INITIAL COMMENTS
|
This report is a result of an on-site licensure renewal inspection conducted on December 11 through December 13, 2012, by staff from the Division of Drug and Alcohol 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.
|
Plan of Correction
|
704.6(e) LICENSURE Supervisory Meetings
704.6. Qualifications for the position of clinical supervisor.
(e) Clinical supervisors are required to participate in documented monthly meetings with their supervisors to discuss their duties and performance for the first 6 months of employment in that position. Frequency of meetings thereafter shall be based upon the clinical supervisor's skill level.
|
Observations
Based on a review of personnel records, the facility failed to document that the clinical supervisor participated in monthly meetings with their supervisor to discuss their duties and performance for the first six months of employment in that position in one of one personnel record.
The findings include:
Personnel records were reviewed on December 11-12, 2012. Three personnel records reviewed were clinical supervisors. One personnel record required the documentation of monthly meetings between the clinical supervisor and their supervisor for the first six months of employment in that position. The facility failed to document monthly supervision meetings in personnel record # 3.
Employee # 3 was hired at the project on February 6, 2012 as the Pharmacotherapy Coordinator/Clinical Supervisor. Monthly supervision meetings were required to take place in February, March, April, May, June and July 2012. There were two months of supervision documented for employee # 3, November 2012 and December 2012. The documentation was started ten months late.
An interview with the clinical director confirmed this finding and was not disputed.
|
Plan of Correction
The clinical director shall document supervisory sessions with all clinical supervisors; monthly for their first six months, and then subsequently as warranted by their skill level. The executive director shall monitor the clinical director's compliance via quarterly reviews of the supervision log.
The clinical director has started this documentation in December 2012 with the newly hired clinical supervisor. |
704.11(c)(1) LICENSURE Mandatory Communicable Disease Training
704.11. Staff development program.
(c) General training requirements.
(1) Staff persons and volunteers shall receive a minimum of 6 hours of HIV/AIDS and at least 4 hours of tuberculosis, sexually transmitted diseases and other health related topics training using a Department approved curriculum. Counselors and counselor assistants shall complete the training within the first year of employment. All other staff shall complete the training within the first 2 years of employment.
|
Observations
Based on a review of the Staffing Requirements Facility Summary Report and training records, the facility failed to provide documentation of HIV/AIDS and TB/STD training five of fifteen records reviewed.
The findings include:
The Staffing Requirements Facility Summary Report and fifteen personnel records were reviewed on December 11-12, 2012. Per regulation, staff persons shall receive a minimum of four hours of TB/STD training and six hours of HIV/AIDS training. Counselors and counselor assistants shall complete the training within the first year of employment and all other staff shall complete the training within the first two years of employment.
Employee # 10 was hired 4/19/2010 as a counselor. This employee was required to obtain four hours of TB/STD training by 4/19/2012. Employee #10 failed to obtain the training as of the date of the inspection.
Employee #11 was hired 9/8/2005 as a support staff member. This employee was required to obtain four hours of STD/TB and 6 hours of HIV/AIDS training by 9/8/2007. Employee #11 failed to obtain the training as of the date of the inspection.
Employee #12 was hired 5/11/2010 as a support staff member. This employee was required to obtain four hours of STD/TB and 6 hours of HIV/AIDS training by 5/11/2012. Employee #12 failed to obtain the training as of the date of the inspection.
Employee # 13 was hired 10/24/2008 as a support staff member. This employee was required to obtain four hours of TB/STD training by 10/24/2010. Employee #13 failed to obtain the training as of the date of the inspection.
Employee # 14 was hired 4/2/2009 as a support staff member. This employee was required to obtain six hours of HIV/AIDS training by 4/2/2011. Employee #14 failed to obtain the training as of the date of the inspection.
This finding was discussed with the clinical director and was not disputed.
|
Plan of Correction
The five listed employees shall provide documentation of having completed the missing trainings within the next three months. The executive director will create an electronic spreadsheet that will be readily available to all supervisors and other staff, which lists the required trainings and completion dates for all staff members. Each supervisor will be responsible for checking this list at least quarterly, and for making sure that their supervisees obtain all the trainings within the applicable timeframes. The executive director will review this list on a quarterly basis to ensure compliance with this requirement. |
704.11(c)(2) LICENSURE CPR CERTIFICATION
704.11. Staff development program.
(c) General training requirements.
(2) CPR certification and first aid training shall be provided to a sufficient number of staff persons, so that at least one person trained in these skills is onsite during the project's hours of operation.
|
Observations
Based on a review of the facilities staff schedule, work hours, and the First Aid and CPR certification cards, the facility failed to provide a sufficient number of staff persons trained in CPR and First Aid during the project's hours of operation.
