INITIAL COMMENTS
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This report is a result of an onsite licensure renewal and methadone monitoring inspection conducted on August 3, 2016 through August 4, 2016 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, The Consortium 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 the inspection:
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Plan of Correction
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704.11(c)(3) & (4) LICENSURE Training types and amounts
704.11. Staff development program.
(c) General training requirements.
(3) At least one-half of all training in this section shall be provided by trainers not directly employed by the project unless the project employs staff persons specifically to provide training for its organization and staff.
(4) An individual who holds more than one position in a facility shall meet the training requirement hours set forth for the individual's primary position. Subject areas shall be selected according to the individual's training plan. Primary position is defined as that position for which an individual was hired.
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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 employees #6 and #7 received at least one-half of their required annual training hours from an outside provider, who is not directly employed by the project. The training period reviewed was 01/01/2015 through 12/31/2015.
Employee #6 obtained a total of 36 training hours during the training period reviewed; however, only 6 hours were provided by an outside training provider.
Employee #7 obtained a total of 23.5 training hours during the training period reviewed; however, only 3.5 hours were provided by an outside training provider.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Plan of Correction:
All staff will be scheduled for external training for at least one half of their annual required training hours.
Responsible Party:
Supervisors will be responsible for ensuring that their respective staff attend at least one half of their annual training hours by an external provider.
Ongoing Monitoring:
Each supervisor will monitor their respective staff's training hours each month to ensure they are receiving training from outside sources.This will be reviewed in monthly supervision.
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704.11(d)(2) LICENSURE Annual Training Requirements
704.11. Staff development program.
(d) Training requirements for project directors and facility directors.
(2) A project director and facility director shall complete at least 12 clock hours of training annually in areas such as:
(i) Fiscal policy.
(ii) Administration.
(iii) Program planning.
(iv) Quality assurance.
(v) Grantsmanship.
(vi) Program licensure.
(vii) Personnel management.
(viii) Confidentiality.
(ix) Ethics.
(x) Substance abuse trends.
(xi) Developmental psychology.
(xii) Interaction of addiction and mental illness.
(xiii) Cultural awareness.
(xiv) Sexual harassment.
(xv) Relapse prevention.
(xvi) Disease of addiction.
(xvii) Principles of Alcoholics Anonymous and Narcotics Anonymous.
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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 document the completion of 12 clock hours of annual training required for the project director and the facility director. The facility's training year that was reviewed was from January 1, 2015 through December 31, 2015.
Employee #1 was hired as the project director on 12/03/2001 and was still in the position as of the date of the onsite inspection. There were only 6 hours of annual training documented in Employee #1's personnel record for the training year reviewed.
Employee #2 was hired as the facility director on 02/20/2010 and was still in the position as of the date of the onsite inspection. There were only 10.5 hours of annual training documented in Employee #2's personnel record for the training year reviewed.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Plan of Correction:
The Project Director and the Facility Director will ensure attendance in training to meet the annual training requirement of 12 hours.
Responsible Party: The Facility Director and the Project Director are responsible for ensuring that they receive at least 12 clock hours of training by December 31st of each year.
Ongoing Monitoring: The Facility Director and the Project Director will register for at least on training per month. |
704.11(e)(2) LICENSURE Annual Trng Req-Clin Sup
704.11. Staff development program.
(e) Training requirements for clinical supervisors.
(2) Each clinical supervisor shall complete at least 12 clock hours of training annually in areas such as:
(i) Supervision and evaluation.
(ii) Counseling techniques.
(iii) Substance abuse trends and treatment methodologies in the field of addiction.
(iv) Confidentiality.
(v) Codependency/Adult Children of Alcoholics (ACOA) issues.
(vi) Ethics.
(vii) Interaction of addiction and mental illness.
(viii) Cultural awareness.
(ix) Sexual harassment.
(x) Developmental psychology.
(xi) Relapse prevention.
(xii) Disease of addiction.
(xiii) Principles of Alcoholics Anonymous and Narcotics Anonymous.
