INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on May 4-5, 2021 by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, ARC Manor 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 one of ten personnel records reviewed, the facility failed to ensure that each counselor meets the qualifications for the position of counselor.
Employee # 3 was hired as a counselor on September 14, 2020 and was still in this position at the time of the inspection. A review of employee # 3's resume/degree/transcripts indicated a Bachelor's degree in a field of study in business/healthcare that does not qualify for a counselor position.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Executive Director and Clinical Director changed this staff's position title to Counselor Assistant on 5/10/21. This staff will continue to receive the necessary/required supervision until appropriately credentialed (PCB certification or receives a masters degree) and can meet full criteria as a counselor.
Moving forward, all transcripts will be reviewed by the Clinical Director and Executive Director, and will be forwarded to DDAP licensure, with any uncertainty regarding meeting criteria for acceptable degrees/qualifications. |
704.9(b) LICENSURE Performance evaluation
704.9. Supervision of counselor assistant.
(b) Performance evaluation. The counselor assistant shall be given a written semiannual performance evaluation based upon measurable performance standards. If the individual does not meet the standards at the time of evaluation, the counselor assistant shall remain in this status until the supervised period set forth in subsection (c) is completed and a satisfactory rating is received from the counselor assistant's supervisor.
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Observations
Based on one of ten personnel records reviewed, the facility failed to provide a written semiannual performance evaluation based upon measurable performance standards for employee # 8.
Employee # 8 was hired as a counselor assistant on September 2, 2020 and was till in this position at the time of the inspection. A semi-annual performance evaluation was due to occur no later than March 2, 2020. There was no semi-annual performance evaluation completed by the counselor assistant's supervisor.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Clinical Director completed the evaluation on 4/29/21. The Executive Director reviewed the regulations with the Clinical Director on 5/6/21 and will ensure that the performance evaluation tracking sheet is kept up to date and checked regularly to confirm completion of performance evaluations in a timely manner. The Executive Director will review this in the integration meeting on 5/25/21 as well. |
705.10 (c) (4) LICENSURE Fire safety.
705.10. Fire safety.
(c) Fire extinguisher. The residential facility shall:
(4) Instruct all staff in the use of the fire extinguishers upon staff employment. This instruction shall be documented by the facility.
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Observations
Based on one of eight personnel records reviewed, the facility failed to instruct all staff in the use of the fire extinguishers upon staff employment.
Employee # 8 was hired as a counselor assistant on September 2, 2020 and was still in this position at the time of the inspection. There was no documentation of fire extinguisher training until December 28, 2020.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Executive Director reviewed with the Clinical Director on 5/18/21 regarding the requirements of completing the safety training within 7 days of hire for new staff. This will be reviewed by the Clinical Director at the next safety meeting on 5/26/21. |
705.10 (d) (3) LICENSURE Fire safety.
705.10. Fire safety.
(d) Fire drills. The residential facility shall:
(3) Ensure that all personnel on all shifts are trained to perform assigned tasks during emergencies.
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Observations
Based on one of eight personnel records reviewed, the facility failed to ensure that all personnel on all shifts are trained to perform assigned tasks during emergencies.
Employee # 8 was hired as a counselor assistant on September 2, 2020 and was still in this position at the time of the inspection. There was no documentation of emergency training until December 28, 2020.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Executive Director reviewed with the Clinical Director on 5/18/21 regarding the requirements of completing the safety training within 7 days of hire for new staff. This will be reviewed by the Clinical Director at the next safety meeting on 5/26/21. |
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 three nineteen client records reviewed, the facility failed obtain an informed and voluntary consent from the client for the disclosure of information contained in the client record.
Client # 4 was admitted to inpatient level of care on December 30, 2020 and discharged on February 24, 2021. A referral was sent to outside agency's on January 19, February 4 and 5 2021 without an informed and voluntary consent from the client for the disclosure of information contained in the client record.
Client # 12 was admitted to outpatient level of care on January 27, 2021 and was still active at the time of the inspection. There was no documentation of an informed and voluntary consent from the client for the disclosure of information to a funding source. A review of the client record indicated the client was receiving funding for services.
