INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on February 24, 2017 by staff from the Department of Drug and Alcohol Programs, Bureau of Quality Assurance for Prevention and Treatment, Program Licensure Division. Based on the findings of the on-site inspection, Northwestern Human Services of Delaware County Inc. was found not to be in compliance with the applicable chapters of 28 PA Code which pertain to the facility. The following deficiencies were identified during this inspection:
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Plan of Correction
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704.11(f)(2) LICENSURE Trng Hours Req-Coun
704.11. Staff development program.
(f) Training requirements for counselors.
(2) Each counselor shall complete at least 25 clock hours of training annually in areas such as:
(i) Client recordkeeping.
(ii) Confidentiality.
(iii) Pharmacology.
(iv) Treatment planning.
(v) Counseling techniques.
(vi) Drug and alcohol assessment.
(vii) Codependency.
(viii) Adult Children of Alcoholics (ACOA) issues.
(ix) Disease of addiction.
(x) Aftercare planning.
(xi) Principles of Alcoholics Anonymous and Narcotics Anonymous.
(xii) Ethics.
(xiii) Substance abuse trends.
(xiv) Interaction of addiction and mental illness.
(xv) Cultural awareness.
(xvi) Sexual harassment.
(xvii) Developmental psychology.
(xviii) Relapse prevention.
(3) If a counselor has been designated as lead counselor supervising other counselors, the training shall include courses appropriate to the functions of this position and a Department approved core curriculum or comparable training in supervision.
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Observations
Based on a review of the Staffing Requirements Facility Summary Report (SRFSR) and personnel records, the facility failed to document the completion of 25 clock hours of annual training required for counselors for employee #4.
Employee #4 was hired as a counselor on November 1, 2010 and was still in the position as of the date of the onsite inspection. The facility's training year that was reviewed was from July 1, 2015 through June 30, 2016. Employee #4's employee record only documented 21.5 hours of annual training for the training year reviewed.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Effective, March, 1, 2017, each employee will review their (My NHS Learning) transcript with their immediate supervisor to ensure that each employee is following their individualized training plan for the current year. This review will be done at least 1x/month during face-to-face individual supervision with the employee's direct supervisor. Employees will have access to internal trainings offered on-site by the Program Director at least 10 times per calendar year. NHS of Delaware County will provide all employees with list of relevant available trainings and will make every effort to support each employee in accomplishing their training goals throughout the year. |
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
The Staffing Requirements Facility Summary Report was completed and reviewed on February 24, 2017. Employee #5 was hired as a counselor on 09/24/12 and was still employed in the position. Employee #5 was reported to have 20 hours per week devoted to their 37 clients on their caseload. Employee #8 was hired as a counselor on 10/10/05 and was still employed in the position. Employee #8 was reported to have 20 hours per week devoted to their 41 clients on their caseload. Employee #9 was hired as a counselor on 06/01/15 and was still employed in the position. Employee #9 was reported to have 25 hours per week devoted to their 27 clients on their caseload.
The counselor Full Time Equivalent (FTE) is determined by dividing the total number of hours the counselor devotes to their patients by 35. Then, in order to obtain the counselor's ratio, the total number of patients on the counselor's caseload is divided by the FTE.
The FTE counselor's caseload calculation for employee # 5 is as follows: 20/35 = 0.5714(FTE); 37/0.5714 = 64.7, which equals to a client/counselor ratio of 65:1.
The FTE counselor's caseload calculation for employee # 8 is as follows: 20/35 = 0.5714(FTE); 41/0.5714 = 71.7, which equals to a client/counselor ratio of 72:1.
The FTE counselor's caseload calculation for employee # 9 is as follows: 25/35 = 0.7142(FTE); 27/0.7142 = 37.8, which equals to a client/counselor ratio of 38:1.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
NHS of Delaware County has increased its recruiting efforts and the program director is actively screening and recruiting FTE counselors to bring the program into compliance by April 15th, 2017, with the state regulations. FTE counselor's caseload will not exceed 35 active clients. |
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
A review of the December 2015 through December 2016 fire drill logs was conducted during the onsite inspection. Each of the fire drill logs for the year reviewed, with the exception of September 2016, failed to include the exit route used.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
NHS of Delaware County has updated the fire drill log to include all exit routes used during fire drills as of February 2017. The Program Director will be responsible for monitoring the ongoing use of the corrected form that indicates all routes used during fire drills. |
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 a review of client records, 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 record #'s 4, 5, and 7. Additionally, consent to release information forms in client record #'s 1, 5, 6, and 7 were missing required information.
Client #1 was admitted on 10/03/11 and was an active client at the time of inspection. The record contained a consent to release information form, signed and dated on 09/28/15, to a personal acquaintance, which was missing the purpose of disclosure. The record also contained a consent to release information form to the primary care physician, signed and dated on 09/19/16, which did not include the name, agency, or organization to which the disclosure would be made.
Client #4 was admitted on 05/09/16 and discharged on 11/17/16. The record contained documentation of a facsimile to the funding source on 08/15/16, which released information that exceeded the limits established by 4 Pa. Code 255.5, including UDS results.
Client #5 was admitted on 09/09/14 and discharged on 2/21/17. The record contained a consent to release information form signed and dated on 08/25/15 to a government official, which was missing the purpose of disclosure and allowed for the release of information that exceeded the limits established by 4 Pa. Code 255.5, including UDS results.
