INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on August 17 - 18, 2022 by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, Ellen O'Brien Gaiser Addiction 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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704.7(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 document each counselor met both the educational and experiential qualifications for the position in two of four personnel records reviewed.
Employee # 3 was promoted to counselor on May 25, 2022 and was still in the position at the time of the inspection. The employee did not have the documentation of at least one year of clinical experience as required with a bachelor's degree.
Employee # 6 was hired as a counselor on June 13, 2022 and was still in the position at the time of the inspection. The employee did not meet the educational requirements for the counselor position.
This finding was reviewed with the facility staff during the licensing process.
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Plan of Correction
Employee #3 was moved back to counselor assistant effective 08/23/2022. Clinical Director is documenting supervision and by 10/31/2022 employee will have all requirements met.
Employer have tried to track down all of Employee #6's documentation from previous employers and were unsuccessful. Therefore, effective 09/01/2022, employee is on status as high school level counselor assistant and will receive direct supervision with clients from counselors for his 3 month period beginning 09/01/2022 and will then move to ca status after that point. Clinical Director is responsible for tracking his supervision and ensuring that caseloads are in compliance and counselors are scheduled to supervise direct service. |
705.4 (3) LICENSURE Counseling areas.
705.4. Counseling areas.
The residential facility shall:
(3) Ensure privacy so that counseling sessions cannot be seen or heard outside the counseling room. Counseling room walls shall extend from the floor to the ceiling.
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Observations
Based on a physical plant inspection, the facility failed to ensure privacy so counseling sessions cannot be seen or heard outside the counseling room.
Video/cameras were located in three areas where counseling is provided.
This finding was reviewed with the facility staff during the licensing process.
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Plan of Correction
Facility Manager was responsible for ensuring cameras were removed from treatment spaces and placed in non-treatment areas in the facility. Project completed on 09/07/2022 and all cameras are now outside of treatment spaces. |
709.28 (a) (1) LICENSURE Confidentiality
§ 709.28. Confidentiality.
(a) A written procedure shall be developed by the project director which shall comply with 4 Pa. Code § 255.5 (relating to projects and coordinating bodies: disclosure of client-oriented information). The procedure must include, but not be limited to:
(1) Confidentiality of client identity and records. Procedures must include a description of how the project plans to address security and release of electronic and paper records and identification of the person responsible for maintenance of client records.
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Observations
Based on a review of client records, the facility failed to ensure the confidentiality of client identity in one of seven records reviewed.
During the review of Client #3 ' s record, the paper record contained identifying information about another client, including verbal orders, pharmacy documentation, and funding information.
This finding was reviewed with the facility staff during the licensing process.
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Plan of Correction
Medical and Clinical Directors reviewed this finding with the medical staff. Clinical Director has established this as part of internal chart reviews and medical staff will now ensure that all records are properly stored in the correct charts. This was all reviewed and effective on 9/01/22. |
709.28 (c) (4) 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 must be in writing and include, but not be limited to:
(4) Dated signature of client or guardian as provided for under 42 CFR 2.14(a) and (b) and 2.15 (relating to minor patients; and incompetent and deceased patients).
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Observations
Based on a review of client records, the facility failed to document the dated signature of the client on release of information forms in two of seven client records reviewed.
Client # 4 was admitted on May 2, 2022 and was discharged on July 1, 2022. A release of information form to another agency was signed and dated by the witness on May 2, 2022, but the form did not include a dated signature of the client.
Client # 6 was admitted on July 15, 2022 and was discharged on July 17, 2022. A release of information form was signed and dated by the witness, but the form did not document the dated signature of the client.
This finding was reviewed with the facility staff during the licensing process.
This is a repeat citation from the August 25 - 26, 2021 annual licensing inspection.
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Plan of Correction
Clinical Director and Executive Director reviewed this finding again with clinical staff on 9/1/2022. We have incorporated this as part of their compliance for annual review and failure to adhere to this will result in affecting performance evaluations effective 9/1/2022. An internal chart compliance committee was organized in response to this finding as well effective 9/1/2022. |
709.32 (c) (3) (i) - (v) LICENSURE Medication control
§ 709.32. Medication control.
(3) Inspection of storage areas that ensures compliance with State and Federal laws and program policy. The policy must include, but not be limited to:
(i) What is to be verified through the inspection, who inspects, how often, but not less than quarterly, and in what manner it is to be recorded.
(ii) Disinfectants and drugs for external use are stored separately from oral and injectable drugs.
(iii) Drugs requiring special conditions for storage to insure stability are properly stored.
(iv) Outdated drugs are removed.
(v) Copies of drug-related regulations are available in appropriate areas.
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Observations
Based on a review of the administrative information and discussion with facility staff, the facility failed to document the inspection of storage areas at least quarterly.
The documentation for the inspection of the storage area has not been completed since August 2021.
This finding was reviewed with the facility staff during the licensing process.
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Plan of Correction
Executive Director reviewed this finding with Medical Director and nurses on 8/22/2022. Effective 9/1/2022, the inspection logs are now stored in one common medication procedure binder for the nurses to fill out and they have already adhered to this new procedure effective 9/2022. |
709.52(b) LICENSURE TX Plan update
709.52. Treatment and rehabilitation services.
(b) Treatment and rehabilitation plans shall be reviewed and updated at least every 30 days. For those projects whose client treatment regime is less than 30 days, the treatment and rehabilitation plan, review and update shall occur at least every 15 days.
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Observations
Based on a review of client records, the facility failed to review and update treatment and rehabilitation plans at least every thirty days in three of five client records reviewed.
Client #2 was admitted on April 6, 2022 and was discharged on June 27, 2022. The individual treatment plan was completed on April 13, 2022 and the first update was due no later than May 13, 2022. A treatment plan update form was signed on June 26, 2022; however, it was blank and did not include a review or update.
Client #4 was admitted on May 2, 2022 and was discharged on July 1, 2022. The individual treatment plan was completed on May 9, 2022 and the first update was due no later than June 9, 2022; however, there was no update completed at the time of the inspection.
Client #7 was admitted on June 27, 2022 and was still active at the time of the inspection. The individual treatment plan was completed on July 4, 2022 and the first update was due no later than August 4, 2022; however, there was no update completed at the time of the inspection.
This finding was reviewed with the facility staff during the licensing process.
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Plan of Correction
Clinical Director and Executive Director reviewed with clinical staff on 9/1/2022. Clinical Director has established an internal chart compliance review committee effective on 9/1/2022 and failure of staff to adhere to this procedure will now affect their performance evaluations. |