INITIAL COMMENTS
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This report is a result of an on-site licensure renewal and a methadone monitoring inspection conducted on January 28-30, 2020 by staff from the Department of Drug and Alcohol Programs, Bureau of Quality Assurance for Prevention and Treatment. Based on the findings of the on-site inspection, Discovery House HA 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 on January 28-30, 2020, the facility failed to ensure employees # 8, 9 and 11 met all the educational and experience requirements to be a counselor.
Client #8 was hired as a counselor on May 20, 2019. At the time of the hire, the employee only had five months of the required one year of experience.
Client #9 was hired as an unpaid intern in July 2018 and was hired with full counselor status on January 21, 2019. The employee did not receive her qualifying Bachelor's degree until May 11, 2019. In addition, the employee did not have the required one year of experience at the time of hire.
Client #11 was hired as a counselor on December 23, 2019. At the time of the hire, the employee had no qualifying experience and at the time of the inspection had not met the experience qualifications for counselor.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Client # 11's:
Counselor position will be reduced to a Counselors Assistant Position. Counselor will obtain 1 year of clinical experience (a minimum of 1,820 hours) in a drug and alcohol setting before eligibility to qualify for a full counselor position.
Clinical Director will assure all clinical positions meet qualifications for a counselor position before the hiring process. Clinical Director will refer to the Department of Drug and Alcohol Program' counselor qualifications for clarity of qualifications.
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704.11(a)(3) LICENSURE Training Feedback
704.11. Staff development program.
(a) Components. The project director shall develop a comprehensive staff development program for agency personnel including policies and procedures for the program indicating who is responsible and the time frames for completion of the following components:
(3) A mechanism to collect feedback on completed training.
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Observations
Based on a review of employee files on January 28-30, 2020, the facility failed to collect feedback on completed trainings for employees # 2 and 4.
Employee #2 was hired on June 14, 2001 and was in the position of facility director at the time of the inspection.
Employee #4 was hired as a counselor on January 24, 2018 and was in that position at the time of the inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The CTC Director will ensure that all Staff complete feedback on the trainings provided for the prior year January 15th. The feedback of completed trainings for 2019 has been obtained for Employee # 2 and # 4 as of 2/19/2020 and is in the HR files. |
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.
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Observations
Based on a review of personnel records and the facility's Staffing Requirement Facility Summary Report (SRFSR) form, the facility failed to ensure that employee #4 received the minimum of at least 4 hours of TB/STD and other health related topics within the regulatory timeframe.
Employee #4 was hired as a counselor on January 24, 2018 and was due to have the communicable disease trainings no later than January 24, 2019. There was no documentation in the personnel file of the completion of the TB/STD training as of the date of the inspection.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Clinical Supervisor will assure new counselors are scheduled and attend a minimum of 6 hours of HIV/AIDS training, minimum of 4 hours tuberculosis, sexually transmitted diseases and other health related topics training using a department approved curriculum within their first 90 days of employment. 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. Clinical Supervisor will be required to submit a sign off sheet from each new counselor indicating they have completed the required training to Clinic Director in allotted time required.
Employee #4 is scheduled for a 6 hour TB/STD training 3/12/2020 and 3/13/2020. |
704.12(a)(6) LICENSURE OutPatient Caseload
704.12. Full-time equivalent (FTE) maximum client/staff and client/counselor ratios.
(a) General requirements. Projects shall be required to comply with the client/staff and client/counselor ratios in paragraphs (1)-(6) during primary care hours. These ratios refer to the total number of clients being treated including clients with diagnoses other than drug and alcohol addiction served in other facets of the project. Family units may be counted as one client.
(6) Outpatients. FTE counselor caseload for counseling in outpatient programs may not exceed 35 active clients.
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Observations
Based on a review of the Staffing Requirements Facility Summary Report, completed and reviewed on January 28, 2020, the facility failed to ensure staff caseloads remained at or under 35:1 for employees # 3 and 9.
The counselor Full time Equivalent (FTE) is determined by dividing the total number of hours the counselor devotes to their clients by the hours work per week at the facility. Then, in order to obtain the counselor's ratio, the total number of clients on the counselor's caseload is divided by the FTE.
Employee #3 was hired June 7, 2012 and was in the role of clinical supervisor at the time of the inspection. The employee was reported to have 25 hours per week devoted to their 92 clients on their caseload. The FTE Counselor's caseload calculation is as follows: 25/40 = .625 (FTE); 92/.625 = 147.2, which equals to a client/counselor ratio of 148:1.
