INITIAL COMMENTS
|
This report is a result of an on-site licensure renewal inspection and methadone monitoring conducted on June 29, 2022 through June 30, 2022 by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, Aldie Counseling 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
|
704.12(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.
|
Observations
Based on a review of personnel records and the Staffing Requirements Facility Summary Report, the facility failed to ensure that the Full Time Equivalent (FTE) counselor caseload in outpatient programs did not exceed 35 active clients in three applicable counselor personnel records reviewed.
The counselor FTE is determined by dividing the total number of hours the counselor devotes to their clients by the facility's workweek. Then, in order to obtain the counselor's ratio, the total number of clients on the counselor's outpatient caseload is divided by the FTE.
Employee #6 was hired as a counselor on February 28, 2012 and was still employed at the time of the inspection. The employee's ratio calculation was as follows: 40/40 = 1 (FTE); 37/1 = 37, which equals to a client/counselor FTE ratio of 37:1.
Employee #7 was hired as a counselor on September 10, 2014 and was still employed at the time of the inspection. The employee's ratio calculation was as follows: 10/40 = .25 (FTE); 9/.25 = 36, which equals to a client/counselor FTE ratio of 36:1.
Employee #8 was hired as a counselor on May 5, 2018 and was still employed at the time of the inspection. The employee's ratio calculation was as follows: 40/40 = 1(FTE); 36/1 = 36, which equals to a client/counselor FTE ratio of 36:1.
This finding was reviewed with facility staff during the licensing process.
|
Plan of Correction
The CEO has reviewed the matter with the Clinical Director. Aldie had experienced a period of an increase in new enrollments which contributed to the higher than normal caseloads. The Clinical Director has made the adjustments and assigned clients to new therapists to bring the ratios into compliance. The Clinical Director will continue to monitor the situation and assigned newly enrolled clients to therapists with capacity. The CEO has authorized the hiring of additional therapists, is necessary to ensure ongoing compliance was the patient census continues to grow. |
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.
|
Observations
Based on a review of client records, the facility failed to document the specific information to be disclosed on a consent to release information form in one of seven client records reviewed.
Client # 5 was admitted into the drug free level of care on July 14, 2021 and was still active at the time of the inspection. The release of information form to a county/government agency was signed and dated by the client and witness on July 14, 2021; however, the specific information to be released was not documented on the form.
These findings were reviewed with facility staff during the licensing inspection.
|
Plan of Correction
The CEO has reviewed the citation with the Clinical Director and with the management team at a meeting held on July 12th. The Clinical Director will provide instruction at a clinical team meeting on the requirements to fully complete all information on release forms. Compliance will be monitored during individual and group supervision, and as part of regular chart audits conducted by the MAT Coordinator. |
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).
|
Observations
Based on a review of client records, the facility failed to document the signature of the client on release of information forms in three of seven client records reviewed.
Client #4 was admitted on March 1, 2021 and was discharged April 28, 2022. A release of information form to a county/government agency was signed and dated by the client on March 1, 2021; however, the form did not include the dated signature of the client.
Client # 5 was admitted on July 14, 2021 and was still active at the time of the inspection. Release of information forms to a government agency, a funding source, and an emergency contact were signed and dated by the client on July 14, 2021; however, none of the forms included the dated signature of the client.
Client # 6 was admitted on December 3, 2021 and was discharged March 23, 2022. Release of information forms to a funding source and an emergency contact were signed and dated by the client on December 3, 2021; however, both forms did not include the dated signature of the client.
This finding was reviewed with facility staff during the licensing process.
|
Plan of Correction
The CEO has reviewed the Citation with the Clinical Director and the management team at a meeting held on July 12th. The Clinical Director has established procedures where all new client orientation sessions are conducted in-person. As such, the forms will be signed in-person during orientation. In the event that an individual requires telehealth only services, they will in instructed to make arrangements to physically visit the facility to sign the form, or sign the forms and return via email or regular mail. The Clinical Director and MAT Coordinator will ensure compliance during individual and group supervision, and as part of chart audits. |
715.23(b)(5) LICENSURE Patient records
(b) Each patient file shall include the following information:
(5) The results of all annual physical examinations given by the narcotic treatment program which includes an annual reevaluation by the narcotic treatment physician.
|
Observations
Based on a review of patient records, the facility failed to document the results of an annual physical examination given by the narcotic treatment program, which includes an annual reevaluation by the narcotic treatment physician, in one of five applicable records reviewed.
Patient #4 was admitted into the methadone monitoring level of care on March 1, 2021 and was discharged April 28, 2022. The last documented physical examination was performed on March 1, 2021.
These findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
The CEO has reviewed the Citation with the Chief Nursing Officer, the Director of Nursing, and the Clinical Director. The issue was also discussed at the July 12th management meeting. Within the last quarter of the year, Aldie implemented a new dispensing EHR. The Director of Nursing will monitor the EHR on a not less than weekly basis to determine individual in need of an annual physical. The clients will be scheduled with the Medical Director or the Physician Assistant, who was hired within the last six months to add capacity for annual physical exams and other services. |
709.93(a)(11) LICENSURE Client records
709.93. Client records.
(a) There shall be a complete client record on an individual which includes information relative to the client's involvement with the project. This shall include, but not be limited to, the following:
(11) Follow-up information.
|
Observations
Based on a review of client records, the facility failed to document a complete client record, which is to include follow-up information, in two of three applicable client records reviewed.
Client # 6 was admitted into the drug free level of care on December 3, 2021 and was discharged March 23, 2022.
Client # 7 was admitted into the drug free level of care on April 14, 2021 and was discharged March 30, 2022.
The findings were discussed with facility staff during the licensing process.
|
Plan of Correction
The CEO has reviewed the Citation with the Clinical Director and with the management team at the July 12th meeting. The Clinical Director and the MAT Coordinator will develop a system whereby discharged clients are referred to the COE staff. A care manager will attempt to make telephone contact within 30 days post-discharge. If after three (3) attempts contact is not made, a letter will be sent to the last know address of the subject client. The MAT Coordinator will ensure compliance as part of supervision and regular chart audits. |