INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection and methadone monitoring inspection conducted on July 15-17, 2014 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Lebanon Treatment Center 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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704.5(c) LICENSURE Qualifications for Proj/Fac Dir
704.5. Qualifications for the positions of project director and facility director.
(c) The project director and the facility director shall meet the qualifications in at least one of the following paragraphs:
(1) A Master's Degree or above from an accredited college with a major in medicine, chemical dependency, psychology, social work, counseling, nursing (with a specialty in nursing/health administration, nursing/counseling education or a clinical specialty in the human services), public administration, business management or other related field and 2 years of experience in a human service agency, preferably in a drug and alcohol setting, which includes supervision of others, direct service and program planning.
(2) A Bachelor's Degree from an accredited college with a major in chemical dependency, psychology, social work, counseling, nursing (with a specialty in nursing/health administration, nursing/counseling education or a clinical specialty in the human services), public administration, business management or other related field and 3 years of experience in a human service agency, preferably in a drug and alcohol setting, which includes supervision of others, direct service and program planning.
(3) An Associate Degree from an accredited college with a major in chemical dependency, psychology, social work, counseling, nursing (with a specialty in nursing/health administration, nursing/counseling education or a clinical specialty in the human services), public administration, business management or other related field and 4 years of experience in a human service agency, preferably in a drug and alcohol setting, which includes supervision of others, direct service and program planning.
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Observations
Based on the review of personnel records, the facility failed to document that the staff person appointed to the position of Project Director met the appropriate educational requirements in one of one personnel records reviewed.
The findings include:
The facility was unable to produce a personnel record which included verification of educational qualifications for Employee # 1. It was unable to be determined, based on the information provided, whether Employee # 1 met the educational requirements for the position of Project Director.
The Facility Director confirmed the findings.
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Plan of Correction
Regional Director will review Project Director background information to ensure that Project Director meets all required qualifications. Current Project Director background information reviewed by Regional Director; Project Director meets requirements; obtained degree- Masters in Business Administration.
Clinic Director will request Project Director background information from HR to maintain on site.
Clinic Director will fax verification of Project Director degree to the appropriate department.
Clinic Director will review Project Director file quarterly to ensure information updated/corrected as needed.
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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, the facility failed to document the completion of 12 clock hours of annual training required for Facility Directors in one of one personnel records reviewed.
The findings include:
One personnel record which pertained to the Facility Director was reviewed on July 17, 2014. This personnel record required the documentation of the completion of 12 clock hours of annual training. The facility failed to document 12 clock hours of annual training in personnel record # 2.
Employee # 2 has been the facility director since April 13, 2013. The facility training year was from January 2013 to December 2013. Employee # 2 had no training hours documented for the 2013 training year.
The Facility Director confirmed the findings.
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Plan of Correction
Training records for the facility director will be requested from the training facility and maintained on site to document training hours. |
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, the facility failed to document the completion of 25 clock hours of annual training required for counselors in two of two personnel records reviewed.
The findings included:
Two personnel records which required 25 clock hours of annual training for counselors were reviewed on July 17, 2014. The facility failed to document the completion of 25 clock hours of annual training in personnel records # 4 and 5.
Employee # 4 was hired on 2/4/08. The facility training year is from January through December. The training year for January 2013 to December 2013 was reviewed. Employee # 4 only completed 19 clock hours of annual training in 2013.
Employee # 5 was hired on 1/3/12. The facility training year is from January through December. The training year for January 2013 to December 2013 was reviewed. Employee # 5 only completed 16 clock hours of annual training in 2013.
The Facility Director confirmed the findings.
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Plan of Correction
Clinical Supervisor will evaluate training plans and records monthly to ensure that all counselors have obtained required number of annual training hours. |
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
Based on a review of the Staffing Requirements Facility Summary Report form and the Narcotic Treatment Program Monitoring Questionnaire completed by the facility as well as the caseload print-out provided by the facility, the facility failed to ensure that staff caseloads remained at or under 35:1 and failed to ensure all patients had an assigned counselor.
The findings include:
The Staffing Requirements Facility Summary Report form completed by the facility was reviewed on July 15, 2014. The form listed five counselors, two counselor assistants, one clinical supervisor, a project director and facility director as clinical staff . The facility's standard work week, as reported by the facility on the Staffing Requirements Facility Summary Report form, was 40 hours per week.
Based on the total number of hours per week that the facility reported the employees devoted to their clients, the total number of hours in the facility's standard work week (40), and the total number of clients assigned to the clinical staff on 7/15/14, employee # 4 exceeded the allowable maximum 35:1 caseload.
The actual client caseload is determined by dividing the Full Time Equivalent (FTE) into the actual number of clients. The FTE is determined by dividing the number of hours devoted to the clients' treatment by the facility's standard workweek.
Employee # 4 was hired as a counselor on 2/4/08. The number of hours per week devoted by employee # 4 to client treatment, as reported by the facility on the Staffing Requirements Facility Summary Report, was 8 hours per week. The facility reported on the Staffing Requirements Facility Summary Report form that employee # 4 had 12 active clients. Based on this information, the calculation resulted in a caseload of 53:1.
Additionally, it was documented on a caseload print-out as well as the Narcotic Treatment Program Monitoring Questionnaire that 32 current patients did not have an assigned counselor.
The Facility Director confirmed the findings.
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Plan of Correction
Clinical Supervisor will monitor caseloads daily to ensure compliance with caseload requirements of 35:1.
Additional counselors have been hired to ensure compliance with caseload requirement of 35:1 and assignment of patients.