Employee #9 was as a counselor on January 21, 2019 and was still acting in that position at the time of the inspection. The employee was reported to have 32 hours per week devoted to their 40 clients on their caseload. The FTE Counselor's caseload calculation is as follows: 32/32 = 1 (FTE); 40/1 = 40, which equals to a client/counselor ratio of 40:1.
These findings were reviewed with facility staff during the licensing process.
This is a repeat citation from the November 21, 2018 inspection.
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Plan of Correction
Clinic Supervisor will redistribute clients to ensure each caseload is a 35:1 ratio for active patients to counselor.
Clinic Director will monitor and maintain a qualified pool of potential counselors to assure facility maintains a 35:1 ratio.
The Clinic Director will continue to work with Human Resources Business Partner in the recruitment and hiring of appropriate staff for the project and to ensure that the FTE counselor caseload for counseling in an outpatient program does not exceed 35:1 active patients.
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705.22 (4) LICENSURE Building exterior and grounds.
705.22. Building exterior and grounds.
The nonresidential facility shall:
(4) Store all trash, garbage and rubbish in noncombustible, covered containers that prevent the penetration of insects and rodents, and remove it at least once every week.
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Observations
Based on a physical site inspection on January 28, 2020, the facility failed to store all trash in covered containers. A dumpster lid was observed to be open and the other dumpster lids were observed to not fully close. In addition, the main parking lot and adjacent grounds had an excessive amount of litter.
The findings were reviewed with facility staff during the licensing process.
This is a repeat citation from the November 21, 2018 inspection.
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Plan of Correction
The Clinic Director will physically assure the dumpster lids are closed at the end of the day. The Clinic Director will also have the building cleaning company assure the dumpster lids are closed before they leave on days they clean the building. The Clinic Director will monitor and check the dumpster quarterly when completing quarterly exterior building audits. |
705.24 (3) LICENSURE Bathrooms.
705.24. Bathrooms.
The nonresidential facility shall:
(3) Have hot and cold water under pressure. Hot water temperature may not exceed 120F.
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Observations
Based on a physical plant inspection on January 29, 2020, the facility failed to meet regulation, as the building did not have any hot water.
The findings were reviewed with facility staff during the licensing process.
This is a repeat citation from the November 21, 2018 inspection.
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Plan of Correction
The Clinic Director contacted the plumbing company, repaired the water heater for hot water access within the bathrooms. The Clinic Director will be checking the water during quarterly building inspections. |
705.28 (c) (3) LICENSURE Fire safety.
705.28. Fire safety.
(c) Fire extinguishers. The nonresidential facility shall:
(3) Ensure fire extinguishers are inspected and approved annually by the local fire department or fire extinguisher company. The date of the inspection shall be indicated on the extinguisher or inspection tag. If a fire extinguisher is found to be inoperable, it shall be replaced or repaired within 48 hours of the time it was found to be inoperable.
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Observations
Based on a physical plant inspection on January 29, 2020, the facility failed to ensure all fire extinguishers were inspected and approved annually. The fire extinguisher located in the dispensary area was last inspected in September 2018.
The findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
The Clinic Director contacted the fire extinguisher company to inspect the fire extinguisher in the dispensary. The fire extinguisher has been inspected and updated date for 2/2020.
The Clinic Director will assure all fire extinguishers are inspected and updated annually. Clinic Director will check fire extinguishers during quarterly building inspections.
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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 employee files on January 28-30, 2020, the facility failed to instruct all staff in the use of fire extinguishers upon hire.
Employee #11 was hired as a counselor on December 23, 2019 and had not been instructed on the use of fire extinguishers as of the time of the inspection.
The findings were reviewed with facility staff during the licensing process.
This is a repeat citation from the November 21, 2018 inspection.
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Plan of Correction
Plan of Correction:
Fire extinguisher training checklist has been added for new staff employees. Employee #11 was trained on fire safety 2/4/2020. An employee signature acknowledgement 16.1 Health & Safety form has been established and an employment checklist will be completed on the first day of employment by the Clinic Director and the Health and Safety Captain. The Clinic Director will review the checklist for compliancy quarterly.
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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 fire drill logs from January 2019 through January 2020 that was conducted on January 28-30, 2020, the facility failed to document all required information on fire drill logs. All the reviewed fire logs were missing whether the fire alarm or smoke detector was operative and if the fire alarms or smoke detectors were set off during the drill. In addition, during all the reviewed fire logs only one exit, the front door, was used during the drills. No alternative exits were used.
These findings were reviewed with facility staff during the licensing process.
This is a repeat citation from the November 21, 2018 inspection.
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Plan of Correction
The Clinic Director will review and train Health and Safety Captain on maintaining 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.
