INITIAL COMMENTS
|
This report is a result of an on-site licensure renewal inspection conducted on November 30, 2015 through December 1, 2015. by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, The Healing Way was found not to be in compliance with the applicable chapters of 28 PA Code which pertain to the facility.
|
Plan of Correction
|
704.11(c)(2) LICENSURE CPR CERTIFICATION
704.11. Staff development program.
(c) General training requirements.
(2) CPR certification and first aid training shall be provided to a sufficient number of staff persons, so that at least one person trained in these skills is onsite during the project's hours of operation.
|
Observations
Based on a review of personnel records and CPR/First Aid certification cards, the facility failed to ensure that a sufficient number of staff persons were trained in CPR/First Aid.
The findings include:
All employee CPR/First Aid certification cards were reviewed on November 30, 2015 and December 1, 2015. There was several staff that had trainings for CPR/First Aid who worked on various shifts, but the trainings were online trainings that the Department does not approve as sufficient training for CPR/First Aid. The facility hours are Monday through Friday 6 am to 3 pm and Saturday/Sunday and Holidays 6 am to 9:30 am. The facility is open 7 days a week. A two and 1/2 month work schedule was reviewed and showed several days where staff worked and there was no CPR/First Aid coverage. Starting from July 30, 2015 to October 21, 2015 the facility only had sufficient coverage on the following days:
October 18, 2015 from 5:30 am to 10 am
October 22, 2015 from 5:30 am to 12 pm
October 8, 2015 from 5:30 am to 12 pm
September 26, 2015 from 5:30 am to 11:15 am
October 1, 2015 from 5:30 am to 11:30 am
September 10, 2015 from 5:30 am to 12 pm
September 17, 2015 from 5:30 am to 12:15 pm
September 20, 2015 from 5:30 am to 10 am
September 24, 2015 from 5:30 am to 12 pm
September 27, 5:30 am to 12:15 pm
September 28, 2015 from 5:30 am to 12 pm
September 29, 2015 from 5:30 am to 11:15 am
September 3, 2015 from 5:30 am to 12:15 pm
September 10, 2015 from 5:30 am to 12 pm
August 13, 2015 from 5:30 am to 12:45 pm
August 16, 2015 from 5:30 am to 12 pm
August 20, 2015 from 5:30 am to 11:45 am
July 30, 2015 from 5:30 am to 12:30 pm
These findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
The findings were reviewed with the facility during the exit interview; The Healing Way Program Director has since schedule for all staff at the facility to be trained in CPR, First Aid and AED, by an independent certified training instructor. The CPR, First Aid and AED instructor was referred to The Healing Way by the American Heart Association. The Training is schedule for Friday January 15, 2016 at The Healing Way facility. The Program Director is in charge of making sure that all staff attends to training as scheduled and obtain their certification for CPR, First Aid and AED. In addition, the program will maintain a yearly training calendar to ensure that the staffs are able to obtain all of their mandated training for the training year. This calendar will be kept in the Executive Director office and will be reviewed often by the Executive Director and Program Director. Program Director will also be in charge of scheduling upcoming training though DDAP and BHTEN as they become available.
Unfortunately, The Healing Way would not be able cover those hours of not having a staff member at the program with a up to date certification in CPR and First aid. The head nurse works five days per week and was able to obtain her CPR certification from the Red Cross. Although, she was able to complete the training online, she was certified by the Red Cross as well as work for the red Cross. |
705.28 (d) (7) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(7) Set off a fire alarm or smoke detector during each fire drill.
|
Observations
Based on a review of the facility's fire drill record and exception letter, the facility failed to show documentation of the facility's annual inspection of the fire alarm system.
The finding includes:
The fire drill record and exception letter was reviewed on November 30, 2015. The facility currently has an exception from setting off the fire alarm during fire drills, but must show documentation that the fire alarm system is in good working condition and must be inspected annually. That last time the alarm system was inspection was in October 4, 2014.
These findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
The Annual fire alarm inspection was completed on December 9, 2015, and The Healing Way program has since address the issue with the landlord and has been granted access to the fire alarm company to be able to schedule our own annual inspections. Moving forward The Healing Way has created an annual calendar with due dates of December 9, 2016 to have the alarm inspected again prior to or on that date, to ensure that this situation doesn't occur again. Executive Director and program Director will be in charge of keeping track of the calendar and the inspection date to make sure that the inspection is completed in a timely manner. |
709.25(a) LICENSURE Fiscal Management
709.25. Fiscal management.
(a) The project shall obtain the services of an independent public accountant for an annual audit of financial activities associated with the project's drug/alcohol abuse services.
|
Observations
Based on a review of administrative documentation, the project failed to obtain the services of an independent public accountant for an annual audit of financial activities associated with the project's drug/alcohol abuse services.