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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 document the completion of 12 clock hours of annual training required for the clinical supervisor. The facility's training year that was reviewed was from January 1, 2015 through December 31, 2015.
Employee #3 was hired as the clinical supervisor on 06/09/2008 and was still in the position as of the date of the onsite inspection. There were only 6.5 hours of annual training documented in Employee #3's personnel record for the training year reviewed.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Plan of Correction:Each Clinical will be registered for one training per month in an attempt to ensure completion of at least 12 clock hours of training by December 31st of each year.
Responsible Party: The Facility Director is responsible for ensuring the completion of 12 clock hours of annual training required for each clinical supervisor.
Ongoing Monitoring:The Facility Director will review status of completed training during monthly supervision. |
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 personnel records and the facility's Staffing Requirement Facility Summary Report (SRFSR) form, the facility failed to document the completion of 25 clock hours of annual training for employee #'s 7, 9, and 10, all of whom are employed as counselors. The facility's training year that was reviewed was from January 1, 2015 through December 31, 2015.
Employee #7 was hired on 03/12/2001 and was still in the position as of the date of the onsite inspection. There were only 23.5 hours of annual training documented in Employee #7's personnel record for the training year reviewed.
Employee #9 was hired on 03/26/2007 and was still in the position as of the date of the onsite inspection. There were only 14 hours of annual training documented in Employee #9's personnel record for the training year reviewed.
Employee #10 was hired on 08/22/2011 and was still in the position as of the date of the onsite inspection. There were only 13.5 hours of annual training documented in Employee
#10's personnel record for the training year reviewed.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Plan of Correction: Each counselor will attend at least 2 hours of training each month in an attempt to meet the annual requirement of 25 clock hours.
Responsible Party: The Clinical Supervisor is responsible for ensuring that all counselors receive 25 hours of training per year.
Ongoing Monitoring: The Clinical Supervisors will review the status of each of their respective counselors while in supervision each month. |
705.22 (2) LICENSURE Building exterior and grounds.
705.22. Building exterior and grounds.
The nonresidential facility shall:
(2) Keep the grounds of the facility clean, safe, sanitary and in good repair at all times for the safety and well being of clients, employees and visitors. The exterior of the building and the building grounds or yard shall be free of hazards.
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Observations
Based on the physical plant inspection that was conducted on August 3, 2016, the facility failed to ensure that the grounds of the facility were maintained in a clean, safe, sanitary, as well as in good repair as evidenced by the following:
#1 - Stained/Missing/Water damaged Ceiling Tiles
1st Floor
Large Waiting Room; Male Bathroom (near child care area); Room 115; Room 121; Room 124; Room 139; Room 142; Room 144; Room 145; Room 147; Room 147
2nd Floor
Unmarked office next to Room 203; Unmarked office next to Room 235; Room 205; Room 207; Room 209; Room 213; Room 216; Room 217; Room 219; Room 233; Room 237
#2 - Light Fixtures Not Secured/Missing Covers
1st Floor
Male Bathroom (near elevator); Room 154 Bathroom; Dosing Area; Female Bathroom (near Room 158); male Bathroom (near Room 158)
#3 - Exposed Wires Protruding From Walls
1st Floor
Room 129; Room 142; Room 162
2nd Floor
Room 218
#4 - Carpets Causing Tripping Hazard/Torn
1st Floor
Hallway Leading to Rooms 108/109/nursing; Room 109; Room 114; Room 115; Room 139; Room 140; Room 147; Room 153; Room 154; metal border in Room 158
