INITIAL COMMENTS
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This report is a result of an on-site licensure renewal and methadone monitoring inspection conducted on September 11, 2023 by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, ARS of Pennsylvania LLC 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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704.12(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 the review of the Staffing Requirements Facility Summary Report, the facility failed to keep client/staff ratios at or below the regulation limit of 35/1.
Employee #5 was hired as a counselor on May 1, 2023 and was still acting in that position. Employee #5 was reported to have 10 hours per week devoted to their 10 clients on their caseload.
The counselor Full Time Equivalent (FTE) is determined by dividing the total number of hours the counselor devotes to their clients by facility's work week. Then, in order to obtain the counselor's ratio, the total number of clients on the counselor's caseload is divided by the FTE.
The FTE counselor's caseload calculation is as follows: 10/40 = .25(FTE); 10/.25= 40, which equals to a client/counselor ratio of 40:1.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
Clinical supervisor will review all counselor's caseloads in monthly supervisions to determine counselor to patient ratios. Clinical Supervisor and Executive Director will review DDAP calculation to ensure understanding. Clinical supervisor will identify the number of patients with exempt status versus non-exempt status in order to ensure that counselor to patient ratio is remaining within the 35:1 ratio that is required. Executive Director will review in 30 days to ensure corrective action implementation is complete. |
709.28 (a) LICENSURE Confidentiality
§ 709.28. Confidentiality.
(a) A written procedure shall be developed by the project director which shall comply with 4 Pa. Code § 255.5 (relating to projects and coordinating bodies: disclosure of client-oriented information). The procedure must include, but not be limited to:
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Observations
Based on an observation of medication administration the facility failed to maintain confidentiality of all patients. Patients were observed throwing away take home bottles without blacking out each name and dose into a trash can.
These findings were discussed with facility staff during the inspection process.
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Plan of Correction
Director of Nursing completed training with nursing team on 9/12/23 regarding the importance of ensuring patients black out their information prior to disposing of it. Nursing staff will ensure this occurs when medicating patients at medication window. |
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 the review of the physician timesheets for the months of May, June, July, and August 2023, the facility failed to provide at least one hour of physician time a week, on site for every ten patients during the month of June 2023.
During the week of June 4th- 10th, 2023, the patient census was 291. The facility was required to provide at least 29.1 physician hours. There were only 23.75 physician hours documented.
These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
Executive Director and Director of Nursing will review census weekly and compare to medical hours to ensure on-site hours match weekly census. Executive Director will ensure appropriate coverage when medical staff are out of the office to fulfill required hours to ensure this deficiency does not recur. |
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 facility failed to document an annual reevaluation by the narcotic treatment physician within the regulatory timeframe in one out of four applicable records reviewed.
Patient #5 was admitted on January 18, 2018 and was still active at the time of the inspection. An annual physical was due on March 1, 2023; however, there was no documentation in the patient's record of it being completed.
These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
Director of Nursing will review all patients with pending Annual appointments and scheduling patients to meet with medical staff. Director of Nursing will complete review by 11/1/2023. All patients pending Annuals will be seen by medical staff by 12/31/2023 in order to regain compliance in 2023. Moving forward, patients will be scheduled and seen within 30 days leading up to their anniversary date to ensure timely compliance. |