INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection and methadone monitoring conducted on June 13, 2024, through June 14, 2024, by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, Aldie Foundation 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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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 a review of personnel records, the facility failed to ensure that each staff was instructed in the use of the fire extinguishers upon employment in one of two applicable records reviewed.
Employee # 4 was hired as a counselor on October 23, 2023 and was due to be trained in the use of fire extinguishers upon employment; however, fire safety training was not documented as complete until November 11, 2023.
This is a repeat citation from the June 2, 2023 annual licensing renewal inspection.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The CEO has reviewed the citation with the administrative assistant responsible for administering the fire safety instructions. The administrative assistant will instruct all new hires to complete the fire extinguisher training on the first day of hire. A certificate of completion will be issued and provided to the CEO to place in the personnel file. |
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 a review of personnel records, the facility failed to ensure that one staff was trained to perform assigned tasks during emergencies prior to being on shift in one of two applicable records reviewed.
Employee # 4 was hired as a counselor on October 23, 2023 and is current in that position. Employee # 4 began working shifts in October 2023 but was not trained to perform assigned tasks during emergencies until November 11, 2023.
This is a repeat citation from the June 2, 2023 annual licensing renewal inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The CEO has reviewed the citation with the administrative assistant responsible for administering the emergency training. The admin. assistant will administer the training at orientation on the first day of hire. A certificate of completion will be provided to the CEO to place in the personnel file. |
705.28 (d) (4) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(4) Maintain a written fire drill record including the date, time, the amount of time it took for evacuation, the exit route used, the number of persons in the facility at the time of the drill, problems encountered and whether the fire alarm or smoke detector was operative.
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Observations
Based on a review of the July 2023 through April 2024 fire drill logs, the facility failed to document the number of persons in the facility at the time of the drill and the exit route used during the October 2023, November 2023, December 2023, January 2024, February 2024, and April 2024 fire drills.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
The CEO has reviewed the citation with the administrative assistant responsible for conducting fire drills. The fire drill form has been modified to include the number of persons in the facility and the exit route to be used. The administrative assistant will use this form in the future and the CEO will review the forms monthly to ensure compliance.
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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
Based on a review of thirteen client records, the facility failed to obtain an informed and voluntary consent from the client for the disclosure of information in two records reviewed.
Client # 2 was admitted to the Outpatient level of care on December 11, 2023 and was active at the time of the inspection. The record contained documentation of a disclosure of information to another treatment provider on December 11, 2023, however, the record did not contain a client signed consent to release information form to the treatment provider.
Client # 10 was admitted to the Intake, Evaluation, and Referral level of care on September 15, 2023. The record contained documentation of a disclosure of information to probation officer on September 18, 2023 and September 25, 2023, however, the record did not contain a client signed consent to release information form to the officer.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The CEO has reviewed the citation with the Clinical Director, the Assessment Manager, and the Chief Nursing Officer. The CEO will also review the matter with the full staff at a meeting on July 17, 2024. Thereafter clinical and nursing supervisors will reinforce compliance at group and individual supervision sessions. Progress will be discussed at monthly management meetings, and further adjustments will be made if necessary. |
715.6(d) LICENSURE Physician Staffing
(d) A narcotic treatment program shall provide narcotic treatment physician services at least 1 hour per week onsite for every ten patients
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Observations
Based on the review of seventeen weeks of physician and physician assistant timesheets, the facility failed to provide at least one hour of physician time a week on site for every ten patients in three weeks reviewed.
During the week of January 1, 2024 through January 7, 2024, the patient census was 208. The facility was required to provide at least 20.8 physician hours. There were 16.25 hours documented.
During the week of January 8, 2024 through January 14, 2024, the patient census was 208. The facility was required to provide at least 20.8 physician hours. There were 11.5 hours documented.
During the week of March 25, 2024 through April 1, 2024, the patient census was 200. The facility was required to provide at least 20.0 physician hours. There were 9 hours documented.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The CEO will seek to obtain the services of a contracted physician to provide coverage during planned vacations and other prolonged absences. Individuals with prior working experience will be contacted first. If needed, the CEO will also seek the assistance from other OTP's as to physician availability, and once found will engage them for coverage. |
715.6(e) LICENSURE Physician Staffing
(e) A physician assistant or certified registered nurse practitioner may perform functions of a narcotic treatment physician in a narcotic treatment program if authorized by Federal, State and local laws and regulations, and if these functions are delegated to the physician assistant or certified registered nurse practitioner by the medical director, and records are properly countersigned by the medical director or a narcotic treatment physician. One-third of all required narcotic treatment physician time shall be provided by a narcotic treatment physician. Time provided by a physician assistant or certified registered nurse practitioner may not exceed two-thirds of the required narcotic treatment physician time.
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Observations
Based on the review of seventeen physician time sheets, the facility failed to provide the required number of hours onsite for the physician based on the census for one week reviewed. A physician must provide one-third of the required hours, with a certified registered nurse practitioner or physician's assistant providing the remaining two-thirds of the required hours.
During the week of January 8, 2024 through January 14, 2024, the patient census was 208. The physician was required to provide one-third of the 20.8 hours, which equals to 6.8 hours. The physician provided 3.5 hours.