Client # 14 was admitted to outpatient level of care on November 20, 2020 and was discharged on March 4, 2021. There was no documentation of an informed and voluntary consent from the client for the disclosure of information to a funding source. A review of the client record indicated the client was receiving funding for services.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
During COVID, the agency conducted intakes via telehealth which created some difficulty obtaining completed consents from clients. This was changed in Feb. 2021 to all intakes being conducted in person (unless COVID safety concerns are present) to allow for completion of necessary forms. The Clinical Director will review the requirements of completing these releases of information prior to beginning treatment with clinical staff on 5/20/21. The CFO will also review this information with administrative assistant staff at the integration meeting on 5/25/21. The Executive Director will conduct file reviews monthly to ensure these forms are completed. |
709.28 (c) (1) 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:
(1) Name of the person, agency or organization to whom disclosure is made.
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Observations
Based on one of nineteen client records reviewed, the facility failed to obtain an informed and voluntary consent from the client for the disclosure of information contained in the client record to include the name of the person, agency or organization to whom disclosure is made.
Client # 5 was admitted on March 26, 2021 and was still active at the time of the inspection. An informed and voluntary consent from the client for the disclosure of information signed and dated March 26, 2021 did not include the name of the person, agency, or organization to whom disclosure is made.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Clinical Director will review the requirements of fully completing a release of information to ensure it is valid with clinical staff on 5/20/21 and the CFO will review this requirement with administrative assistant staff in integration meeting on 5/25/21. The Executive Director will conduct file reviews monthly to ensure these forms are completed accurately. |
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 two of nineteen client records reviewed, the facility failed to obtain an informed and voluntary consent from the client for the disclosure of information contained in the client record to include the specific information disclosed.
Client # 1 was admitted on March 19, 2021 and was still active at the time of the inspection. An informed and voluntary consent from the client for the disclosure of information signed and dated March 19, 2021 to a funding source allowed for the release of "ASAM, date of birth, dates and types of treatment, demographics, diagnosis, discharge and aftercare planning, encounter details, GPRA interview and assessment, intake transaction, liability information, policy number and secondary insurance information, screening tool, and social security number."
Client # 16 was admitted on March 12, 2021 and was still active at the time of the inspection. An informed and voluntary consent from the client for the disclosure of information signed and dated March 12, 2021 to a funding source allowed for the release of "ASAM, date of birth, dates and types of treatment, demographics, diagnosis, discharge and aftercare planning, encounter details, GPRA interview and assessment, intake transaction, liability information, policy number and secondary insurance information, screening tool, and social security number."
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The additional information was added to the release of information due to the requirements to provide this information for funding purposes only. The requirement to provide this additional information was directed by DDAP through the SCA due to the funding source requirements. The Executive Director changed the releases of information on 5/11/21 to limit the information provided on the billing release and added the additional information to the case management release, despite this information only being required for funding purposes. The Clinical Director will review with clinical staff on 5/20/21 the requirement to ensure these forms are completed correctly. |
715.9(a)(1) 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:
(1) Verify that the individual has reached 18 years of age.
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Observations
Based on one of eight patient records reviewed, the facility failed to screen each individual to determine eligibility for admission to include verifying that the individual has reached 18 years of age.
Patient # 17 was admitted on January 12, 2021 and was still active at the time of the inspection. There was no photograph or ID available in the patient record verifying that the individual has reached 18 years of age.
These findings were reviewed with facility staff during the licensing process.
This is a repeat citation from the September 30, 2020 inspection.
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Plan of Correction
The Clinical Director will review with all clinical staff and nursing staff during the weekly staff meeting on 5/20/21 to ensure all staff complete the required forms prior to referring a client to the MAT program. This paperwork will be required to be reviewed by the Clinical Director and Nurse before the client is seen by the physician to ensure that the appropriate forms of identification for age are completed. |
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 one of eight patient records reviewed, the facility failed to screen each individual to determine eligibility for admission to include verifying the individual 's identity, including name, address, date of birth, emergency contact and other identifying data.
Patient # 17 was admitted on January 12, 2021 and was still active at the time of the inspection. There was no photograph or ID available in the patient record verifying the individual 's identity, including name, address, date of birth, emergency contact and other identifying data.