The Clinic Director will assure all information is included in the fire drill record. Clinic Director will check quarterly to assure 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 the review of client records on January 28-30, 2020, the facility failed to document an informed and voluntary consent to release information form prior to the disclosure of information in client records #'s 6 and 11.
Client #6 was admitted on March 25, 2019 and discharged on October 28, 2019. There was no consent to release information form to a funding source in the client's record. The record reflected that billing to a funding source had occurred.
Client #11 was admitted on June 11, 2019 and was still active at the time of the inspection. There was no a consent to release information form to a funding source in the client's record. The record reflected that billing to a funding source had occurred.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Clinical Supervisor will present a staff training on Confidentiality of Patient records 2-13-2020. Patient #11 will sign a consent form for his/her funding source by 2/28/2020. Change the corrective action date to reflect when this task will be completed.
Clinic Director will assure all staff attends the mandatory training. Clinical Director and Clinical Supervisor will review patient records monthly to assure compliance. |
709.28 (c) (2) 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:
(2) Specific information disclosed.
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Observations
Based on a review of client records on January 28-30, 2020, the facility failed to keep disclosures of client identifying information within the limits established by 4 Pa. Code 255.5(b) for releases of information in client records #'s 1, 8, 12, 13, 14, and 15.
Client #1 was admitted on January 22, 2019 and was still active at the time of the inspection. A consent to release information form, dated January 22, 2019, to a funding source permits release of the treatment plan.
Client #8 was admitted on February 4, 2019 and was still active at the time of the inspection. A consent to release information form, dated February 4, 2019, to a funding source permits release of the treatment plan.
Client #12 was admitted on June 4, 2019 and discharged on December 26, 2019. A consent to release information form, dated June 5, 2019 to a funding source, permitted release of medical history, current dose level, lab work results, and treatment plan. In addition, two consent to release information forms, both dated June 5, 2019 to government agencies, permitted release of medical history, current dose level, lab work results, treatment plan, drug test results and discharge summary.
Client #13 was admitted on September 17, 2019 and was still active at the time of the inspection. Two consent to release information forms, dated September 17, 2019 to a funding source and a government agency, permits release of the treatment plan.
Client #14 was admitted on April 25, 2019 and was still active at the time of the inspection. Two consent to release information forms, dated April 25, 2019 to two different funding sources, permits release of the treatment plan.
Client #15 was admitted on December 19, 2019 and was still active at the time of the inspection. A consent to release information form, dated September 24, 2019 to a government agency permits release of lab work results. In addition, a consent to release information form, dated January 14, 2020 to a funding source permits release of medication history.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Clinical Supervisor will present a staff training on Confidentiality of Patient records 2-13-2020 to include obtaining an informed and voluntary consent from the client for the disclosure of information contained in the client record. Patients #1, 8, 12, 13, 14, 15 will sign updated consent to release forms which reflect the disclosures permitted within 4 Pa. Code 255.5(b) by 2/28/2020. The training will include consents must be in writing and include, but not be limited to: (2) Specific information disclosed.
Clinic Director will assure all staff attends the mandatory training. Clinical Director and Clinical Supervisor will review patient records monthly to assure compliance.
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709.28 (c) (3) 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:
(3) Purpose of disclosure.
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Observations
Based on the review of client records on January 28-30, 2020, the facility failed to document completed consent to release information forms. The purpose of disclosure was missing the specific reason for information to be released in client records # 8 and 15.
Client #8 was admitted on February 4, 2019 and was still active at the time of the inspection. The consent to release information form, dated February 4, 2019 was to a family member.
Client #15 was admitted on September 19, 2019 and was still active at the time of the inspection. During a previous admission from May 10 - July 17, 2019, a consent to release information form, dated May 17, 2019 to a government agency was missing the required information.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Clinical Supervisor will present a staff training on Confidentiality of Patient records 2-13-2020 to include obtaining an informed and voluntary consent from the client for the disclosure of information contained in the client record. Patient #8 and #15 will sign updated consent to release forms by 2/28/2020. The training will include consents must be in writing and include, but not be limited to: (3) Purpose of disclosure.
Clinic Director will assure all staff attends the mandatory training. Clinical Director and Clinical Supervisor will review patient records monthly to assure compliance.
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709.28 (c) (6) 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:
(6) Date, event or condition upon which the consent will expire.
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Observations
Based on a review of client records on January 28-30, 2020, the facility failed to documented completed consent to release forms, as the forms were missing an expiration date in client records # 6 and 8.
Client #6 was admitted on March 25, 2019 and discharged on October 28, 2019. A consent to release information form, dated March 25, 2019 was to another treatment facility.
