INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection and the inspection conducted for the approval to use a narcotic agent, specifically methadone and buprenorphine, in the treatment of narcotic addiction. This inspection was conducted on July 7-8, 2015, by staff from the Department of Drug and Alcohol Programs, Program Licensure Division. Based on the findings of the on-site inspection, Clear Choices, LLC was found not to be in compliance with the applicable chapters of 4 PA Code and 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 a review of personnel records, the facility failed to ensure that each counselor met the qualifications for the position in one of two personnel records.
The findings include:
Three personnel records were reviewed on July 7-8, 2015. Two personnel records were required to have documentation of the qualifications for the position of counselor. The facility failed to provide documentation of counselor qualifications in personnel record # 3
Employee # 3 was hired as a counselor on April 28, 2015. The documentation on the diploma showed that the employee had a M.A. degree. There was no documentation of the major. There was no documentation of a transcript to verify the major the M.A degree conferred. There was no documentation of the employee's bachelor's degree or major.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Facility Director has obtained copy of Counselor's transcript and will maintain that in the employee record. On going hires, will need to provide their transcripts prior to beginning their employment with this facility. Facility Director will monitor through random chart audits. |
709.22(e) LICENSURE Governing Body
709.22. Governing body.
(e) If a facility is publicly funded, the governing body shall make available to the public an annual report which includes, but is not limited to:
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Observations
Based on a review of the 2014 annual report, the governing body failed to make it available to the public.
The findings include:
The 2014 annual report was reviewed on July 7, 2015. The facility is publicly funded and required to make the annual report available to the public. There was no documentation that the governing body made the 2014 annual report available to the public.
These finding were discussed with facility staff during the licensing process.
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Plan of Correction
Facility Director has placed the advertisement for 2014 Annual Report and will maintain documentation of completion on site for review as needed. Future ads will be placed as required by June 30th each year by the Facility Director and documentation will be maintained on site for review with each audit. |
715.1(a)(b) LICENSURE General Provisions
(a) An entity within this Commonwealth which uses agents for maintenance or detoxification of persons shall obtain the approval of the Department to operate a narcotic treatment program.
(b) The Department's approval of a narcotic treatment program shall be contingent upon the narcotic treatment program's compliance with the standards and conditions in this part. In addition, the program shall comply with applicable Federal laws and regulations.
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Observations
Based on the review of administrative documentation, the facility failed to comply with Federal laws and regulations regarding documentation of certification.
The findings include:
The administrative material was reviewed on July 7-8, 2015. The facility is required to comply with Federal laws, specifically, 42 CFR; Chapter 1; Part 8, which includes maintaining current certification with the Substance Abuse and Mental Health Services Administration (SAMHSA). The SAMHSA certificate was expired as of June 30, 2015.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Facility Director has submitted request and necessary materials for the extended CSAT licensure. New CSAT licensure will be obtained with a date to run concurrently to this facilities CARF Accreditation which is set to expire June 30, 2018. Future requests for licensure extension will be made by the Facility Director and obtained timely. Licensure will be posted as required and maintained by the Facility Director. |
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 the review of patient records, the facility failed to document a complete initial urinalysis for each prospective patient in three of three patient records.
The findings include:
Eleven patient records were reviewed on July 7-8, 2015. Three records were reviewed as buprenorphine patients. All patients were required to complete a drug screen urinalysis prior to the administration of buprenorphine, a narcotic agent and at least monthly thereafter. A complete urine drug screen includes receiving the results from the CLIA and Department of Health approved laboratory. The facility did not document a complete an initial drug-screening urinalysis in patient records # 1, 2, and 3.
Patient # 1 was admitted on May 6, 2015. The patient received their first dose of buprenorphine on May 6, 2015. The initial urine screen had been completed by the facility on May 6, 2015 using the dip stick method. However, there was no documentation that the initial urine screen had been sent out to a laboratory for urinalysis.
Patient # 2 was admitted on April 8, 2015. The patient received their first dose of buprenorphine on April 8, 2015. The initial urine screen had been completed by the facility on April 8, 2015 using the dip stick method. However, there was no documentation that the initial urine screen had been sent out to a laboratory for urinalysis.
Patient # 3 was admitted on June 3, 2015. The patient received their first dose of buprenorphine on June 3, 2015. The initial urine screen had been completed by the facility on June 3, 2015 using the dip stick method. However, there was no documentation that the initial urine screen had been sent out to a laboratory for urinalysis.
These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
Facility Director will train staff to obtain urine specimens ad the results prior to the administration of any medication assisted treatment. Urine samples will be sent to the contracted lab and all results maintained as part of the patient's file. Facility Director will complete training with all staff by 8/22/15 and will maintain documentation on site of training completion for review. Facility Director and staff will monitor compliance through random patient chart audits. |
715.23(b)(5) LICENSURE Patient records
(b) Each patient file shall include the following information:
(5) The results of all annual physical examinations given by the narcotic treatment program which includes an annual reevaluation by the narcotic treatment physician.
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Observations
Based on the review of patient records, the narcotic treatment program failed to document the results of an annual physical examination by the narcotic treatment physician in one of two patient records.
The findings include:
Eleven patient records were reviewed on July 7-8, 2015. Eight patient records were reviewed as methadone patients. Two records required documentation of an annual physical examination by the narcotic treatment physician. The narcotic treatment program failed to document the results of the annual physical examination in patient record # 4.
Patient # 4 was admitted on April 28, 2011. An annual physical examination was due to be completed by April 28, 2015. The last documented physical examination was completed on June 2, 2014.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Facility Director will train all staff regarding timeliness of annual physical examinations and will encourage both clinical and medical staff to monitor patient compliance with this requirement. Facility Director shall complete this training on site by 8/22/15 and will maintain documentation on site for review. Facility Director and staff will monitor compliance through random chart audits. |
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 the review of patient records, the narcotic treatment program failed to document the results of an annual evaluation, completed by the patient 's counselor, in one of two patient records.
The findings include:
Eleven patient records were reviewed on July 7-8, 2015. Eight patient records were reviewed as methadone patients. Two records required documentation of an annual evaluation. The narcotic treatment program failed to document the results of the annual evaluation in patient record # 9.
Patient # 9 was admitted on May 21, 2014. An annual evaluation was due to be completed by May 21, 2015. There was no documentation of an annual evaluation 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
Facility Director will train all staff regarding timeliness of annual clinical evaluations. Facility Director shall complete this training on site by 8/22/15 and will maintain documentation on site for review. Facility Director and staff will monitor compliance through random chart audits. |