The findings include:
The CPR certification cards and First Aid certification cards were reviewed on December 13, 2012. The facility's hours of operation are Monday through Thursday 6 a.m. - 9 p.m., Friday 6 a.m. - 5 p.m., Saturday 6:30 am - 9:15 a.m. and Sunday 6:00 a.m. - 11:15 a.m. The facility failed to have sufficient coverage. The schedule was reviewed for the months of November and December 2012. Employee # 15 is a part-time dispensing nurse and did not have documentation of current CPR certification. Employee # 15 was scheduled to work alone in the dispensary on the following days:
November 3, 2012, November 4, 2012, November 17, 2012, November 18, 2012, November 22, 2012, November 24, 2012, November 25, 2012, December 1, 2012, December 2, 2012, December 8, 2012, and December 9, 2012.
The administrative staff who work with employee # 15 to cover the front desk on the weekend also failed to have current CPR documentation.
|
Plan of Correction
All nursing staff members now have valid CPR certification. The executive director will create an electronic spreadsheet that will be readily available to all supervisors and other staff, which includes CPR and First Aid training completion and expiration dates for all staff members. Each supervisor will be responsible for checking this list at least quarterly, and for making sure that their supervisees obtain and maintain certification, or are scheduled to attend these trainings when offered next. The executive director will review this list on a quarterly basis to ensure compliance with this requirement. |
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.
|
Observations
Based on a review of staff development records, the facility failed to document the completion of 25 clock hours of annual training required for counselors in one of four personnel records reviewed.
The findings included:
Fourteen personnel records were reviewed on December 11-12, 2012. Six personnel records reviewed were counselors. Four personnel records were required to document the completion of 25 clock hours of annual training. The facility failed to document 25 clock hours of annual training in personnel record # 7.
Employee # 7 was hired on January 2, 2008. The facility training year reviewed was from July 1, 2011 through June 30, 2012. Employee # 7 only completed 21 clock hours of annual training in the 2011/2012 training year.
The Clinical Supervisor confirmed this finding on December 12, 2012.
|
Plan of Correction
The executive director will create an electronic spreadsheet that will be readily available to all supervisors and other staff, which lists the training topics, hours and attendance dates for all staff members. Each supervisor will be responsible for checking this list at least quarterly, and for making sure that their supervisees obtain all the required training hours within the applicable timeframes. The executive director will review this list on a quarterly basis to ensure compliance with this requirement. |
705.23 (3) LICENSURE Counseling or activity areas and office space
705.23. Counseling or activity areas and office space.
The nonresidential 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.
|
Observations
Based on an overheard counseling session during the facility licensure inspection, the facility failed to ensure privacy in order that counseling sessions could not be seen or heard outside the counseling room.
The findings include:
On December 11, 2012 a counseling session between a counselor and patient were overheard by the licensing specialist. The licensing specialist was located in the conference room next to the office where the counseling session was taking place. The counseling session was overheard at approximately 1:50 p.m. on December 11, 2012.
The counselor and clinical director were interviewed and confirmed that sound travel was an issue in the facility. This finding was not disputed.
|
Plan of Correction
Every counseling room not already equipped with a white noise machine to prevent others from hearing the content of the sessions will have one installed by 1/31/2013. Counselors have been instructed to have the sound machine on whenever they are with a client. Program coordinators shall ensure that their counselors are in compliance with this and are properly using the machines at all times.
Additionally, the CFO shall obtain bids from contractors to make any other reasonably cost improvements to the office structures wherever possible in order to further reduce the potential of sound traveling between offices and other rooms. This work shall be completed as soon as possible according to the agency's available financial resources.
|
709.24(d) LICENSURE Treatment/Rehabilitation Management
709.24. Treatment/rehabilitation management.
(d) Provisions shall be made, through written agreement with a licensed hospital or physician, for 24-hour emergency psychiatric and medical coverage.
|
Observations
Based on a review of letters of agreement, the facility failed to provide documentation of a written agreement with a licensed hospital or physician, for 24-hour emergency medical coverage.
The findings include:
The letters of agreement were reviewed on December 12 and December 13, 2012. There was a letter of agreement with a local hospital, however, it failed to indicate that they provided 24- hour emergency medical coverage The agreement was signed on July 13, 2012. There was no other documentation of a 24-hour emergency medical coverage agreement.
