INITIAL COMMENTS
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Based on the concerns arising from COVID-19, The Department of Drug and Alcohol Programs, Bureau of Program Licensure, has implemented temporary procedures for conducting an annual renewal inspection.
The inspection will be divided into two parts.
-Part 1, an abbreviated off-site inspection, will be conducted off site, and will require the submission of administrative information via email to a Licensing Specialist.
-Part 2, an abbreviated on-site inspection, will be conducted on-site at a later date and will include a review of client/patient records, and a physical plant inspection.
This report is a result of Part 2, an abbreviated on-site inspection, conducted on January 27, 2021 and February 8, 2021 by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Not all regulations were reviewed, the remainder of the regulations were reviewed during Part 1.
Based on the findings of Part 2, an abbreviated on-site inspection, Marworth 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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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 client records, the project failed to obtain an informed and voluntary consent from the client for the disclosure of information contained in the client record in two of twenty-five client records reviewed.
Client #1 was admitted on June 29, 2020 and was a current client at the time of the inspection. A release of information form for the funding source was signed and dated by the client on January 6, 2021 and expired on January 6, 2020. An updated release of information form was not documented in the record at the time of the inspection.
Client #23 was admitted on October 21, 2019 and was discharged on November 18, 2019. There was no release of information form for the funding source documented in the client record.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Marworth failed to obtain a current informed and voluntary consent to disclose information to the funding source. Client #1 had a Release form in the chart that had expired on 1/6/2020. Client was admitted on 6/29/2020. A new release was placed in chart on 1/6/2021. Client #23 did not have a funding source consent documented in the chart.
The Director of Counseling will conduct re-education to the Outpatient Counseling Staff regarding completion of releases for funding sources on day of admission. This will be completed by 3/12/2021.
Outpatient Counseling staff to obtain the proper consent information for all clients going forward. This will be ongoing.
Outpatient Counseling staff will be responsible to secure new authorization for funding sources annually prior to the expiration date of previous authorization. This will be ongoing.
Director of Counseling will review a monthly report of the previous years' admissions to Outpatient treatment and provide notification to the counseling staff to secure updated authorization prior to the expiration of previous authorization during the weekly Master Treatment Plan meeting. This will be ongoing.
Director of Counseling will monitor records of new admissions to the Outpatient program on a weekly basis to confirm authorization has been secured for funding sources. This will be until there has been 6 months at 100% compliance. This will be reported out at the Performance Improvement Committee.
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709.28 (c) (2) 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 must be in writing and include, but not be limited to:
(2) Specific information disclosed.
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Observations
Based on a review of client records, the project failed to keep disclosures of client identifying information within the limits established by 4 Pa. Code 255.5 (b) for releases of information in one of twenty-five client records reviewed.
Client #3 was admitted on December 6, 2019 and was discharged on March 13, 2020. A release of information form to a probation agency, signed and dated by the client on January 10, 2020, allowed for the release of medications, case consolations, treatment plans and the continuing care plan, all of which exceeds the limits established by 4 Pa. Code 255.5. Additionally, release of information form to court officials, signed and dated by the client on January 10, 2020, allowed for the release of the continuing care plan and urine drug screens, all of which exceeds the limits established by 4 Pa. Code 255.5.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Marworth exceeded the limits established by 4 pa. Code 255.5 for the releasing of information.
The Director of Counseling will provide re-education of 4Pa. Code 255.5 to all outpatient staff. This will be completed by 3/12/2021.
Director of Counseling will conduct weekly caseload supervision and will monitor at least 3 records per counselor for compliance standards. This will be audited monthly until 6 consecutive months are 100% compliant. The results will be reported to the Performance Improvement Committee.
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715.9(a)(4) LICENSURE Intake
(a) Prior to administration of an agent, a narcotic treatment program shall screen each individual to determine eligibility for admission. The narcotic treatment program shall:
(4) Have a narcotic treatment physician make a face-to-face determination of whether an individual is currently physiologically dependent upon a narcotic drug and has been physiologically dependent for at least 1 year prior to admission for maintenance treatment. The narcotic treatment physician shall document in the patient 's record the basis for the determination of current dependency and evidence of a 1 year history of addiction.
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Observations
Based on the review of patient records, the program failed to have a narcotic treatment physician make a face-to-face determination of whether an individual is currently physiologically dependent upon a narcotic drug and has been physiologically dependent for at least one year prior to admission for maintenance treatment in three of four applicable patient records reviewed.
Patient #15 was admitted on January 12, 2021 and was an active patient at the time of the inspection. There was no documentation in the patient records by a narcotic treatment physician that patient had a current physiologically dependency and had been physiologically dependent for at least one year prior to admission.
Patient #16 was admitted on January 13, 2021 and was an active patient at the time of the inspection. There was no documentation in the patient records by a narcotic treatment physician that patient had a current physiologically dependency and had been physiologically dependent for at least one year prior to admission.