Additionally, based on a review of patient records, the facility failed to ensure that documentation of duties performed by physician assistant or certified registered nurse practitioner (CRNP) were properly countersigned in seven of eight applicable records reviewed. The written agreement between the physician assistant and the narcotic treatment physician indicates that orders written by the physician assistant will be countersigned within 72 hours.
Patient # 1 was admitted on June 28, 2023 and was active at the time of the inspection. The record contained documentation of an order by the physician assistant on July 13, 2023, which was not countersigned by the narcotic treatment physician until July 19, 2023.
Patient # 2 was admitted on December 11, 2023 and was active at the time of the inspection. The record contained documentation of orders by the physician assistant on December 11, 2023, December 27, 2023, and February 28, 2024, which were not countersigned by the narcotic treatment physician until December 15, 2023, January 3, 2024, and March 7, 2024, respectively.
Patient # 4 was admitted on November 21, 2016 and was active at the time of the inspection. The record contained documentation of orders by the physician assistant on November 8, 2023, January 17, 2024, February 28, 2024, and March 20, 2024, which were not countersigned by the narcotic treatment physician until November 17, 2023, January 24, 2024, March 7, 2024, and March 25, 2024, respectively.
Patient # 5 was admitted on July 25, 2019 and was discharged on April 19, 2024. The record contained documentation of an order by the physician assistant on March 20, 2024, which was not countersigned by the narcotic treatment physician until March 25, 2024.
Patient # 6 was admitted on July 10, 2023 and was active at the time of the inspection. The record contained documentation of an order by the physician assistant on September 29, 2023, which was not countersigned by the narcotic treatment physician until October 6, 2023.
Patient # 7 was admitted on July 19, 2022 and was active at the time of the inspection. The record contained documentation of orders by the physician assistant on December 8, 2023 and December 15, 2023, which were not countersigned by the narcotic treatment physician until December 15, 2023 and December 26, 2023, respectively.
Patient # 8 was admitted on January 19, 2024 and was active at the time of the inspection. The record contained documentation of orders by the physician assistant on January 19, 2024 and June 7, 2024, which were not countersigned by the narcotic treatment physician until January 24, 2024 and June 13, 2024, respectively.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The CEO will seek to engage the services of a contracted physician to provide coverage during vacations and prolonged absences.
Regarding the countersigning of documents, the CEO has reviewed the matter with the medical director and the chief nursing officer. The Supervising Physician Agreement has been modified to allow for a longer time period to countersign documents. The existing agreement will remain in effect, until the modified agreement in approved. Compliance will be verified during regular chart audits throughout the year. |
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 a review of eight patient records, the facility failed to ensure that emergency contact information was obtained in one of five applicable records reviewed.
Patient # 8 was admitted on January 19, 2024 and was active at the time of the inspection. The record did not contain emergency contact information.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The CEO has reviewed the matter with the Clinical Director and Chief Nursing Officer. The CEO will further review the matter at a management meeting on July 9, 2024 and a full staff meeting on July 17, 2024. An audit of every active client chart will also be conducted to confirm that emergency contact information is on file. If missing, the receptionist will request this information from the client and upload the documentation to the client record. Ongoing compliance will be verified during regular chart audits. |
715.12(1-5) LICENSURE Informed patient consent
A narcotic treatment program shall obtain an informed, voluntary, written consent before an agent may be administered to the patient for either maintenance or detoxification treatment. The following shall appear on the patient consent form:
(1) That methadone and LAAM are narcotic drugs which can be harmful if taken without medical supervision.
(2) That methadone and LAAM are addictive medications and may, like other drugs used in medical practices, produce adverse results.
(3) That alternative methods of treatment exist.
(4) That the possible risks and complications of treatment have been explained to the patient.
(5) That methadone is transmitted to the unborn child and will cause physical dependence.
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Observations
Based on a review of patient records, the facility failed to obtain an informed, voluntary, written consent before an agent was administered in one of five applicable records reviewed.
Patient # 8 was admitted on January 19, 2024 and was active at the time of the inspection. The patient was initially administered an agent on January 19, 2024; however, the informed, voluntary, written consent was not signed by the client until January 26, 2024.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The CEO has reviewed the matter with the Chief Nursing Officer, who in turn provided instruction to the nursing staff. Proper procedure was reinforced that written consent must be obtained prior to the administration of any medication. The Chief Nursing Officer will provide ongoing instruction to the dispensing nurses in advance for all new admissions, and will review the medical record to ensure compliance. |
715.23(c)(1-7) LICENSURE Patient records
(c) An annual evaluation of each patient 's status shall be completed by the patient 's counselor and shall be reviewed, dated and signed by the medical director. The annual evaluation period shall start on the date of the patient 's admission to a narcotic treatment program and shall address the following areas:
(1) Employment, education and training.
(2) Legal standing.
(3) Substance abuse.
(4) Financial management abilities.
(5) Physical and emotional health.
(6) Fulfillment of treatment objectives.
(7) Family and community supports.
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Observations
Based on the review of patient records, the facility failed to document a completed annual evaluation that was reviewed, dated and signed by the medical director in two of three applicable records.