The Operations Director was interviewed on December 13, 2012 and confirmed no other documentation of a 24-hour emergency medical agreement was available.
|
Plan of Correction
A revised referral agreement will be re-submitted to the local general hospital for approval and signature, which will specify that the hospital's emergency department does indeed provide 24-hour medical coverage to persons needing such service. The office manager responsible for maintaining the referral agreements will ensure that written agreement is returned by the hospital to the facility and is placed in the facility's agreement binder. |
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:
|
Observations
Based on the review of patient records, the facility failed to ensure that an informed and voluntary consent to release information was obtained in five of twelve patient records reviewed. The facility exceeded 4 Pa. Code, Subsection 255.5(b) in two of twelve records reviewed.
The findings included:
Twelve patient records were reviewed December 12-13, 2012. Twelve records were reviewed regarding release of information documentation. The facility failed to ensure that an informed and voluntary consent to release information was obtained in five patient records reviewed, # 3, 4, 6, 7, and 9. Additionally, patient records # 11 and 12 have information documented that exceeded 4 Pa. Code, Subsection 255.5(b).
A review of patient record # 3 revealed information was released to a funding source on December 22, 2011. The patient did not sign a release prior to releasing information for the funding entity.
A review of patient record # 4 revealed a letter was faxed on March 8, 2012 to an outside agency. The consent to release for this agency was signed on March 14, 2012. The consent to release was documented after the correspondence took place.
A review of patient record # 6 revealed a fax was sent to another treatment facility on May 8, 2012. There was no consent to release for the treatment facility prior to the correspondence taking place. Additionally, there was a fax sent on May 9, 2012 to a specific person without identification of the the agency that the individual represented. The name of the agency was not completed on the fax cover sheet and was no way to determine if a consent to release was signed for this correspondence.
A review of patient record # 7 revealed the Single County Authority was the patient's funding source. There was no consent to release documented in the patient record for treatment staff to release information to the funding entity.
A review of patient record # 9 revealed a letter was sent to another treatment program on October 23, 2012. There was no consent to release documented in the patient record for this facility.
A review of patient record # 11 revealed a consent to release signed on April 13, 2012 that allowed for the treatment plan, aftercare plan and a discharge summary to be released to a government agency. The information permitted to be released exceeded 4 Pa. Code, Subsection 255.5(b).
A review of patient record # 12 revealed a consent to release signed on July 12, 2012 allowed for the treatment plan, urine drug screens, and assessment results to be released to a government agency. The information permitted to be released exceeded 4 Pa. Code, Subsection 255.5(b).
These findings were discussed with the clinical director and were not disputed.
|
Plan of Correction
The clinical director and operations director/compliance officer shall conduct a staff training on confidentiality that will include specifics about the proper use and completion of consent forms, and what information may or may not be release to various entities according to Chapter 255.5. Program coordinators shall monitor staff compliance with the proper use and completion of consent forms via their quarterly review of client records, and will address any non-compliance via supervision sessions.
This training has been scheduled for Feb. 20, 2013. |
709.91(b)(3)(ii) LICENSURE Intake and admission
709.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(3) Histories, which include the following:
(ii) Drug or alcohol history, or both.
|
Observations
Based on a review of client records, the facility failed to document the lengths and patterns related to the client's progression of drug and alcohol use in six of eight records.
The findings were:
Twelve patient records were reviewed on December 12-13, 2012. Eight records were reviewed for documentation of a drug and alcohol history that included lengths and patterns related to the client's progression of use. The facility failed to document the lengths and patterns related to the client's progression of use in patient records # 1, 3, 7, 8, 9, and 10.
This finding was discussed with the clinical director and was not disputed.
|
Plan of Correction
Staff who conduct client intake assessments will be re-trained by the clinical director on how to properly complete the section in the biopsychosocial assessment document that indicates the client's drug and alcohol history, to be sure to include information on lengths and patterns of progressive use. Program coordinators shall monitor staff compliance with including this information via their quarterly review of client records, and will address any non-compliance via supervision sessions. |
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.
|
Observations
Based on the review of patient records, the facility failed to document support services on five of eight patient records reviewed.
The findings include:
Twelve patient records were reviewed on December 12-13, 2012. Five patient records were reviewed for documentation of proposed support services on the patient's treatment and rehabilitation plan. Patient records # 7, 8, 9, 10, and 12 failed to have documentation of proposed support services on the treatment and rehabilitation plan.
|
Plan of Correction
The treatment plan section of the facility's electronic health record program will be revised to include documentation of proposed support services. Program coordinators shall monitor staff compliance with the proper completion of treatment plans via their quarterly review of client records, and will address any non-compliance via supervision sessions. |