INITIAL COMMENTS
|
This report is a result of an on-site licensure renewal and a methadone monitoring inspection conducted on May 18-19, 2021 by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, Williamsport Family Medical 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:
|
Plan of Correction
|
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.
|
Observations
Based on a review of eight personnel records on May 18-19, 2021, the facility failed to document that each counselor met both the education and experiential qualifications for the position. Employee #4, who was hired as a counselor on March 29, 2021 did not have a qualifying degree nor did they meet the experience requirements to be a counselor.The findings were reviewed with facility staff during the licensing process.This is a repeat citation from the licensing inspection that took place on May 19, 2020.
|
Plan of Correction
Approvals for Counselors and Counselor Assistants will be reviewed with Performance Improvement/Quality Improvement Department to ensure that hiring practices are consistent with licensing guidelines. Offers to Counselor/Counselor Assistant candidates will not be extended until approval from PI/QI is received noting any required supervision
Identified staff member will continue to be supervised and managed as a counselor assistant and proper job description will be signed and filed. |
715.9(e) LICENSURE Intake
(e) A narcotic treatment program shall secure a personal history from the patient within the first week of admission. The personal history shall be made a part of the patient record.
|
Observations
Based on a review of eight patient records on May 18-19, 2021, the facility failed to secure a personal history from the patient within the first week of admission in three records reviewed. Patient #1 was admitted on October 8, 2020 however, a personal history was not documented until December 16, 2020. Patient #2 was admitted on November 3, 2020 however, a personal history was not documented until December 31, 2020. Patient #7 was admitted on January 7, 2021 however, a personal history was not documented until January 18, 2021, The findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
Training on time-frame regulations was completed by Facility Director with all clinical/medical staff on 6/10/21. As of 6/11/21, Executive Director will monitor and verify the completion of personal history through a monitoring report in EMR. Admissions will be reviewed daily by Clinical Supervisor checking for personal history completion, with counselors responsible for the completion. Clinical Supervisor will then provide report to Facility Director each day to verify and ensure all signatures are obtained in regulatory time-frame and information is collected in a timely manner. |
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.
|
Observations
Based on a review of client records, the facility failed to document treatment plan updates within the regulatory timeframe in three out of eight client records reviewed. Client #1 was admitted on October 8, 2020 and was still active at time of the inspection. A treatment plan update was completed on March 3, 2021 and the next update was due no later than May 3, 2021; however, there was none documented in the record. Client #3 was admitted on August 20, 2020 and was still active at time of the inspection. A treatment plan update was completed on October 15, 2020 and the next update was due no later than December 15, 2020; however, was not completed until January 8, 2021. The following treatment update was completed on March 9, 2021 and the next update was due no later than May 9, 2021; however, there was none documented in the record. Client #5 was admitted on October 14, 2019 and was still active at the time of the inspection. Client #7 had a treatment plan update completed on December 14, 2020 with the next update due no later than February 14, 2021: however, was not completed until March 25, 2021. These findings were reviewed with facility staff during the licensing process.This was a repeat citation from the licensing inspection that took place on September 20, 2020.
|
Plan of Correction
Training on time-frame regulations was completed by Facility Director with all clinical/medical staff on 6/10/21. As of 6/11/21, Executive Director will monitor and verify the completion of treatment plan updates through a monitoring report in EMR. Upcoming treatment plan updates will be reviewed during group clinical supervision on a weekly basis with counselors responsible for the completion. Clinical Supervisor will provide individual reports in weekly supervision and report will be reviewed by Facility Director each week to verify and ensure all signatures from Medical Director, counselor, patient, and supervisor are obtained in regulatory time-frame. |