2nd Floor
Room 214; Room 215
#5 - Stained/Dirty Carpets and Floors
1st Floor
Main Hallway; Male Bathroom (near elevator); Female Bathroom (near elevator); Stairwell (near elevator); Maintenance Room (near Room 121); Room 154 Bathroom; Unmarked Room (next to Room 154); Medical Records Room (near nursing); male bathroom (near dosing area); Female Bathroom (near room158); Male Bathroom (near Room 158); Room 111; Room 114; Room 115; Room 119; Room 122; Room 140; Room 142; Room 143; Room 144; Room 145; Room 147; Room 148; Room 151; Room 152; Room 153; Room 158
2nd Floor
Conference Room (near Facility Director's office); Male Bathroom; Room 202; Room 207; Room 215; Room 217; Room 235; Room 236; Room 237; Room 245
#6 - Peeling/Chipped Paint
1st Floor
Room 121; Room 123; Room 129; Room 142, Room 143; Room 151 (paint chips inside air vent); Stairwell (near elevator)
2nd Floor
Room 217; Room 218; Room 235 (door); Room 236 (door); Female Bathroom
#7 - Cracks and/or Holes in Walls
1st Floor
Room 108; Room 123; Room 124; Room 136; Room 143; Room 144; Room 145; Room 147; Room 151; Room 152; Room 154 Bathroom; Large Waiting Room (near child care area); Hallway (near elevator); Maintenance Room (room with water heater); Dosing Area
2nd Floor
Room 201; Room 202; Room 203; Room 209; Room 217; Room 235; Room 236; Room 237; Room 239; Room 241; Room 249; Unmarked Room (next to Room 203); Male Bathroom; Maintenance Room Across from 2nd floor bathrooms (Large Hole in Floor)
#8 - Tiled Flooring Cracked/Broken
1st Floor
Large Waiting Room; Female Bathroom (near child care area); Hallway (outside all 1st floor bathrooms); Female Bathroom (near elevator); Hallway (near Room 122); Hallway (near Room 151); Hallway (near Room 154); Female Bathroom (near Room 158); Dosing Area; Room 158; Room 162
#9 - Loose Airvent
1st Floor
Male Bathroom (near elevator)
Dosing Area
#10 - Baseboard Molding Torn/Missing/Rotting
1st Floor
Female Bathroom (near child care area); Room 121; Room 153; Room 157
#11 - The outside garbage dumpster was not covered upon the arrival of Licensing Specialist 08/03/2016 at 08:30am, as well as during the physical plant inspection conducted outside at approximately 12:45pm.
This is a repeat citation from the complaint investigation conducted on-site on 03/23/2016.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Plan of Correction:
#1 - Stained/Missing/Water damaged Ceiling Tiles.
All stained/Missing/Water Damaged tiles will be replaced by the Facilities Dept by 9/9/16.
#2 - Light Fixtures Not Secured/Missing Covers
All Light Fixtures Not Secured or Missing Covers will be repaired or secured by 9/2/16 by the Facilities Dept.
#3 - Exposed Wires Protruding From Walls
All rooms identified as having Exposed Wires Protruding From Walls will be repaired by 9/9/16.
#4 - Carpets Causing Tripping Hazard/Torn
All areas identified as having Carpets Causing Tripping Hazard/Torn will be replaced or repaired by 10/7/16.
#5 - Stained/Dirty Carpets and Floors
All areas identified as having stained or dirty carpets and floors will have either the carpets or floors cleaned or replaced by 10/7/16.
#6 - Peeling/Chipped Paint
All areas identified as having peeling and/or chipping paint,will be repainted by 9/30/16 by the Facilities Dept.
#7 - Cracks and/or Holes in Walls
All areas identified as having cracks and/or holes in the walls will be repaired by 9/30/16 by the Facilities Dept.
#8 - Tiled Flooring Cracked/Broken
All areas identified as having cracked or broken floor tiles will be repaired or replaced by 10/7/16.
#9 - Loose Air Vent
Both areas identified as having a loose air vent, will have vents repaired by 8/19/16.
#10 - Baseboard Molding
All areas identified as having missing, torn,or rotting baseboard molding will have baseboards repaired by 9/30/16.
#11 - The outside garbage dumpster will be covered at all times. For projects that require the dumpster to be open for an extended period of time, the dumpster will be closed within 5 minutes of the completion of the project. The Facilities Dept will ensure the lid on the dumpster is close during hourly check of exterior grounds.