The findings include:
The facility's administrative records were reviewed for documentation of an annual audit of financial activities associated with the project's drug/alcohol abuse services on November 30, 2015 and December 1, 2015. The facility ' s fiscal year runs from January 2014 to December 2014. The facility did not document an independent financial audit for the 2014 fiscal year.
These findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
Program Director will complete and submit a letter to the State as a formal request of an exception from the requirements of 28 Pa. Code 709.25 (a). This letter for the request of an exception will be created by the Program Director and submit to the State Division of Drug and Alcohol Program Licensure. The Program Director will make sure that the request for an exception submitted on a timely manner upon completing this plan of correction. In the event that the exception is not granted, The Healing Way has been discussing with their accountant to devise a plan to be able to complete the Annual financial audit for The Healing Way. The Hope is, the State would grant The Healing Way with the exception for the requirement of 28 Pa. Code 709.20 (a). |
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. The consent shall be in writing and include, but not be limited to:
|
Observations
Based on the review of client records, the facility failed to document an informed and voluntary consent in ten of ten client records.
Per the State Law 255.5 (b) Information released to judges, probation or parole officers, insurance company, health or hospital plan or governmental officials, pursuant to paragraphs (1), (2), (4), (7), (3) of subsection (a) of this section, is for the purpose of determining the advisability of continuing the client with the assigned project and shall be restricted to the following:
(1) Whether the client is or is not in treatment,
(2) Client's prognosis,
(3) The nature of the Project,
(4) A brief description of the client's progress and
(5) A short statement as the whether the client has relapsed into drug or alcohol abuse and the frequency of such relapse.
The findings include:
Ten client records were reviewed on November 30, 2015 and December 1, 2015. The facility failed to document informed and voluntary consents in six of ten client records, #1, 2, 5, 6, 8 and 9.
Client #1 - Consent to release dated January 2, 2015 to a government agency exceeded 4 PA Code 255.5 by allowing the agency to receive a social summaries and drug test results of the client.
Client #2 - Consent to release dated April 6, 2015 to social media/website failed to have on the consent form whether or not the client was offered a copy of the consent.
Client #5 - Consent to release dated July 28, 2015 to a criminal justice agency exceeded 4 PA Code 255.5 by allowing the facility to release the client's lab results. Additionally, the consent failed to have on the form the purpose of the release. Consent to release dated July 28, 2015 to the client's probation and parole officer exceeded 4 PA Code 255.5 by allowing the facility to release the client's methadone dose and lab results.
Client #6 - Consent to release dated September 21, 2015 to a government agency exceeded 4 PA Code 255.5 by allowing the facility to release the client's social summaries, drug test results and other communication about the client.
Client #8 - Consent to release dated June 8, 2015 to the client's doctor failed to have on the form what was being release.
Client #9 - Progress notes to the client's emergency contact dated January 22, 2015 and February 18, 2015 had identifying information that was provided to the client's emergency contact without an informed and voluntary consent on file for the emergency contact.
Additionally, the facility failed to include on the informed and voluntary consent forms that the client has the right to revoke their consent in writing or verbally. The facility only documented that the client has the right to revoke the consent in writing.
These findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
The Program Director will conduct an in-house training on PA 255.5 to review and discuss informed consent and limitations for information disclosure from a patient record to governmental agencies, the criminal justice system, medical doctor and all third party payers. This training will take place on January 11, 2016, upon the return of all staff members from holiday vacation. For charts identified as being deficient during this inspection, we will have the patients sign new release forms allowing for only the information which can be released under PA 255.5 to governmental agencies, criminal justice system, probation, DHS or child protective services, doctors and third party payers.
The previous release forms, which did not comply with PA 255.5, will be revoked at the same time and both copies will remain in the patient charts.
Additionally, compliance with PA 255.5 will be monitored via the monthly quality record review by the program Director, as well as during supervision with counselors. The Program Director is in charge of making sure that the training gets completed as well as the staffs are applying the PA 255.5 code to their release of information.
|
715.28(a)(1-10) LICENSURE Unusual incidents
(a) A narcotic treatment program shall develop and implement policies and procedures to respond to the following unusual incidents:
(1) Physical assault by a patient.