Client #8 was admitted on February 4, 2019 and was still active at the time of the inspection. A consent to release information form, dated February 4, 2019 was to another treatment facility.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Clinical Supervisor will present a staff training on Confidentiality of Patient records 2-13-2020 to include obtaining an informed and voluntary consent from the client for the disclosure of information contained in the client record. The training will include consents must be in writing and include, but not be limited to: (6) Date, event or condition upon which the consent will expire. Patient #8 is scheduled to sign an updated consent to release form 2/28/2020.
Clinic Director will assure all staff attends the mandatory training. Clinical Director and Clinical Supervisor will review patient records monthly to assure compliance.
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709.30 (3) LICENSURE Client rights
709.30. Client rights.
The project shall develop written policies and procedures on client rights and document written acknowledgement by clients that they have been notified of those rights.
(3) Clients have the right to inspect their own records. The project, facility or clinical director may temporarily remove portions of the records prior to the inspection by the client if the director determines that the information may be detrimental if presented to the client. Reasons for removing sections shall be documented in the record.
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Observations
Based on a review of the facility's policy and procedures manual, electronic signed version of the clients rights and the client handbook, the facility failed to document all parts of regulation 709.30(3). The documentation was missing that the facility may temporarily remove portions of the records prior to inspection by the client if the director determined that the information may be detrimental if presented to the client. Reasons for removing section shall be documented in the record.
The findings were reviewed with facility staff during the licensing inspection.
This is a repeat citation from the November 21, 2018 inspection.
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Plan of Correction
The CTC Director will work with the Director of Quality and Compliance to revise the Patient Rights form in the EHR and Patient handbook to conform with regulation. The revision will be completed by 2/28/2020. The CTC Director will review policy revisions during March 2020 All Staff Meeting. |
709.34 (c) (4) LICENSURE Reporting of unusual incidents
§ 709.34. Reporting of unusual incidents.
(c) To the extent permitted by State and Federal confidentiality laws, the project shall file a written unusual incident report with the Department within 3 business days following an unusual incident involving:
(4) Event at the facility requiring the presence of police, fire or ambulance personnel.
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Observations
Based on a review of unusual incident reports on January 28-30, 2020, the facility failed to file a written unusual incident report with the Department within three business days following an event at the facility requiring the presence of police, fire or ambulance personnel. Ambulance personnel were present at the facility on January 3, 2019. There was no documentation that an unusual incident report was filed with the Department within three business days.
The findings were reviewed with facility staff during the licensing process.
This is a repeat citation from the November 21, 2018 inspection.
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Plan of Correction
The Clinic Director will file the PA Dept. of Drug & Alcohol unusual incident reporting form narcotic treatment program form with the Department within 3 business days following an event at the facility that requires the presence of police, fire or ambulance personnel or other occurrence which closes the facility for more than one day including if the project requires the presence of police, fire, or ambulance personnel on site. Clinical Supervisor, Nurse Manager, and Clinic Director will sign a checklist to assure compliancy. |
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 a review of the physician time sheets and weekly census reports on January 28-30, 2020, the facility failed to provide at least one hour of physician services per week for every ten patients. During the week of September 22-28, 2019, the patient census was 506. The facility was required to provide at least 50.6 physician hours. There were 47.75 physician hours documented.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Medical Director physician services shall provide at least 1 hour per week onsite for every ten patients. A scheduled calendar of physicians will be submitted to the medical staff monthly to ensure there is adequate coverage. The Clinic Director will monitor the monthly calendar to ensure there is adequate coverage.
. "Ongoing compliance will be monitored during quality record reviews. Continued non-compliance will be addressed via the EIP process."
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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 a review of client records on January 28-30, 2020, the facility failed to obtain an emergency contact in client records # 11 and 15.
Client #11 was admitted on June 11, 2019 and was still active at the time of the inspection.
Client #15 was admitted on September 19, 2019 and was still active at the time of the inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Clinic Director and Clinical Supervisor will complete a training on verification on the patients individual identity, including name, address, date of birth, emergency contact and other identifying data prior to administration of an agent 2/27/2020. The Clinic Supervisor will monitor weekly for new admissions. The Clinic Director will monitor quarterly to assure compliance. Patient #11 and 15 are scheduled to sign their emergency contact form by 2/28/2020. |
715.9(c) LICENSURE Intake
(c) If a patient was previously discharged from treatment at another narcotic treatment program, the admitting narcotic treatment program, with patient consent, shall contact the previous facility for the treatment history.
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Observations
Based on a review of client records on January 28-30, 2020, the facility failed to contact the previous narcotic treatment program to obtain a treatment history in client record #3.