Responsible Party: The Facilities Department is responsible for ensuring that the facility keeps the grounds of the facility clean, safe, sanitary and in good repair at all times for the safety and well being of clients, employees and visitors.
They are also responsible for ensuring that the exterior of the building and the building grounds or yard is free of hazards.
Ongoing Monitoring:
The Facilities Department will conduct daily rounds of exterior and interior areas of the building to ensure reporting of safety hazards to the Facilities Director within 24 hours.
Facilities Director will ensure prompt repair of all issues identified through daily rounds and reports of safety hazards.
Facilities Director will maintain a log of daily round sheets
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705.23 (2) LICENSURE Counseling or activity areas and office space
705.23. Counseling or activity areas and office space.
The nonresidential facility shall:
(2) Maintain counseling areas with furnishings which are in good repair.
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Observations
Based on a physical plant inspection conducted on August 3, 2016, the facility failed to maintain furnishings which were in good repair.
During the inspection, there were multiple office chairs that were stained and/or dirty in the following areas within the facility:
1st Floor
Room 140
2nd Floor
Room 237; Room 245
This is a repeat citation from the complaint investigation conducted on-site on 03/23/2016.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Plan of Correction:
Facilities Personnel will remove all stained/dirty and torn furniture in all rooms identified.
All furniture will be replaced with new furniture, or furniture in good repair.
Responsible Party: The Facilities Dept is responsible for maintaining counseling areas with furnishings which are in good repair.
Ongoing Monitoring: The Facilities Dept will ensure that all furniture in the building is assessed during daily rounds and if necessary, furniture removed within 48 hours if not in good repair. |
705.23 (3) LICENSURE Counseling or activity areas and office space
705.23. Counseling or activity areas and office space.
The nonresidential facility shall:
(3) Ensure privacy so that counseling sessions cannot be seen or heard outside the counseling room. Counseling room walls shall extend from the floor to the ceiling.
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Observations
Based on observation during the physical plant inspection conducted on August 3, 2016, the facility failed to ensure that counseling sessions could not be heard outside of the counseling room.
As the Licensing Specialists were inspecting several rooms on the second floor, there was a group counseling session being conducted in Room 236 at approximately 10:30 am. The Licensing Specialists, as well as facility staff, were able to clearly hear the content of the group session.
This is a repeat citation from the complaint investigation conducted on-site on 03/23/2016.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Plan of Correction:
Sound machines have been ordered to ensure that sessions cannot be heard outside of the counseling office. Counselors will be reminded to ensure that sound machines are powered on during group and/or individual sessions.
Counselors will also ensure that doors are closed during individual and group sessions.
Responsible Party: All staff is responsible for ensuring that noise cannot be heard outside of the counseling office.
Ongoing Monitoring:
Facilities and Security staff will conduct walk throughs of the hallways outside of the counseling areas daily to ensure noise cannot be heard outside of the session. |
705.24 (7) LICENSURE Bathrooms.
705.24. Bathrooms.
The nonresidential facility shall:
(7) Maintain each bathroom in a functional, clean and sanitary manner at all times.
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Observations
Based on the physical plant inspection conducted on August 3, 2016, the facility failed to maintain each bathroom in a functional, safe, and sanitary manner as evidenced by:
1. The 1st floor female bathroom (near the dosing area) did not have any running water (hot or cold). It was reported that this bathroom was not used by anyone; however, there was no proper signage informing patients, staff, or visitors that the bathroom was out of order.
2. The 1st floor male bathroom and female bathroom (both near the elevator) were dirty and unsanitary.
3. The 1st floor male bathroom (near the child care area) sink had faucets that leaked when turned on as well as an inoperable cold water faucet on the right sink.
5. The 1st floor female bathroom (near the child care area) had an inoperable hot water faucet on the left sink.
6. There was graffiti on the stalls and walls of the 1st floor male bathroom (near the child care area), as well as on the stalls and walls of the 1st floor female bathroom (near Room 158).