(2) Inappropriate behavior by a patient causing disruption to the narcotic treatment program.
(3) Selling of drugs on the premises.
(4) Complaints of patient abuse (physical, verbal, sexual and emotional).
(5) Death or serious injury due to trauma, suicide, medication error or unusual circumstances.
(6) Significant disruption of services due to disaster such as fire, storm, flood or other occurrence.
(7) Incident with potential for negative community reaction or which the facility director believes may lead to community concern.
(8) Theft, burglary, break-in or similar incident at the facility.
(9) Drug related hospitalization of a patient.
(10) Other unusual incidents the narcotic treatment program believes should be documented.
|
Observations
Based on the review of facility documentation that included incident reports and staff discussions, the facility failed to provide documentation of incident reports to the Department.
The findings include:
During the November 30, 2014 - December 1, 2015 licensing inspection and methadone monitoring, the facility had documentation of incident reports that identified patients taken to the hospital, selling of drugs on the premises, and an incident that pose a potential negative community reaction. The facility failed to provide the Department with written reports that provided an account of each incident.
The following unusual incidents were reviewed and not submitted to the Department:
September 24, 2015 - medical response called and client sent to hospital
April 30, 2015 - Selling of drugs/potential community reaction
These findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
The findings were reviewed with the facility during the exit interview. The Healing Way has reviewed their policies to reflect mandates of self-reporting to the department of Drug and Alcohol any unusual incidents. Affective immediately and moving forward The Healing way has established a protocol to report any unusual incident to the Department of Drug and Alcohol any unusual incidents relating to The Healing Way. The program Director will meet with the staff during a special meeting on January 11, 2016 to review all of the deficiencies from the State inspection and train the staff on these plans of correction. Program Director will ensure that all unusual incidents are reported to him for review and Program Director will them call the State as well as complete a report on the unusual incidents. |
709.91(b)(6) LICENSURE Intake and admission
709.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(6) Psychosocial evaluation.
|
Observations
Based on a review of client records, the facility failed to provide a psychosocial evaluation to include the client's problems/needs, assets/strengths, support systems, coping mechanisms, negative factors that may inhibit treatment and/or counselor conclusions and impressions in four of nine records reviewed.
The findings include:
Ten client records were reviewed November 30, 2015 - December 1, 2015. A psychosocial evaluation was reviewed in nine client records.
The psychosocial evaluations in client records #2, 3, 5 and 9 did not include an evaluation of the client's assets/strengths and how they would impact treatment.
The psychosocial evaluations in client records #2, 3, 5 and 9 did not include an evaluation of the client's problems and needs.
The psychosocial evaluations in client records #2, 3, 5 and 9 did not include an evaluation of the client's support systems.
The psychosocial evaluations in client records #2, 3, 5 and 9 did not include an evaluation of the client's coping mechanisms and how they would relate to or impact treatment.
The psychosocial evaluations in client records #2, 3, 5 and 9 did not include an evaluation of the negative factors of the client.
The psychosocial evaluations in client records #2, 3, 5 and 9 did not include an evaluation of the counselor conclusions/impressions of the client.
These findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
The Program Director will conduct an in-house training on Monday January 11, 2016 to make sure everyone that is completing the intake process to make sure that they include all the information that is needed in the biopsychosocial evaluation of each patient. However, after the exit interview, the Program Director was able to meet with staff as well as the tower system programmers to discuss what are needed in the psychosocial evaluation moving forward and they are to be implemented in the next intake. Program Director will conduct internal audit of each patient chats to ensure that the information need are added to each client charts. Effective immediately, and moving forward, all staff that complete an intake will ensure the chart have the clients strengths, coping mechanisms that can impact the client treatment, their support system, negative factors that can impact the patients treatments. All these questions were added into the Tower electronic system to help the counselor when completing intakes. Program Director will monitor and review all intakes to ensure this information is being added to the client's psychosocial evaluation. |
709.92(b) LICENSURE Treatment and rehabilitation services
709.92. Treatment and rehabilitation services.
(b) Treatment and rehabilitation plans shall be reviewed and updated at least every 60 days.
|
Observations
Based on a review of client records, the facility failed to complete sixty day treatment plan updates in three of nine client records.