Client #3 was admitted on February 10, 2017 as a transfer from another treatment facility and was still active at the time of the inspection. There was no documentation in the client record that contact had been made with the previous treatment facility.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Clinical Supervisor will complete a training 2/27/2020 on patients consent on discharge procedures from one treatment facility to another narcotic treatment program. The facility shall contact the previous program for the treatment history with confirmation. All consents will be documented and submitted into patient's charts. The Clinic Supervisor will monitor weekly. The Clinic Director will monitor quarterly to assure compliance. |
715.10(b) LICENSURE Pregnant patients
(b) A narcotic treatment program shall give pregnant patients the opportunity for prenatal care either by the narcotic treatment program or by referral to appropriate health-care providers.
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Observations
Based on the review of client records on January 28-30, 2020, the facility failed to document the opportunity for prenatal care either by the narcotic treatment program or by referral to appropriate health-care providers in client record #15.
Client #15 was admitted on September 19, 2019 and was still active at the time of the inspection. Client had a previous admission from May 10 through July 17, 2019. The client provided a positive pregnancy urine screen on May 21, 2019 with a pregnancy due date of November 2019. The child was born on November 16, 2019. The client's record did not show documentation of prenatal care by the facility's physician or include documentation that the client was seen by a doctor outside the facility's care.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Patient Pregnant Acknowledgement of Risks Form has been added to the intake process checklist. Counselors will be responsible for assuring new pregnant female patients are educated on the risks of MAT and pregnancy. New patients will review and acknowledge the information with their signature on the form. Clinical Supervisor and Medical Team will review new admissions intake process checklist 24 hours after admission for compliancy. MD and CRNP will educate and address concerns of pregnant females during their visits as well as document in their charts before prescribing medication. The facility will provide ongoing prenatal care and support throughout the pregnancy, by the narcotic treatment physician or a referral to an outside doctor if needed.
Clinic Director will review new admission process quarterly to assure compliancy. Ongoing compliance will be monitored during quality record reviews. The Clinical Supervisor will address non-compliance in this area during individual supervision. Continued non-compliance will be addressed via the EIP process.
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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 client records on January 28-30, 2020, the facility failed to inform patients in the signed consent to treat form that methadone is transmitted to the unborn child and will cause physical dependence.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Clinical Supervisor will conduct a clinical staff training to review and address the policy and procedures of informed, voluntary, and written consents. All clinical staff will have an opportunity to address any questions and/or concerns during the staff clinical training. All clients will sign an informed, voluntary, written consent prior to the administration of an agent. The Clinical Supervisor will ensure all clinical staff revoke prior incorrect releases will patient and have each patient renew releases with appropriate information needed for compliancy.
The Clinical Supervisor will conduct peer reviews quarterly on charts to ensure the written consent policy is maintained.
Clinic Director and Clinical Supervisor will meet quarterly to assure policy is maintained.
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715.17(c)(1)(i-vi)) LICENSURE Medication control
(c) A narcotic treatment program shall develop and implement written policies and procedures regarding the medications used by patients which shall include, at a minimum:
(1) Administration of medication.
(i) A narcotic treatment physician shall determine the patient 's initial and subsequent dose and schedule. The physician shall communicate the initial and subsequent dose and schedule to the person responsible for the administration of medication. Each medication order and dosage change shall be written and signed by the narcotic treatment physician.
(ii) An agent shall be administered or dispensed only by a practitioner licensed under the appropriate Federal and State laws to dispense agents to patients.
(iii) Only authorized staff and patients who are receiving medication shall be permitted in the dispensing area.
(iv) There shall be only one patient permitted at a dispensing station at any given time.
(v) Each patient shall be observed when ingesting the agent.
(vi) Administering and dispensing shall be conducted in a manner that protects the patient from disruption or annoyance from other individuals.
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Observations
Based on observation of narcotic treatment medication being dispensed on January 29, 2020, the facility failed to ensure clients ingested the agent as three clients did not speak after receiving their dose.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Clinic Director and Nurse Supervisor will complete a training on Policy 6.1 "Dispensing of Medication" on 03/05/2020. The Nurse Supervisor will observe dispensing weekly to ensure compliance in this area and address non-compliance during individual supervision. |
715.19(1) LICENSURE Psychotherapy services
A narcotic treatment program shall provide individualized psychotherapy services and shall meet the following requirements:
(1) A narcotic treatment program shall provide each patient an average of 2.5 hours of psychotherapy per month during the patient 's first 2 years, 1 hour of which shall be individual psychotherapy. Additional psychotherapy shall be provided as dictated by ongoing assessment of the patient.