This is a repeat citation from the complaint investigation conducted on-site on 03/23/2016.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Plan of Correction:
1. The 1st floor female bathroom (near the dosing area) will have proper signage alerting clients and staff that there is no running water by 9/9/16.
2. The 1st floor male bathroom and female bathroom (both near the elevator) will be cleaned twice daily, along with all other bathrooms. The Facilities Director will ensure cleaning staff documents each time the bathroom is cleaned.
3. The 1st floor male bathroom (near the child care area) sink will have the faucets that leaked when turned on, as well as the inoperable cold water faucet on the right sink repaired by 9/9/16.
4. The 1st floor female bathroom (near the child care area, which had the inoperable hot water faucet on the left sink, will have the sink repaired by 9/9/16 by the Facilities Dept.
5. Graffiti on the stalls and walls of the 1st floor male bathroom (near the child care area), and the 1st floor female bathroom (near Room 158), will have graffiti painted over by 9/9/16.
Responsible Party:
The Facilities Dept is responsible for maintaining each bathroom in a functional, clean and sanitary manner at all times.
Ongoing Monitoring:
Facilities Staff will ensure bathrooms are thoroughly cleaned and repaired as part of their daily rounds. |
705.27 (3) LICENSURE General safety and emergency procedures.
705.27. General safety and emergency procedures.
The nonresidential facility shall:
(3) Limit smoking to designated smoking areas.
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Observations
The facility failed to ensure that patients smoked in the outside designated smoking area. The entrance of the building is located on the side of the building and the designated smoking area is located roughly 50-60 feet away from that entrance. When the Licensing Specialist arrived at the facility on August 3, 2016 at 8:30am, there were several individuals smoking directly in front of the side entrance door, as well as near the front exit door. The same situation occurred on the second day of the inspection (August 4, 2016) when the Licensing Specialist arrived at the facility at approximately 8:30 am.
This is a repeat citation from the 03/23/2016 complaint investigation.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Plan of Correction:
The facility has designated a specific smoking area, which is away from any of the facility entrances to the building, for members and staff to smoke. All staff will assist with ensuring that all clients continue to adhere to process of smoking in the designated area.
Responsible Party:
Facility Director and Security staff are responsible for limiting smoking to designated smoking areas
Ongoing Monitoring: Security Staff will monitor smoking activity to ensure smoking does not occur around any of the facility entrances. Additionally, they will ensure that smoking activity is limited only to the designated smoking area on a daily basis. |
705.28 (d) (1) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(1) Conduct unannounced fire drills at least once a month.
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Observations
Based on a review of the August 2015 through July 2016 Fire Drill Logs, the facility failed to ensure that unannounced fire drills were conducted at least once per month as there was no verification that a completed fire drill was conducted for the months of November 2015 and June 2016.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Plan of Correction:
The Security Supervisor will provide the Facility Director with a tentative schedule documenting at least one scheduled fire drill per month.
Responsible Party: Security staff is responsible for ensuring that unannounced fire drills are conducted at least once per month .
Ongoing Monitoring. All fire drill schedules will be submitted to and reviewed by the Facility Director to ensure that one drill is scheduled per month, as well as ensuring that the drill occurs. |
705.29 (1) (i) LICENSURE Child care.
705.29. Child care.
When a nonresidential facility admits children for services or for custodial care, the following requirements apply:
(1) Building exterior and grounds. The nonresidential facility shall:
(i) Fence off or have natural barriers to protect children from all areas determined to be unsafe including steep grades, open pits, swimming pools, high voltage boosters or roads.
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Observations
Based on observation during the physical plant inspection conducted on August 3, 2016, the facility failed to provide a fence/barrier to an area that was determined to be unsafe for children.
The facility lacked a fence or gate from the children's exterior play area leading to the building's exterior basement entrance/exit door, which is situated at the bottom of a concrete stairwell.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Plan of Correction:
A gate will be added to the children's exterior play area leading to the building's exterior basement entrance/exit door to ensure safety for all children utilizing the outdoor child playroom area.
The outdoor play area will not be utilized until after the gate is added.