The findings include:
Ten client records were reviewed on November 30, 2015 - December 1, 2015. Sixty day treatment plan updates were required in nine client records. The facility did not document treatment plan updates every sixty days in client records # 1, 2 and 6.
Client # 1 was admitted on January 2, 2015 and the comprehensive treatment plan was completed on January 29, 2015. A treatment plan update was due by March 29, 2015. Treatment plan updates were completed on April 25, 2015, June 5, 2015, August 31, 2015 and October 8, 2015.
Client # 2 was admitted on April 6, 2015 and the comprehensive treatment plan was completed on June 3, 2015. A treatment plan update was due by August 3, 2015. Treatment plan updates were completed on August 3, 2015 and October 9, 2015.
Client # 6 was admitted on January 2, 2015 and the comprehensive treatment plan was completed on February 20, 2015. A treatment plan update was due by April 20, 2015. Treatment plan updates were completed on April 2, 2015, June 2, 2015, August 7, 2015 and October 2, 2015.
These findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
The Program Director during regular clinical supervision work with the counselor on how to create a clinically sound treatment plan that reflects the date and time. All treatment plan must been completed within the time frame of the 60 days period prior to that due date or at the due date of the treatment plan. Program Director has instructed the Tower System programmers to create an alert system for the counselor to remind them of pending due treatment plan which will reflect in the patient email; this has already been implemented into the Tower system for the counselor to start using. Counselors will be remained of their pending treatment plan 10 days prior, and will continue to be reminded until the treatment plan has been updated. The Tower System has already implemented the alert system per The Healing Way request. For charts identified as being deficient during this inspection Program Director will have the Counselor create addendums to the client's treatment plans. Program Director will also create a spreadsheet with all the upcoming due dates for all of patient documentations. |
709.93(a) 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:
|
Observations
Based on a review of client records, the facility failed to have a complete record in six of ten records reviewed.
The findings include:
Ten client records were reviewed on November 30, 2015 - December 1, 2015. The facility failed to have a complete record in six records reviewed. The facility failed to have a mechanism in their electronic record system to be able to conduct case consultations on clients. Additionally, the facility failed to have case consultations documented in the following client records, # 4, 6, 7, 8, 9 and 10.
Client #4 was admitted on September 26, 2015. As of the date of the licensing inspection and methadone monitoring the facility hasn't documented a case consultation.
Client #6 was admitted on January 2, 2015 and discharged on November 10, 2015. As of the date of the licensing inspection and methadone monitoring the facility hasn't documented a case consultation.
Client #7 was admitted on August 18, 2015 and discharged on July 1, 2015. As of the date of the licensing inspection and methadone monitoring the facility hasn't documented a case consultation.
Client #8 was admitted on June 8, 2015 and discharged on July 17, 2015. As of the date of the licensing inspection and methadone monitoring the facility hasn't documented a case consultation.
Client #9 was admitted on January 15, 2015 and discharged on March 15, 2015. As of the date of the licensing inspection and methadone monitoring the facility hasn't documented a case consultation. Additionally, the facility failed to document a follow-up as of the date of the licensing inspection.
Client #10 was admitted on September 16, 2014 and discharged on February 18, 2015. As of the date of the licensing inspection and methadone monitoring the facility hasn't documented a case consultation. Additionally, the facility failed to document a follow-up as of the date of the licensing inspection.
These findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
Plan of Correction:
Once the exit interview with the inspector had concluded on December 1, 2015, Program Director had The Tower electronic record system create Case consultation program for the clinic to be able to record case consultations. The counselors were instructed to start conducting case consultations with all the clients. Program Director has encouraged the counselors to meet with him and the Medical Director to complete these case consultations. Base on the findings, all the charts that were deemed deficient during the State inspection. Counselors have been scheduling these clients to meet with treatment team for case consultations. Program Director will ensure that all case consultation is being complete quarterly by the counselors during monthly quality review and supervision with the counselors. To date, The Healing counselor has been able to complete and update all of the client's charts to reflect the case consultation.
In addition, the program failed to complete discharge follow-up for client #9 and client #10. However; client #9 had been incarcerated prior to being discharge and was discharge do to her being incarcerated. Client #10 unfortunately died do to natural causes, there was documentation to support the death and a report was sent the State regarding client # 10 death. Moving forward all client's that has been discharge from The Healing Way has gotten follow-up calls and it has been added to client's chart.
|