implement policies and procedures to respond to the following unusual incidents:
(1) Physical assault by a patient.
(2) Inappropriate behavior by a patient causing disruption to the narcotic treatment program.
(3) Selling of drugs on the premises.
(4) Complaints of patient abuse (physical, verbal, sexual and emotional).
(5) Death or serious injury due to trauma, suicide, medication error or unusual circumstances.
(6) Significant disruption of services due to disaster such as fire, storm, flood or other occurrence.
(7) Incident with potential for negative community reaction or which the facility director believes may lead to community concern.
(8) Theft, burglary, break-in or similar incident at the facility.
(9) Drug related hospitalization of a patient.
(10) Other unusual incidents the narcotic treatment program believes should be documented.
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Observations
Based on a review of fire drill logs, the facility failed to notify the Department of an unusual incident involving a fire, other disaster or situation which affects the continuation of services.
The findings include:
The fire drill logs were reviewed on August 8, 2013. An entry dated January 3, 2013 included that the building was on lockdown for 2 hours and 18 minutes due to an alleged gunman being in the building. There was no documentation that this incident was reported to the Department within 48 hours of the event.
An interview with the project director took place on August 8, 2013 at which time the aforementioned information was confirmed.
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Plan of Correction
A training was held focusing on "Reporting of Unusual Incident". Project Director specifically discussed the importance of adhering to proper protocol as outlined in the Policy and Procedures manual.
Project Director discussed the proper utilization of the Unusual Incident report and the necessity of providing documentation of any incident to the Department of Health within 48 hours of the event.
Within the trainings, staff was instructed to provide Incident reports to Project Director immediately for review of proper utilization of report and documentation of notification of Department of Health.
As part of our ongoing quality management plan, Project Director will review and initial incident report binder and follow up with staff weekly to ensure any unusual incidences were not reported or communicated. |
709.91(b)(5) LICENSURE Intake and admission
709.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(5) Physical examination, if applicable.
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Observations
Based on a review of client records, the facility failed to document a physical examination in five of six client records.
The findings include:
Ten client records were reviewed on August 7-8, 2013. Six of the clients reviewed were required to have documentation of a physical examination. Client records # 1, 2, 3, 4 and 5 did not include documentation of a physical examination.
Client #1 was admitted on July 9, 2013. There was no documentation of a physical examination in client record #1.
Client #2 was admitted on July 12, 2013. There was no documentation of a physical examination in client record #2.
Client #3 was admitted on July 12, 2013. There was no documentation of a physical examination in client record #3.
Client #4 was admitted on July 13, 2013. There was no documentation of a physical examination in client record #4.
Client #5 was admitted on August 1, 2013. There was no documentation of a physical examination in client record #5.
An interview with the project director and facility director was conducted on August 8, 2013 at which time the aforementioned information was confirmed.
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Plan of Correction
A Certified Registered Nurse Practitioner has been hired to complete physicals for patients requiring a physical.
The narcotic treating physician will review all physicals and information collected by the CRNP.
To ensure a physical review has occurred for every patient receiving the physical by the CRNP, the narcotic treating physician will also sign all physical forms.
Facility Director will complete chart audits to ensure all patients requiring a physical have one completed before treatment begins and to ensure all physicals were reviewed by the narcotic treating physician. |
709.91(b)(6) LICENSURE Intake and admission
709.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(6) Psychosocial evaluation.
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Observations
Based on a review of client records, the facility failed to document psychosocial evaluations that provided a composite picture of the individual in relationship to the collected historical information in order to identify possible relationships, conditions and causes leading to the client's current situation in six of six client records.
The findings include:
Ten client records were reviewed on August 7-8, 2013. Six of the records were reviewed for the content of the psychosocial evaluation. Client records # 1, 2, 3, 4, 5 and 6 failed to include a psychosocial evaluation that included a composite picture of the client's problems and needs to be addressed in treatment, the client's assets and strengths, coping mechanisms, support systems, the negative factors that might inhibit treatment, and the counselor's impressions regarding the patient. The documentation included a repeat of the client historical information and did not include an evaluation by the clinician for all required components.
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Plan of Correction
A training was conducted by the Project Director to address proper utilization of the Psychosocial evaluation, specifically focusing on documenting an evaluation by the clinician for all required components. This new procedure will be included in new employee orientation procedure. As part of our ongoing quality management process, this component will added to the quality assurance chart audit procedures that are completed and reviewed by the Project Director |
709.92(a)(3) 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:
(3) Proposed type of support service.
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Observations
Based on a review of client records, the facility failed to provide written documentation of the proposed type of support service, in the individual treatment and rehabilitation plans, in five of five client records.
The findings include:
Ten client records were reviewed on August 7-8, 2013 The individual treatment and rehabilitation plans were reviewed in five client records and all five were required to include the proposed type of support services. The facility did not document proposed type of support services in client records # 1, 2, 3, 4 and 6.
Client # 1 was admitted on July 9, 2013. The individual treatment and rehabilitation plan was completed on July 25, 2013. There was no documentation of support services in the treatment plan.
Client # 2 was admitted on July 12, 2013. The individual treatment and rehabilitation plan was completed on July 12, 2013. There was no documentation of support services in the treatment plan.
Client # 3 was admitted on July 12, 2013. The individual treatment and rehabilitation plan was completed on July 25, 2013. There was no documentation of support services in the treatment plan.
Client # 4 was admitted on July 13, 2013. The individual treatment and rehabilitation plan was completed on July 27, 2013. There was no documentation of support services in the treatment plan.
Client # 6 was admitted on July 12, 2013. The individual treatment and rehabilitation plan was completed on July 12, 2013. There was no documentation of support services in the treatment plan.
An interview with the project director and facility director was held on August 8, 2013 at which time the aforementioned information was confirmed.
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Plan of Correction
Initial and comprehensive treatment plan forms have been amended to include area for documentation of proposed type of support services. Counselors and counselor assistants have been trained by Project Manager on the proper utilization of the new forms and how to assess for proper offering of support services. This new policy will be included in new employee orientation procedure and added to the quality assurance chart audit procedures that are completed by the Project Director. |