Patient #18 was admitted on July 1, 2020 and was discharged on August 3, 2020. There was no documentation in the patient records by a narcotic treatment physician that patient had a current physiologically dependency and had been physiologically dependent for at least one year prior to admission.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Marworth failed to screen and document that a physician made a face to face determination that the client had a current physiologically dependency on a narcotic drug for at least one year.
Marworth will provide 2 check boxes in each clients' history and physical section of the electronic record that the client has a history of being physiologically dependent for at least 1 year prior to admission or that the patient is suffering current Opioid Dependence.
Our electronic medical record will provide a hard stop to ensure this has been asked on each patient when documenting in their History and Physical to ensure 100% compliance rate.
The Physician will begin this process on all new patients beginning March 15, 2021.
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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.
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Observations
Based on the review of client records, the project failed to document a reviewed and updated treatment and rehabilitation plan at least every 60-days in two of seven applicable client records reviewed.
Client #1 was admitted on June 29, 2020 and was a current client at the time of the inspection. A treatment and rehabilitation plan update was completed on November 16, 2020 and the next update was due no later than January 16, 2020; however, there was no update documented in the client record at the time of the inspection.
Client #7 was admitted on February 25, 2020 and was discharged on October 13, 2020. A treatment and rehabilitation plan update was completed on June 19, 2020 and the next update was due no later than August 19, 2020; however, the update was not documented in the record until September 9, 2020.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Marworth failed to document that a reviewed and updated treatment and rehabilitation plan was completed at least every 60 days.
Director of Counseling will provide re-education to the Outpatient Counselors about Marworth' s policy on Documentation Guidelines. This will be completed by 3/12/2021.
Outpatient Counselors will submit names of clients to be reviewed at the MTP meetings on a weekly basis to the Clinical Director. This will be initiated the week of 3/15/2021.This will be audited until 6 months at 100% compliance is reached. This will be reported out at the Performance Improvement Committee.
Director of Counseling will monitor documentation of MTP notes monthly by reviewing records of all clients presented for review in the weekly MTP meetings. This will be ongoing.
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709.92(c) LICENSURE Treatment and rehabilitation services
709.92. Treatment and rehabilitation services.
(c) The project shall assure that counseling services are provided according to the individual treatment and rehabilitation plan.
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Observations
Based on the review of client records, the project failed to ensure that counseling services are provided according to the individual treatment and rehabilitation plan in four of seven applicable client records reviewed.
Client #1 was admitted on June 29, 2020 and was a current client at the time of the inspection. A comprehensive treatment and rehabilitation plan was completed on June 29, 2020, indicating that the client was to receive one individual counseling session per week. There were no individual counseling sessions documented in the client record for the weeks of September 13, 2020 through September 19, 2020, September 27, 2020 through October 3, 2020, October 18, 2020 through October 24, 2020, November 1, 2020 through November 7, 2020, November 15, 2020 through November 28, 2020, December 6, 2020 through December 12, 2020, December 20, 2020 through December 26, 2020 and December 27, 2020 through January 2, 2021.
Client #2 was admitted on August 6, 2020 and was a current client at the time of the inspection. A comprehensive treatment and rehabilitation plan was completed on August 6, 2020, indicating that the client was to receive one individual counseling session per week. There were no individual counseling sessions documented in the client record for the weeks of November 1, 2020 through November 7, 2020, November 22, 2020 through November 28, 2020, December 13, 2020 through December 19, 2020, December 20, 2020 through December 26, 2020 and December 27, 2020 through January 2, 2021.
Client #3 was admitted on December 6, 2019 and was discharged on March 13, 2020. A comprehensive treatment and rehabilitation plan was completed on December 12, 2019, indicating that the client was to receive one individual counseling session per week. There were no individual counseling sessions documented in the client record for the weeks of December 15, 2019 through December 21, 2019, December 22, 2019 through December 28, 2019, January 12, 2020 through January 18, 2020, February 16, 2020 through February 22, 2020 and March 1, 2020 through March 7, 2020.
Client #4 was admitted on July 13, 2020 and was discharged on November 12, 2020. A comprehensive treatment and rehabilitation plan was completed on July 20, 2020, indicating that the client was to receive one individual counseling session per week. There were no individual counseling sessions documented in the client record for the weeks of September 6, 2020 through September 12, 2020 and September 20, 2020 through September 26, 2020.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Marworth failed to document that counseling services are provided according to their individual treatment plan.
Outpatient Counselors will accurately document in the treatment plan the frequency of Individual Counseling sessions and when an appointment is not attended to or is rescheduled, the Counselor will document this change in the client record. This will be ongoing.
Outpatient Counselors will document in the client record (MTP note, Individual Counseling note, or Counseling note) when frequency of sessions change. This will be ongoing.
This will be audited for 3 months at 100% compliance until goal is reached. This will be reported out at the Performance Improvement Committee.
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