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Observations
Based on a review of client records on January 28-30, 2020, the facility failed to provide patients # 1, 6, 8, 11, 12, and 14 with two and a half hours of psychotherapy per month, one which shall be individual psychotherapy during the patient's first two years of treatment.
Client #1 was admitted on April 2, 2019 and was still active at the time of the inspection. In November and December 2019, the client received 2 hours of group therapy and zero hours of individual therapy.
Client #6 was admitted on March 25, 2019 and discharged on October 28, 2019. The client received a total of three hours of individual therapy and zero group sessions during the period of July through September 2019.
Client #8 was admitted on February 4, 2019 and was still active at the time of the inspection. During the months of October 2019 through December 2019, the client received a total of three hours of individual therapy and zero hours of group therapy.
Client #11 was admitted on June 11, 2019 and was still active at the time of the inspection. During the month of October 2019, the client received one hour of individual therapy. During the month of November 2018, the client received zero therapy hours. In December 2018, the client received 90 minutes of group therapy.
Client #12 was admitted on June 4, 2019 and discharged on December 26, 2019. During the months of July and September 2019, the client received 90 minutes of group therapy. In August 2019, the client received one hour sessions of individual and group therapy.
Client #14 was admitted on April 25, 2019 and was still active at the time of the inspection. During the month of October 2019, the client received 2.5 hours of group therapy but only 30 minutes of individual therapy. In November 2019, the client received 90 minutes of group sessions and in December 2019, the client received one hour of group therapy.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Clinical Supervisor and Lead Counselor will make every effort to ensure each patient are provided with an average of 2.5 hours of psychotherapy per month during the patient's first 2 years, 1 hour of which shall be individual psychotherapy and/or additional psychotherapy shall be provided as dictated by ongoing assessment of the patient by conducting monthly ongoing monitoring during quality record reviews.
The Clinical Services Coordinator will conduct a meeting with Clinical Supervisor bi-weekly to ensure patients are receiving the appropriate psychotherapy per month requirements.
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715.19(2) LICENSURE Psychotherapy services
A narcotic treatment program shall provide individualized psychotherapy services and shall meet the following requirements:
(2) A narcotic treatment program shall provide each patient at least 1 hour per month of group or individual psychotherapy during the third and fourth year of treatment. Additional psychotherapy shall be provided as dictated by ongoing assessment of the patient.
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Observations
Based on a review of client records on January 28-30, 2020, the facility failed to provide patient #3 with one hour of psychotherapy per month during the patient's third and fourth year of treatment.
Client #3 was admitted on February 10, 2017 and was still active at the time of the inspection. The client did not receive any therapy sessions during the month of October 2019.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Clinical Supervisor and Lead Counselor will make every effort to provide individualized psychotherapy services and shall meet the following requirements: (2) A narcotic treatment program shall provide each patient at least 1 hour per month of group or individual psychotherapy during the third and fourth year of treatment. Additional psychotherapy shall be provided as dictated by ongoing assessment of the patient.
The Clinical Services Coordinator will conduct a meeting with Clinical Supervisor bi-weekly to ensure patients are receiving the appropriate psychotherapy per month requirements.
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715.20(4) LICENSURE Patient transfers
A narcotic treatment program shall develop written transfer policies and procedures which shall require that the narcotic treatment program transfer a patient to another narcotic treatment program for continued maintenance, detoxification or another treatment activity within 7 days of the request of the patient.
(4) The receiving narcotic treatment program shall document in writing that it notified the transferring narcotic treatment program of the admission of the patient and the date of the initial dose given to the patient by the receiving narcotic treatment program.
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Observations
Based on a review of client records on January 28-30, 2020, the facility failed to document that the transferring narcotic treatment program was notified of the admission of the patient and initial dose in client # 2.
Client #2 was transferred from another facility and admitted on July 12, 2019. The client was still active at the time of the inspection. There was no documentation that a transfer acknowledgement was sent to the transferring facility.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Clinic Supervisor will have a training on written transfer policies and procedures to transfer a patient to another narcotic treatment program for continued maintenance, detoxification or another treatment activity within 7 days of the request of the patient and a transfer acknowledgement form has been completed.
The Clinical Supervisor will review charts monthly to ensure policies are being maintained. The Clinical Supervisor will address non-compliance in this area during individual supervision.
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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 a review of client records on January 28-30, 2020, the facility failed to document an annual clinical evaluation of the patient in client records # 3 and 7.
Client #3 was admitted on February 10, 2017 and was still active at the time of the inspection. The most recent annual evaluation was due no later than May 31, 2019; however, it was not documented as of the date of the inspection.
