INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection and methadone monitoring inspection conducted on June 19-21, 2019 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, New Directions Healthcare, LLC 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
The facility failed to document that each counselor met both the educational and experiential qualifications for the position of counselor.
Staff records were reviewed on June 19, 2019. Staff #5 and #10 were hired as bachelor's level counselors, but did not have at least one year clinical experience documented prior to being hired.
Staff #5 was hired as a counselor on September 4, 2018. At the time of hire, staff #5 had a qualifying bachelor's degree, but only 8 months of clinical experience.
Staff #10 was hired as a counselor on August 14, 2017. At the time of hire, staff #10 had a qualifying bachelor's degree, but only 10 months of clinical experience.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Facility Director is responsibilities for ensure that all new hires meet the qualifications for the position of counselor prior to hiring. A Check list has been developed outlining the 704.12 that will be used to determine level of qualification. This form will be added to the required paperwork in the human resource personal file. The Facility Director will assign a qualified clinical staff to develop and supervise a written training plan of a new hire that does not meet the qualification of a counselor. The supervising clinical staff will meet with the new hire weekly for documented supervision until the counselor has meet the minimal requirements outlined in 704.12. The job description of Counselor Assistant will remain as well as a limited case load and additional training hours until the new hire and supervisor feel that the qualification of counselor have been obtained. Once qualified, a new job description of counselor will be reviewed, signed and placed in the counselor's personal file with the documentation of the process. Both Staff #5 and #10 now meet qualifications for a Counselor. This is based on supervision notes; functions of counseling check list and staff report that they feel competent in the job description and roles of a counselor. Through supervision and chart reviews each have met the standards and qualification for their current positions of counselor. |
709.30 (1) 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.
(1) A client receiving care or treatment under section 7 of the act (71 P. S. § 1690.107) shall retain civil rights and liberties except as provided by statute. No client may be deprived of a civil right solely by reason of treatment.
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Observations
The facility failed to document that it notified clients of all the required client rights.
The policy & procedure manual and client records were reviewed on June 19-21, 2019. The policy & procedure manual included all of the required client rights; however, the client handbook, which is provided to clients, did not include 709.30 (1).
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
On 7/3/19 the Project Director revised the client handbook to include the statement; "Clients have the right to inspect their own records. The project, facility or clinical director may temporarily remove portions of the record prior to the inspection by the client if the director determines that the information may be detrimental if present to the Client." As of 7/4/19 the fill in form in the EMR that is signed at assessment has been corrected to reflect the statement. All new clients will receive a copy of the revised handbook at admission. An updated copy of the client hand book has been placed in the lobby for existing clients to review. The clinical supervisor will review for the next 30 days for 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
The facility failed to document that it notified clients of all the required client rights.
The policy & procedure manual and client records were reviewed on June 19-21, 2019. The policy & procedure manual included all of the required client rights; however, the client handbook, which is provided to clients, did not include 709.30 (3).
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
On 7/3/19 the Project Director revised the client handbook to include the statement; "A Client receiving care or treatment at New Directions Healthcare shall retain civil rights and liberties except as provided by statute. No client may be deprived of a civil right solely by reason of treatment." As of 7/4/19 the fill in form in the EMR that is signed at assessment has been corrected to reflect the statement. All new clients will receive a copy of the revised handbook at admission. An updated copy of the client hand book has been placed in the lobby for existing clients to review. The clinical supervisor will review for the next 30 days for compliance. |
709.33 (a) LICENSURE Notification of termination.
§ 709.33. Notification of termination.
(a) Project staff shall notify the client, in writing, of a decision to involuntarily terminate the client ' s treatment at the project. The notice shall include the reason for termination.
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Observations
The facility failed to document that it notified the client, in writing, of the decision to involuntarily terminate the client's treatment at the project.
Client records were reviewed on June 19-21, 2019. Two of the clients reviewed were involuntarily terminated from treatment. Client records #3 and #9 did not have documentation of a written notification of involuntary termination.
Client #3 was admitted on June 25, 2018 and involuntarily terminated on November 6, 2018. There was no written notice of involuntary termination in client record #3.
Client #9 was admitted on November 2, 2018 and involuntarily terminated on January 22, 2019. There was no written notice of involuntary termination in client record #9.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
On 7/3/19, the Project Director developed a discharge letter that as of 7/5/19 is being sent out to all clients at the time of discharge. This letter includes notice of the discharge date, decision to involuntarily terminate the client from the program, why the client has been discharged, and the process for a client to appeal the termination decision. The clinical supervisor will audit all discharge charts for the next 30 days for compliance of the process. |
709.91(b)(4) LICENSURE Intake and admission
709.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(4) Consent to treatment.
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Observations
The facility failed to document a consent to treatment in two of two outpatient drug-free client records.
Client records were reviewed on June 20 & 21, 2019. Two of the records reviewed were outpatient drug-free clients. Neither client #1 or client #2 had documentation of a consent to treatment.
Client #1 was admitted on on August 17, 2018 and discharged on November 8, 2018, There was no consent to treatment in client record #1.
Client #2 was admitted on on October 29, 2018 and discharged on May 3, 2019 There was no consent to treatment in client record #2.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
On 7/3/19, a "Consent to Treatment" fill in form was added to the EMR. This form will be signed by all outpatient clients at the time of admission. The Facility Director will ensure that all outpatients sign a consent to treatment. The client rights are addressed in the previous plans of correction. Compliance will be monitored via chart review by the Performance Quality Improvement staff, which reports to the Facility Director.
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