In the future, PRN counselors and temp agency counseling staff will be utilized during staff shortages/turnover to ensure that counseling requirements are met.
Clinical supervisor will monitor cases weekly to ensure counseling requirements are met. |
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 facility documentation, the facility failed to complete an annual report for the fiscal year of January 1, 2013 to December 31, 2013.
The findings included:
During the onsite inspection of July 15-17, 2014, the annual report for the fiscal year January 1, 2013, to December 31, 2013 was requested for review.
During a dialogue with the Facility Director on July 15, 2014, the Facility Director acknowledged that an annual report had not been completed to provide to the public. The findings were not disputed.
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Plan of Correction
Clinic Director has requested a copy of the annual report to be available on site for review by 8/22/2014.
Annually, prior to the due date of the annual report, clinic director will request a copy of the report to maintain on site for licensing purposes and public review. |
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 monthly random urinalysis in one of eleven patient records reviewed.
The findings include:
Eleven patient records which required documentation of a monthly random urinalysis were reviewed July 15-17, 2014. The facility failed to document a monthly random urinalysis in patient record # 6
Patient # 6 was admitted on 8/23/13 and was still an active patient at the time of the inspection. The facility failed to document a monthly random urinalysis in this patient record during the month of April 2014.
The Facility Director confirmed the findings.
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Plan of Correction
Director of Nursing will utilize computer system to generate weekly report of any missed random urine drug screens.
Director of Nursing will review computer generated report weekly to ensure all patients are scheduled for random monthly urine drug screens. |
715.19(1) LICENSURE Psychotherapy services
A narcotic treatment program shall provide individualized psychotherapy services and shall meet the following requirements:
(1) A narcotic treatment program shall provide each patient an average of 2.5 hours of psychotherapy per month during the patient 's first 2 years, 1 hour of which shall be individual psychotherapy. Additional psychotherapy shall be provided as dictated by ongoing assessment of the patient.
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Observations
Based on the review of patient records, the facility failed to provide an average of 2.5 hours of psychotherapy per month during the patient's first 2 years, 1 hour of which shall be individual psychotherapy in two of five applicable records reviewed.
The findings include:
Five patient records which required documentation of an average of 2.5 hours of psychotherapy per month were reviewed July 15-17, 2014. The facility failed to provide an average of 2.5 hours of psychotherapy per month in patient records # 6 and 9.
Patient # 6 was admitted on 8/23/13 and was still an active patient at the time of the inspection. For the months of March 2014, April 2014 and May 2014, the facility documented an average of 1 hour of psychotherapy per month.
Patient # 9 was admitted on 10/17/13 and was discharged on 4/17/14. For the months of January 2014, February 2014 and March 2014, the facility documented an average of 1.75 hours of psychotherapy per month.
The Facility Director confirmed the findings.
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Plan of Correction
Clinical supervisor will generate computerized report weekly and review psychotherapy units per patient to ensure facility provides required 2.5 hours of psychotherapy per month. |
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 a review of patient records, the facility failed to complete an annual physical examination in one of seven applicable patient records.
The findings include:
Seven patient records which required documentation of an annual physical were reviewed on July 15-17, 2014. The facility failed to document an annual physical examination in patient record # 8.
Patient # 8 was admitted on 3/4/13 and discharged on 4/15/14. The initial physical examination for this patient was completed on 2/27/13. The annual physical examination was due to be completed by 2/27/14. There was no documentation of the completion of the annual physical examination in this patient record.
The Facility Director confirmed the findings.
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Plan of Correction
Director of Nursing will utilize computer system to generate and review monthly report identifying annual physical examination due dates.
Director of Nursing will audit schedule for annual physical examinations weekly to identify and reschedule any missed appointments.
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715.23(b)(6) LICENSURE Patient records
(b) Each patient file shall include the following information:
(6) Results of laboratory tests or other special examinations given by the narcotic treatment program.
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Observations
Based on the review of patient records, the facility failed to complete all required laboratory tests as part of the admission process in two of eleven patient records reviewed.
The findings include:
Eleven patient records which required documentation of completed laboratory tests, which includes a tuberculosis Mantoux test (PPD) and a serological test, as part of the admission process were reviewed July 15-17, 2014. The facility failed to document the completion of the tuberculosis Mantoux test (PPD) and serological tests in patient records # 6 and 8.
The Facility Director confirmed the findings.
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Plan of Correction
Director of Nursing will utilize computer system to generate weekly report of admissions and review for completed laboratory tests. |
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 facility failed to complete annual evaluations in accordance with the regulations in two of seven patient records reviewed.
The findings included:
Seven patient records which required documentation of an annual evaluation were reviewed July 15-17, 2014. The facility failed to document an annual evaluation in patient records # 1 and 2.
Patient # 1 was admitted on 6/22/09 and was still an active client at the time of the inspection. This patient record did not include an annual evaluation for the year of 2013. The last annual evaluation was completed on 8/13/12.
Patient # 2 was admitted on 9/11/09 and was still an active client at the time of the inspection. This patient record did not include an annual evaluation for the year of 2013. The last annual evaluation was completed on 9/27/12.
The Facility Director confirmed the findings.
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Plan of Correction
Clinical Supervisor will conduct training on 8/21/14 regarding completion of annual evaluations.
Clinical supervisor will utilize computer system to generate report for review monthly of annual evaluations due and monitor timely completion of all annual evaluations.
Annual evaluations outlined in this citation will be completed by 8/30/14.
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