Client #7 was admitted on December 1, 2017 and was still active at the time of the inspection. The most recent annual evaluation was due no later than December 20, 2019; however, it was not documented as of the date of the inspection.
These findings were reviewed with facility staff during the licensing process.
This is a repeat citation from the November 21, 2018 inspection.
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Plan of Correction
The Nurse Manager will collaborate with the Clinical Supervisor to ensure the Medical Director is aware of upcoming patient annual evaluations to review, date, and sign at the beginning of each month.
The Clinic Director will meet with the Nurse Manager and Clinical Supervisor quarterly to assure this procedure is being maintained.
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709.92(a)(2) 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:
(2) Type and frequency of treatment and rehabilitation services.
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Observations
Based on a review of client records on January 28-30, 2020, the facility failed to document type and frequency of treatment and rehabilitation in client record #'s 1, 3, 6, 7, 8, 11, 12, 13, 15 and 17.
Client #1 was admitted on April 2, 2019 and was still active at the time of the inspection. In the client's treatment plan, dated June 13, 2019, the specific frequency of each therapy was not documented. The treatment plan states two and a half hours of either individual or group sessions per month.
Client #3 was admitted on February 10, 2017 and was still active at the time of the inspection. In the client's treatment plan, dated December 31, 2019, the specific frequency of each therapy was not documented. The treatment plan states two and a half hours of either individual or group sessions per month.
Client #6 was admitted on March 25, 2019 and discharged on October 28, 2019. The client's treatment plan, dated April 24, 2019, the specific frequency of each therapy was not documented. The treatment plan states two and a half hours of individual or group sessions per month.
Client #7 was admitted on December 1, 2017 and was still active at the time of the inspection. In client's treatment plan, dated December 6, 2019, the specific frequency of each therapy was not documented. The treatment plan states two and a half hours of individual or group therapy each month.
Client #8 was admitted on February 4, 2019 and was still active at the time of the inspection. The treatment plan dated April 23, 2019 did not indicate any type and frequency of therapy.
Client #11 was admitted on June 11, 2019 and was still active at the time of the inspection. In the treatment plan, dated December 27, 2019, the specific type of therapy was not documented. The treatment plan states two and a half hours of therapy every month.
Client #12 was admitted on June 4, 2019 and discharged on December 26, 2019. The client's treatment plan, dated July 16, 2019, did not indicate any type and frequency of therapy.
Client #13 was admitted on September 17, 2019 and was still active at the time of the inspection. The treatment plan, dated November 8, 2019, did not indicate any type and frequency of therapy.
Client #15 was admitted on September 19, 2019 and was still active at the time of the inspection. The treatment plan, dated October 29, 2019, did not indicate any type and frequency of therapy.
Client #17 was admitted on January 4, 2018 and discharged on July 12, 2019. The treatment plan, dated December 19, 2018, did not indicate any type and frequency of therapy.
These findings were reviewed with facility staff during the licensing process.
This is a repeat citation from the November 21, 2018 inspection.
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Plan of Correction
The Clinical Supervisor will do a training/review on individual treatment plans to include what written documentation is needed within the treatment plan, how frequent a patient should obtain services, and what type of service is required.
The Clinical Supervisor will conduct peer reviews as well as quarterly checks to ensure procedures are being maintained.
The Clinic Supervisor will update the Clinic Director quarterly on treatment plan compliance.
. "Ongoing compliance will be monitored during quality record reviews. The Clinical Supervisor will address non-compliance in this area during individual supervision. Continued non-compliance will be addressed via the EIP process."
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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 on January 28-30, 2020, the facility failed to document treatment plan updates every 60 days in client record #'s 1, 3, 4, 8, 9, 10, 12, 14, 16 and 17.
Client #1 was admitted on April 2, 2019 and was still active at the time of the inspection. A treatment plan update was completed on October 10, 2019 and the next update was due no later than December 10, 2019; however, the next update was completed on January 2, 2020.
Client #3 was admitted on February 10, 2017 and was still active at the time of the inspection. A treatment plan update was completed on October 18, 2019 and the next update was due no later than December 10, 2019; however, the next update was completed on December 31, 2019.
Client #4 was admitted on August 7, 2019 and was still active at the time of the inspection. A treatment plan was completed on August 30, 2019 and an update was due no later than October 30, 2019; however, the next update was completed on November 7, 2019.
Client #8 was admitted on February 4, 2019 and was still active at the time of the inspection. A treatment plan was completed on April 23, 2019 and an update was due no later than June 23, 2019; however, the update was completed on August 9, 2019.