Patient # 4 was admitted on November 21, 2016 and was active at the time of the inspection. The annual clinical evaluation completed on November 21, 2023 was signed but not dated by the medical director.
Patient # 7 was admitted on July 19, 2022 and was active at the time of the inspection. The annual clinical evaluation completed on July 19, 2023 was signed but not dated by the medical director.
This is a repeat citation from the June 2, 2023 annual licensing renewal inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The CEO has reviewed the citation with the medical director and the chief nursing officer. The medical director has been reminded of the importance of dating the annual evaluations. The Clinical Director will continue to dialog with the medical director on this issue at clinical team meetings. Ongoing compliance will be monitored as part of regular chart audits. |
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 and the facility's policies and procedures, the facility failed to document a psychosocial evaluation, within 30 days of admission, in three of five applicable records reviewed.
Client # 2 was admitted on December 11, 2023 and was active at the time of the inspection. The psychosocial evaluation was not completed until January 17, 2024.
Client # 8 was admitted on January 19, 2024 and was active at the time of the inspection. The record did not contain a psychosocial evaluation.
Client # 9 was admitted on July 8, 2023 and was discharged on February 2, 2024. The psychosocial evaluation was not completed until September 19, 2023.
These finding were discussed with facility staff during the licensing process.
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Plan of Correction
The CEO has reviewed the citation with the Clinical Director and the Intake/Assessment Manager. The issue at hand stems largely from initial intakes that are done via telehealth, and individuals engaging in treatment at a later date. The Assessment Manager will revise the existing tracking system to note the admission date and the 30-day period in which the psychosocial evaluation must be performed. The CEO is also exploring a potential enhancement to the EHR which could track this requirement. If the individual does not engage in treatment within 29 days they will be discharged from the system. A care manager will follow-up separately in a effort to reengage the individual. |
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
Based on a review of client records, the facility failed to ensure that treatment and rehabilitation plans are reviewed and updated at least every sixty days in five of eight applicable client records reviewed. The facility has a Department approved exception indicating that treatment plans may be updated every 120 days for long-term patients who are stable and receiving counseling less than twice per month.
Client # 2 was admitted on December 11, 2023 and was active at the time of the inspection. A treatment plan update was completed on March 20, 2024, and the next treatment plan update was due no later than May 20, 2024; however, the next treatment plan update was not completed until June 5, 2024.
Client # 3 was admitted on April 4, 2023 and was discharged on February 21, 2024. The individual treatment and rehabilitation plan was completed on April 28, 2023, and the treatment plan update was due no later than June 28, 2023; however, the treatment plan update was not completed until August 4, 2023. A treatment plan update was completed on October 3, 2023, and the next treatment plan update was due no later than December 3, 2023, however, the next treatment plan update was not completed until December 26, 2023.
Client # 4 was admitted on November 21, 2016 and was active at the time of the inspection. A treatment plan update was completed on August 11, 2023, and the next treatment plan update was due no later than December 11, 2023; however, the next treatment plan update was not completed until January 3, 2024.
Client # 7 was admitted on July 19, 2022 and was active at the time of the inspection. A treatment plan update was completed on November 27, 2023, and the next treatment plan update was due no later than January 27, 2024; however, the next treatment plan update was not completed until February 16, 2024.
Client # 9 was admitted on July 28, 2023 and was discharged on February 2, 2024. The individual treatment and rehabilitation plan was completed on August 8, 2023, and the treatment plan update was due no later than October 8, 2023; however, the treatment plan update was not completed until November 30, 2023.
This is a repeat citation from the June 2, 2023 annual licensing renewal inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The CEO has reviewed the citation with the Clinical Director. The matter will also be discussed at a management meeting on July 9, 2024 and a full staff meeting on July 17, 2024. The Clinical Director and Assistant Clinical Director will prioritize compliance in group and individual supervision. As part of regular individual supervision sessions the counselor will review treatment plan updates due within the next 30 days. The supervisor will then verify completion at the next session. The CEO is also exploring a possible enhancement to the EDR to assist with tracking the deadlines. |
709.43(e) LICENSURE Consent to TX
709.43. Client management.
(e) A consent to treatment form should be completed and signed by the client and intake worker at intake.
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Observations
Based on a review of four client records, the facility failed to ensure that a consent to treatment form was completed and signed by the client and intake worker at intake in two records reviewed.
Client # 10 was admitted to the Intake, Evaluation, and Referral level of care on September 15, 2023. The record did not contain a consent to treatment form.
Client # 13 was admitted to the Intake, Evaluation, and Referral level of care on January 2, 2024. The record did not contain a consent to treatment form.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The CEO has reviewed the citation with the Clinical Director and Assessment Manager. The deficiency stems from initial intakes being done via telehealth. The matter will also be discussed at a July 9th management meeting and a full staff meeting on July 17th. The Assessment Director will ensure that the consent to treatment form is signed at the first opportunity when the individual as available to do so. In addition, a note will be made in the client record instructing any staff person that has contact with the client, that a consent form must be signed prior to engaging in treatment. Progress will be monitored as part of regular chart audits. |