Responsible Party:
The Facilities Dept is responsible for ensuring the fencing off or natural barrier to protect children from all areas determined to be unsafe.
Ongoing Monitoring:
The childcare staff and the Facilities Dept will assess outdoor grounds daily to ensure that the gates are closed daily and that the area is safe for the children to be outdoors. |
705.29 (2) (iii) LICENSURE Child care.
705.29. Child care.
When a nonresidential facility admits children for services or for custodial care, the following requirements apply:
(2) Interior space. The nonresidential facility shall:
(iii) Maintain protective caps over each electrical outlet.
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Observations
Based on a physical plant inspection conducted on August 3, 2016, the facility failed to maintain protective caps over the two electrical outlets located in the large waiting room (which is directly outside of the child care room) as well as the electrical outlet near the door inside child care room #135.
This is a repeat citation from the 03/23/2016 complaint investigation.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Plan of Correction:
All outlets identified as being missing, will be covered by outlet covers.
Responsible Party:
The Facilities Staff is responsible for maintaining protective caps over each electrical outlet in areas designated as child play areas.
Ongoing Monitoring:
The Childcare staff will report any missing outlet covers within the same day identified.
The Facilities Staff will ensure covering of the outlet by the next business day. |
709.28 (b) LICENSURE Confidentiality
§ 709.28. Confidentiality.
(b) The project shall secure hard copy client records within locked storage containers. Electronic records must be stored on secure, password protected data bases.
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Observations
Based on a physical plant inspection conducted on August 3, 2016, the facility failed to secure hard copy patient records within locked storage containers in Room 203 and Room 213.
There were multiple patient records sitting on the desk in the narcotic treatment physician's office (Room 203). The doctor was not in the office at the time of the physical plant inspection and facility staff were unaware of how long the patient records were in the office.
There was a patient record sitting on the floor underneath other paperwork in the counselor's office (Room 213). The counselor was not in the office at the time of the physical plant inspection and facility staff were unaware of how long the patient record was in the office.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Plan of Correction:
All areas identified that have records stored outside of locked storage containers will have all records stored and locked appropriately.
Responsible Party: The Facility Director/Medical Records Supervisor/Facilities Staff is responsible for ensuring that all records are stored in a locked storage container, while limiting access to unauthorized staff.
Ongoing Monitoring: All rooms will be checked daily by the Facilities staff as part of the daily rounds. Any records not locked in storage containers will be reported as identified to the Facility Director who will resolve the issue within 2 business days. |
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 patient records, the facility failed to document an informed and voluntary consent to release information form prior to the disclosure of information in patient record #'s 3 and 10.
Patient #3 was admitted on 03/12/2004 and was still an active patient at the time of the inspection. There was documentation that urinalysis tests were conducted on 4/12/16, 4/18/16, 5/11/16, 6/09/16, 7/06/16, and 7/15/16; however, the consent to release information form for the urinalysis laboratory had expired on 4/6/16.
Patient #10 was admitted on 07/12/2013 and was still an active patient at the time of the inspection. There was documentation that a urinalysis test was conducted on 07/29/16; however, the consent to release information form for the urinalysis laboratory had expired on 6/29/16.
The findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
Plan of Correction:
The Facility Director will retrain Staff completing releases by 9/23/16. Training will focus on the proper completion of treatment consents, as well as non disclosure without the proper signed releases.
Responsible Party: Program Staff of the project are responsible for obtaining an informed and voluntary consent from the client for the disclosure of information contained in the client record.
Ongoing Monitoring: Proper completion of releases will be reviewed by the Clinical Supervisor through the chart review process at least quarterly. |
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 timesheets presented during the presubmission process and re-reviewed on August 3, 2016, the facility failed to ensure that the narcotic treatment physician provided at least 1 hour per week onsite for every ten patients during the weeks of 4/11/16, 7/04/16, and 7/11/16.
During the week of 4/11/16, the facility's weekly census was 293, which results in the physician required to provide at least 29.3 hours for the week. The timesheets for all three physicians employed by the facility have a total of 24.5 hours for the week.