Client #6 was admitted on 12/20/16 and discharged on 01/25/17. The record contained two consent to release information forms to government agencies and one to a lab, all signed and dated on 12/20/16, which were missing the purpose of disclosure. The record also contained a consent to release information form to the primary care physician, signed and dated on 12/20/16, which did not include the name, agency, or organization to which the disclosure would be made.
Client #7 was admitted on 06/24/16 and was discharged on 11/03/16. The record contained two consent to release information forms to government agencies and one to a lab, signed and dated on 06/24/16 and all were missing the specific information to be released. The record also contained documentation of a facsimile to the funding source on 09/09/16, which released information that exceeded the limits established by 4 Pa. Code 255.5, including UDS results.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The program director took immediate action and held a team meeting to review the confidentiality policy. In order to ensure compliance to the policy set forth, the following protocol has been put in place, effective March, 30th, 2017:
All staff, including front desk / administrative staff, will have an internal confidentiality refresher training on March 30th, 2017.
In addition to the confidentiality training held during orientation, all new staff, administrative and clinical, will receive in-depth confidentiality training addressing the following areas during their on-site orientation:
1) A review of PA Code 255.5.
2) Completing a Release of Information.
3) Client's rights and responsibilities.
Staff will be given a pre and post-test at the beginning and the end of the training.
All new clinical staff will attend the Confidentiality training offered by DDAP within 6 months of employment.
Confidentiality refresher courses will be offered internally quarterly.
The consent to release information forms that are missing components will be voided, redone and corrected, checked by the program director for accuracy and the signature of the client shall be obtained again. |
709.34 (c) (2) 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:
(2) Death or serious injury due to trauma, suicide, medication error or unusual circumstances.
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Observations
On February 24, 2017, it was discovered that since the previous licensing inspection the facility had 2 client deaths while they were active clients. The facility discharged the clients on 9/13/16 and 11/03/16, respectively, because the clients were deceased. Upon further inspection, it was discovered that the facility had not submitted a written unusual incident report to the Department within the regulatory timeframe for either of the client deaths.
These findings were reviewed with project and facility staff during the licensing process.
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Plan of Correction
Program director gathered information from DOH and reviewed licensing alert 5-97. All clinical staff will be trained on the reporting requirements on March 30th, 2017. During the training, staff will review the documentation that is to be completed when there is an unusual incident. Staff will be given a post-test after the training.
Program director will serve as the primary point of contact and staff have been made aware that the all incident reports should be submitted within 24 hrs of the incident.
In order to correct the deficiency, Program Director will formally report unusual incidents that have not been reported by March 30th, 2017. |
715.10(f) LICENSURE Pregnant patients
(f) The narcotic treatment program shall ensure that each female patient is fully informed of the possible risk to her or her unborn child from continued use of illicit drugs and from use of, or withdrawal from a narcotic drug administered or dispensed by the program in comprehensive maintenance or detoxification treatment.
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Observations
Based on a review of client records, client record #'s 3, 5, and 6 did not contain documentation that the facility informed female clients of the potential risks to her or her unborn child of continued use of illicit drugs or withdrawal from a narcotic drug prescribed by the program.
Client # 3 was admitted on 08/03/16 and was an active client at the time of the inspection.
Client # 5 was admitted on 09/09/14 and was discharged on 02/21/17.
Client # 6 was admitted on 12/20/16 and was discharged on 01/25/17.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Effective immediately, all female clients admitted into the suboxone program will be counseled by the prescribing physician regarding the potential risks to an unborn child. This consultation will be documented and signed and dated by the female client during the induction process. |
709.91(b)(6) LICENSURE Intake and admission
709.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(6) Psychosocial evaluation.
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Observations
Based on a review of client records, the facility failed to document a psychosocial evaluation in client record #'s 2 and 6 as of the date of the licensing inspection.
Client #2 was admitted on 08/24/16 and was still an active client at the time of the inspection.
Client #6 was admitted on 12/20/16 and was discharged on 1/25/17.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Program Director will ensure that staff will continue to receive ongoing bi-weekly supervisions and weekly team meetings around maintaining the integrity of the client's records. All staff are required to sign and date the service logs on the date that the service was provided. The program director will provide refresher trainings related to "Clinical Documentation" will be offered 4xs/year. Internal audits will continue as scheduled to monitor compliance.
Internal review revealed that a psychosocial evaluation was completed for client #2 and filed appropriately by due date of 3/30/17. |
709.93(a)(3) 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:
(3) Record of services provided.
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Observations
Based on a review of client records, the facility failed to provide a complete client record in client records #'s 2, 4, and 5.
Client #2 was admitted on 08/24/16 and was an active client at the time of inspection. The client record did not contain a record of service that was updated since 10/31/16, despite evidence that services were provided since that time.
Client #4 was admitted on 05/09/16 and was discharged on 11/17/16. The record did not contain documentation of case consultation notes or follow-up information as of the date of the inspection.
Client #5 was admitted on 09/09/14 and discharged on 02/21/17. The client record did not contain a record of service that was updated since July 2016, despite evidence that services were provided since that time. Additionally, there was no documentation of case consultation notes as of the date of the inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Staff will continue to receive ongoing bi-weekly supervisions and weekly team meetings around maintaining the integrity of the client's records. All staff are required to sign and date the service logs on the date that the service was provided. Refresher trainings related to "Clinical Documentation" will be offered 4xs/year. Internal audits will continue as scheduled to monitor compliance.
To bring records into compliance, record of services for client #2 and #5 by 3/31/17 and follow-up should be completed will be completed and documented for client #4 by 3/31/17. |