These findings were reviewed with facility staff during the licensing process.
This is a repeat citation from the September 30, 2020 inspection.
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Plan of Correction
The Clinical Director will review with all clinical staff and nursing staff during the weekly staff meeting on 5/20/21 to ensure all staff complete the required forms prior to referring a client to the MAT program. This paperwork will be required to be reviewed by the Clinical Director and Nurse before the client is seen by the physician to ensure that the appropriate forms of identification are completed. |
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 two of eight patient records reviewed, the facility failed to obtain an informed, voluntary, written consent before an agent may be administered to the patient in patient records # 2 and 17.
Patient # 2 was admitted on November 25, 2020 and was discharged on December 16, 2020. The patient was prescribed buprenorphine on November 25, 2020 with subsequent prescriptions provided on December 2 and 16, 2020, January 13, 2021 and February 17, 2021. An informed, voluntary, and written consent was not provided by the patient until February 26, 2021.
Patient # 17 was admitted on January 12, 2021 and was still active at the time of the inspection. The patient was prescribed buprenorphine on January 13, 2021. There was not an informed, voluntary, and written consent provided in the patient record.
These findings were reviewed with facility staff during the licensing process.
This is a repeat citation from the September 30, 2020 inspection.
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Plan of Correction
The Clinical Director will review with all clinical staff and nursing staff during the weekly staff meeting on 5/20/21 to ensure all staff complete the required forms prior to referring a client to the MAT program. This paperwork will be required to be reviewed by the Clinical Director and Nurse before the client is seen by the physician to ensure that the appropriate forms of consent are completed. |
715.13(b) LICENSURE Patient identification
(b) A narcotic treatment program shall maintain onsite a photograph of each patient which includes the patient 's name and birth date. The narcotic treatment program shall update the photograph every 3 years.
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Observations
Based on one of eight patient records reviewed, the facility failed to maintain onsite a photograph of each patient which includes the patient 's name and birth date in patient record # 17.
Patient # 17 was admitted on January 12, 2021 and was still active at the time of the inspection. There was no photograph or ID available in the patient record identifying the patients name or date of birth.
These findings were reviewed with facility staff during the licensing process.
This is a repeat citation from the September 30, 2020 inspection.
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Plan of Correction
The Clinical Director will review with all clinical staff and nursing staff during the weekly staff meeting on 5/20/21 to ensure all staff complete the required forms prior to referring a client to the MAT program. This paperwork will be required to be reviewed by the Clinical Director and Nurse before the client is seen by the physician to ensure that the appropriate forms of identification are completed. |
715.14(a) LICENSURE Urine testing
(a) A narcotic treatment program shall complete an initial drug-screening urinalysis for each prospective patient and a random urinalysis at least monthly thereafter.
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Observations
Based on four of eight patient records reviewed, the facility failed to complete an initial drug-screening urinalysis for each prospective patient and a random urinalysis at least monthly thereafter in-patient record # 2, 4, and 17.
Patient # 2 was admitted to inpatient on November 25, 2020 and was discharged to another level of care on December 16, 2020. There was not an initial drug screening urinalysis documented in the patient record.
Patient # 4 was re-admitted to inpatient on December 30, 2020 and was discharged on February 24, 2021. There was not an initial drug screening urinalysis documented in the patient record.
Patient # 17 was admitted on January 12, 2021 and was still active at the time of the inspection. There was not an initial drug screening urinalysis documented in the patient record until March 4, 2021.
Patient # 19 was admitted on February 3, 2021 and was discharged on April 20, 2021. There was not a monthly drug screening urinalysis documented in the patient record until for the month of February 2021.
These findings were reviewed with facility staff during the licensing process.
This is a repeat citation from the September 30, 2020 inspection.
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Plan of Correction
Drug screen results were on file for Client #2 and #4. Clinical Director will review with clinical staff and nursing staff during weekly staff meeting on 5/20/21 to review the requirements of initial and ongoing drug screening prior to client seeing physician for MAT services. The nurse will be responsible to ensure this is completed prior to client's appointment with the physician. The nurse will monitor this monthly to ensure drug screens are completed. |