During the week of 7/04/16, the facility's weekly census was 303, which results in the physician required to provide at least 30.3 hours for the week. The timesheets for all three physicians employed by the facility have a total of 0 hours for the week.
During the week of 7/11/16, the facility's weekly census was 304, which results in the physician required to provide at least 30.4 hours for the week. The timesheets for all three physicians employed by the facility have a total of 26 hours for the week.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Plan of Correction: The Medical Director will collaborate with the Nursing Supervisor who will develop a schedule to ensure adequate coverage for the physicians to cover the census each week. Schedule will be submitted to the Facility Director. The first schedule will be submitted for the week starting 9/12/16.
Responsible Party: The Nursing Supervisor will be responsible for the development of the weekly physician's schedule. The Medical Director will ensure coverage during all physician's call outs and vacation time.
Ongoing Monitoring: The weekly schedule will be reviewed by the Facility Director to ensure compliance. |
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 the review of patient records, the facility failed to ensure that the patient signed an informed, voluntary, wirtten consent before the administration of a narcotic agent in patient record #11.
Patient #11 was admitted on 10/09/2015 and was discharged on 04/22/2016. There was no documentation that the patient signed an informed, voluntary, written consent at the time of the inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Plan of Correction:
The Facility Director will reiterate to the Narcotic Treatment Physicians, the importance of the patient signing the informed consent prior to the administration of a narcotic agent.
Chart #11 will be reviewed. If the consent is not present, that person will be scheduled to see the onsite physician for review and execution of consent by 9/1/16.
Responsible Party:
The Narcotic Treatment Physician is responsible for ensuring that the patient signs the informed consent prior to the administration of a narcotic agent.
Ongoing Monitoring:
The Nurse Manager will review admission charts to ensure that the physician has executed consent prior to receiving the first medication dosage. |
715.23(b)(15) LICENSURE Patient records
(b) Each patient file shall include the following information:
(15) Psychosocial evaluations of the patient.
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Observations
Based on a review of patient records, patient #'s 5 and 12 did not have psychosocial evaluations documented in the patient records.
Patient #5 was admitted on 10/07/2015 and was discharged on 11/20/2015.
Patient #12 was admitted on 06/01/2015 and was discharged on 09/03/2015.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Plan of Correction: Client charts #5 and #12 will be reviewed by 9/1/16. If psycho social evaluations are still deficient, they will be completed by 9/8/16.
Responsible Party:Clinical supervisors are responsible for ensuring that psycho social evaluations are completed within 30 days of admission of each client.
Ongoing Monitoring:Supervisors will ensure they utilize the internal documentation tracking system to track timelines. Timelines will be discussed in monthly supervision.
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715.23(b)(24) LICENSURE Patient records
(b) Each patient file shall include the following information:
(24) Follow-up information regarding the patient.
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Observations
Based on a review of client records, patient #'s 4, 5, 12, and 13 did not have follow-up information documented in the patient records as of the date of the inspection.
Patient #4 was admitted on 07/16/2014 and was discharged on 10/27/2015.
Patient #5 was admitted on 10/07/2015 and was discharged on 11/20/2015.
Patient #12 was admitted on 06/01/2015 and was discharged on 09/03/2015.
Patient #13 was admitted on 03/29/2012 and was discharged on 08/12/2015.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Plan of Correction: Record #'s 4, 5, 12, and 13 will be reviewed. In the case that follow-up information is still deficient, all records will be have follow up letters mailed out. Staff will be retrained on the follow up process by 9/30/16.
Responsible Party: The counselor of record is responsible for ensuring that follow up on each discharged client is documented.
Ongoing Monitoring: The Clinical Supervisor will ensure that all discharges completed by their respective counselors, have accurate follow up post discharge. |
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 patient records, patient #10 did not have a completed counselor's annual evaluation. Additionally, patient #3 had a counselor's annual evaluation that was missing the medical director's signature.