Client #9 was admitted on December 6, 2017 and was discharged on January 28, 2019. A treatment plan update was completed on June 11, 2018 and an update was due no later than August 11, 2018; however, the next update was completed on December 20, 2018.
Client #10 was admitted on December 21, 1998 and was still active at the time of the inspection. A treatment plan update was completed on August 9, 2019 and the next update was due no later than October 9, 2019; however, the next update was completed on November 7, 2019.
Client #12 was admitted on June 4, 2019 and discharged on December 26, 2019. A treatment plan update was completed on September 16, 2019 with the next update due no later than November 16, 2019; however, the next update was completed on December 2, 2019.
Client #14 was admitted on April 25, 2019 and was still active at the time of the inspection. A treatment plan was completed on May 14, 2019 with an update due no later July 14, 2019; however, the update was completed on July 31, 2019. In addition, a treatment plan update was completed on October 9, 2019 with an update due no later than December 9, 2019; however, the next update was completed on December 19, 2019.
Client #16 was admitted on December 5, 2017 and discharged on April 10, 2019. A treatment plan updated as completed on October 12, 2018 with an update due no later than December 12, 2018; however the next update was completed on February 8, 2019.
Client #17 was admitted on January 4, 2018 and discharged on July 12, 2019. A treatment plan update was completed on December 19, 2018 with an update due no later than February 19, 2019; however, the next update was completed on March 1, 2019.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Clinical Supervisor will do a training/review on treatment and rehabilitation services. Treatment and rehabilitation plans shall be reviewed and updated at least every 60 days.
The Clinical Supervisor will conduct peer reviews as well as quarterly checks to ensure procedures are being maintained.
The Clinic Supervisor will update the Clinic Director quarterly on treatment plan compliance.
. "Ongoing compliance will be monitored during quality record reviews. The Clinical Supervisor will address non-compliance in this area during individual supervision. Continued non-compliance will be addressed via the EIP process."
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709.92(c) LICENSURE Treatment and rehabilitation services
709.92. Treatment and rehabilitation services.
(c) The project shall assure that counseling services are provided according to the individual treatment and rehabilitation plan.
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Observations
Based on a review of client records on January 28-30, 2020, there was no documentation that the clients received counseling services according to their individual comprehensive treatment plan in client record #'s 3, 9, 10, 11, 14 and 16.
Client #3 was admitted on February 10, 2017 and was still active at the time of the inspection. The comprehensive treatment plan, dated September 6, 2019, indicated two and a half hours of either individual or group sessions per month. The record of service and progress notes indicated that the client had received no group sessions after July 15, 2019. The client received one hour individual sessions on September 20, November 26, December 30, 2019 and January 13, 2020.
Client #9 was admitted on December 6, 2017 and was discharged on January 28, 2019. The comprehensive treatment plan, dated June 11, 2018 indicated two hours of group and one hour of individual therapy each month. The record of service and progress notes indicated that the client had received no group sessions after November 5, 2018. In addition, the client did not receive any individual sessions in December 2018.
Client #10 was admitted on December 21, 1998 and was still active at the time of the inspection. The comprehensive treatment plan, dated August 9, 2019, indicated one half an hour of individual sessions every month. The record of service and progress notes indicated that the client received no individual sessions in October and December 2019.
Client #11 was admitted on June 11, 2019 and was still active at the time of the inspection. The comprehensive treatment plan, dated August 22, 2019 indicated two and a half hours of therapy every month. The record of service and progress notes indicated that the client received no therapy hours in November, and 90 minutes of group therapy only in December 2019.
Client #14 was admitted on April 25, 2019 and was still active at the time of the inspection. The comprehensive treatment plan, dated August 16, 2019 indicated one and a half hours of group therapy each month. The record of service and progress notes indicated that the client one hour of group therapy in December 2019.
Client #16 was admitted on December 5, 2017 and discharged on April 10, 2019. the comprehensive treatment plan, dated October 12, 2018 indicated one hour of individual and one and a half hours of group therapy monthly. The record of service and progress notes indicated that the client did not receive any individual sessions in March 2019 and no group sessions in December 2018, February 2019 and March 2019.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Clinical Supervisor will do a training/review on treatment and rehabilitation services. The project shall assure that counseling services are provided according to the individual treatment and rehabilitation plan.
The Clinical Supervisor will conduct peer reviews as well as quarterly checks to ensure procedures are being maintained.
The Clinic Supervisor will update the Clinic Director quarterly on treatment plan compliance.
. "Ongoing compliance will be monitored during quality record reviews. The Clinical Supervisor will address non-compliance in this area during individual supervision. Continued non-compliance will be addressed via the EIP process."
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