INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on August 3, 2021 by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, WPIC Narcotic Addiction Program 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 the review of personnel record, the facility failed to ensure that each counselor completed at least 25 clock hours of training annually in one of two records.
Employee # 3 was hired as a counselor on July 1, 2014. There were only 9.5 hours of training documented for the 2020 training year.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Under the direction of the Facility Director or designee:
A. Clinicians will complete 25 training hours annually.
B. Clinical Supervisors will review training hours in weekly supervision to ensure that clinicians are on target to meet training requirements and to offer training resources if needed.
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715.9(a)(1) 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:
(1) Verify that the individual has reached 18 years of age.
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Observations
Based on the review of client records, the facility failed to verify the individual has reached 18 years of age in one of five client records.
Client # 2 was admitted on March 5, 2021 and was still an active client at the time of the inspection. There was no verification the individual had reached the age of 18.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
715.9(a)(1) INTAKE
Under the direction of the Facility Director or designee:
A. All patients admitted will provide photo ID on day of intake to indicate they have reached 18 years of age.
B. Clinical Supervisors will ensure through weekly chart audits that a copy of a photo ID for included in intake paperwork and uploaded into EMR.
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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 client records, the facility failed to verify the individual 's identity, including name, address, date of birth, emergency contact and other identifying data in one of five client records.
Client # 2 was admitted on March 5, 2021 and was still an active client at the time of the inspection. There was no verification of the individual 's identity.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Under the direction of the Facility Director or designee:
A. All patients admitted will provide proof of identity on day of intake which consists of name, address, date of birth, emergency contact and other identifying information.
B. Clinical Supervisors will ensure through weekly chart audits that there is documented proof of identity included in intake paperwork and uploaded into EMR.
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715.15(a) LICENSURE Medication Dosage
(a) The narcotic treatment physician shall review the dosage levels at least twice a year, with each review occurring at least 2 months apart, to determine a patient 's therapeutic dosage.
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Observations
Based on the review of client records, the facility failed to document that the narcotic treatment physician reviewed the dosage levels at least twice a year, in one of one client record.
Client # 4 was admitted on November 18, 2014 and was still an active client at the time of the inspection.
There was only one dosage level review documented from January to December 2020.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Under the direction of the Medical Director or designee:
A. All patients will receive a medication dose reviews twice annually.
B. Nurse Manager will ensure through monthly dose review reports that all patients have received dose reviews twice annually.
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