Patient #3 was admitted on 03/12/2004 and was still an active client at the time of the inspection. The annual evaluation completed on 06/29/2016 was not signed by the medical director at the time of the inspection.
Patient #10 was admitted on 07/12/2013 and was still an active client at the time of the inspection. The last annual evaluation was completed on 06/29/15 and another one should have been completed no later than 07/12/16. There was no documentation in the patient record at the time of the inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Plan of Correction: Record #10 will have an annual evaluation completed by 9/1/16, if not done so. Record #3 will be submitted to the onsite physician for signing and review of the annual evaluation by 9/1/16.
Responsible Party: The Counselors are responsible for completing the annual evaluation and ensuring all signature are applied.
Ongoing Monitoring: Clinical Supervisors will increase monitoring through the internal tracking process to ensure all annual evaluations are completed by the anniversary of each assigned client's admission date. The nursing supervisor will review all completed documents by the physicians to ensure accurate signatures are applied. |
715.23(d)(2) LICENSURE Patient records
(d) A narcotic treatment program shall prepare a treatment plan that outlines realistic short and long-term treatment goals which are mutually acceptable to the patient and the narcotic treatment program.
(2) The narcotic treatment physician or the patient 's counselor shall review, reevaluate, modify and update each patient 's treatment plan as required by Chapters 157, 709 and 711 (relating to drug and alcohol services general provisions; standards for licensure of freestanding treatment activities; and standards for certification of treatment activities which are a part of a health care facility).
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Observations
Based on the review of patient records, the facility failed to document treatment plan updates within the regulatory timeframe in patient record #'s 1, 2, 3, 6, 7, 11, and 12.
Patient #1 was admitted on 08/25/2014 and was still an active patient at the time of the inspection. An updated treatment plan was completed on 04/22/16 and the next treatment plan update was due no later than 06/22/15; however, it was not completed until 07/14/16.
Patient #2 was admitted on 08/12/2015 and was still an active patient at the time of the inspection. An updated treatment plan was completed on 04/26/16 and the next treatment plan update was due no later than 06/26/16; however, it was not completed until 06/28/16.
Patient #3 was admitted on 03/12/2004 and was still an active patient at the time of the inspection. An updated treatment plan was completed on 12/28/15 and the next treatment plan update was due no later than 02/28/16; however, it was not completed until 03/07/16.
Patient #6 was admitted on 05/05/2011 and was discharged on 03/24/2016. An updated treatment plan was completed on 08/05/15 and the next treatment plan update was due no later than 10/05/15; however, it was not completed until 10/14/15. Additionally, the last treatment plan update was completed on 01/06/16 and the next treatment plan update was due no later than 03/06/16; however, the 03/06/16 update was not documented at the time of the inspection.
Patient #7 was admitted on 10/08/2014 and was discharged on 01/07/2016. An updated treatment plan was completed on 06/16/15 and the next treatment plan update was due no later than 08/16/15; however, it was not completed until 09/11/15.
Patient #11 was admitted on 10/09/2015 and was discharged on 04/22/2016. The comprehensive treatment plan was completed on 10/09/15 and a treatment plan update was due no later than 12/05/15; however, it was not completed until 12/31/15. Additionally, a treatment plan update was due to be completed no later than 02/31/2016; however, the 02/31/16 update was not documented at the time of the inspection.
Patient #12 was admitted on 06/01/2015 and was discharged on 09/03/2015. An updated treatment plan was completed on 07/01/15 and the next treatment plan update was due no later than 09/01/15; however, the 09/01/15 update was not documented at the time of the inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Plan of Correction: The Clinical Supervisors will increase monitoring of treatment plan due dates to ensure they are being completed as required.
Responsible Party: The Counselor of record is responsible for ensuring that each patient file includes updated treatment plans every 60 days.
Ongoing Monitoring: Clinical Supervisors will track and monitor completion of treatment plans to ensure they are being done as required.
Clinical Supervisors will review sampling of charts quarterly to ensure all treatment plans completed are in the client record as required. |