INITIAL COMMENTS
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This report is a result of an on-site licensure renewal and methadone monitoring inspection conducted on September 30-October 1, 2024 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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709.28 (c) (4) 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:
(4) Dated signature of client or guardian as provided for under 42 CFR 2.14(a) and (b) and 2.15 (relating to minor patients; and incompetent and deceased patients).
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Observations
Based on a review of patient records, the facility failed to obtain a completed informed and voluntary consent which included the dated signature of the patient in one out of eight records reviewed.Patient #5 was admitted on May 24, 2024 and was still active at that the time of the inspection. One release of information to a transportation company was not signed or dated. This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
The Clinical Supervisor (CS) on 11/1/2024 will retrain the clinical staff on release of information. Primary Counselors will complete an audit of current patient records and will place a Kipu flag on patient chart if there are documents pending review and signature. Moving forward primary counselors will obtain patient signature within 48 hours of creation of document. CS will audit the Kipu Dashboard signatures weekly to monitor any unsigned documents. |
709.33 (a) LICENSURE Notification of termination.
§ 709.33. Notification of termination.
(a) Project staff shall notify the client, in writing, of a decision to involuntarily terminate the client ' s treatment at the project. The notice shall include the reason for termination.
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Observations
Based on the review of patient records, the facility failed to notify the patient, in writing, of a decision to involuntarily terminate the patient's treatment at the project in one out of one applicable client record.Patient #7 was admitted on November 30, 2023 and discharged on July 23, 2024. This finding was reviewed with facility staff during the licensing inspection.
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Plan of Correction
The Clinical Supervisor (CS) on 11/1/2024 will retrain the clinical staff on Termination of Treatment policy. This will include review of required notification and documentation. Moving forward CS will audit all patient charts prior to administrative discharge to ensure proper notification. |
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 physician timesheets, the facility failed to provide at least one hour of physician time a week, onsite for every ten patients. During the week of May 26-June 1, 2024, the patient census was 302. The facility was required to provide at least 30.2 physician hours. It provided 23 hours.This finding was reviewed with facility staff during the licensing inspection. This is a repeat from the September 11, 2023 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. |
715.6(e) LICENSURE Physician Staffing
(e) A physician assistant or certified registered nurse practitioner may perform functions of a narcotic treatment physician in a narcotic treatment program if authorized by Federal, State and local laws and regulations, and if these functions are delegated to the physician assistant or certified registered nurse practitioner by the medical director, and records are properly countersigned by the medical director or a narcotic treatment physician. One-third of all required narcotic treatment physician time shall be provided by a narcotic treatment physician. Time provided by a physician assistant or certified registered nurse practitioner may not exceed two-thirds of the required narcotic treatment physician time.
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Observations
Based on the review of physician time sheets, the facility failed to provide the required number of hours onsite for the physician based on the census. The facility has been granted an exception request which permits the physician to provide one-fifth of the required hours with a certified registered nurse practitioner or physician's assistant providing the remaining four-fifths of the required hours. During the week of May 26-June 1, 2024, the patient census was 302. The physician was required to provide one-fifth of the 30.2, which equals to 6.04 hours. The physician did not provide any hours that week. In addition, the facility failed to have the physician countersign the annnual completed by the physician assistant within three business days.Patient #6 was admitted on January 9, 2019 and was discharged on March 21, 2024. The annual physical evaluation completed on January 26, 2024 was not dated and signed by the physician.This finding was 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. |
715.19(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 a review of patient records, the facility failed to provide patients with 2.5 hours of psychotherapy per month during the patient's first two years of treatment, one hour of which shall be individual psychotherapy, in four out of four applicable records reviewed.Patient #2 was admitted on December 20, 2023 and was still active at the time of the inspection. In January 2024, the patient received only 60 minutes of individual psychotherapy sessions and no groups. Patient #5 was admitted on May 24, 2024 and was still active at the time of the inspection. In August 2024, the patient received 60 minutes of individual psychotherapy sessions and no groups. In July 2024, the patient received 60 minutes of individual psychotherapy and no groups. In June 2024, the patient received 20 minutes of individual psychotherapy and no groups. Patient #7 was admitted on November 30, 2023and was discharged on July 23, 2024. In March 2024, the patient received 60 minutes of individual psychotherapy sessions and no groups. In April 2024, the patient received 60 minutes of individual psychotherapy and no groups. In May 2024, the patient received 60 minutes of individual psychotherapy and no groups. Patient #8 was admitted on May 6, 2024 and was still active at the time of the inspection. In June, 2024, the patient received 30 minutes of individual psychotherapy and no groups. In July, 2024, the patient received 60 minutes of individual psychotherapy and no groups. In August 2024, the patient did not receive any individual or group psychotherapy.These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
The Clinical Supervisor (CS) will retrain the clinical staff regarding clients need to have 2.50 hours of counseling in the first 0-2 years of treatment, 1 hour of counseling for patients in 2-4 years of treatment and 1 hour of counseling every other month for patients in treatment more than 4 years. The CS will review each counselor's engagement on a monthly basis and discuss how improvements can be made. The CS will train each counselor on how to monitor their own engagement through the course of the month by viewing their KIPU BI dashboard to see which patients are still in need of being seen. The CS will also review this report and discuss areas of concern/improvement during bi-weekly supervision. |
715.20(4) LICENSURE Patient transfers
A narcotic treatment program shall develop written transfer policies and procedures which shall require that the narcotic treatment program transfer a patient to another narcotic treatment program for continued maintenance, detoxification or another treatment activity within 7 days of the request of the patient.
(4) The receiving narcotic treatment program shall document in writing that it notified the transferring narcotic treatment program of the admission of the patient and the date of the initial dose given to the patient by the receiving narcotic treatment program.
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Observations
Based on a review of patient records, the facility failed to document the notification of the previous narcotic treatment program of the admission and initial dose of the patient in one out of one applicable record.Patient #3 was admitted on March 7, 2024 and was still active at the time of the inspection. This finding was reviewed with facility staff during the licensing inspection.
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Plan of Correction
The Executive Director will review with all staff at the all-staff meeting held in November what documentation is required for a client to transfer into the clinic upon admission, as well as what notification must be made to the prior facility to ensure a safe transfer of the patient to ARS. The primary counselor will ensure all clients admitted as a transfer from another facility complete an ROI from their previous treatment facility. A member of the medical team will also complete the Patient Transfer Acknowledgement Form in KIPU to document the MAT dose upon admission from their prior facility. The Clinical Supervisor will audit all new patient charts on a weekly basis to ensure that all necessary documentation has been received and completed. |
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 two out of three applicable records reviewed.Patient #1 was admitted on October 22, 2022 and was still active at the time of the inspection. The last annual physical was completed on February 16, 2023. An annual physical was due no later than February 16, 2024; however, it was not completed until March 25, 2024.Patient #4 was admitted on November 26, 2021 and was still active at the time of the inspection. The last annual physical was completed on May 19, 2023. An annual physical was due no later than May 19, 2024; however, none was completed.These findings were reviewed with facility staff during the licensing inspection.This is a repeat from the September 11, 2023 licensing inspection.
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Plan of Correction
The Director of Nursing will run a report monthly on all current patients to determine which patients are in need of annual/bi-annual physical examinations by a medical provider. This document will be shared with the medical provider. The DON and/or medical provider will then place a flag on the clients chart the month the clients physical exam is due to be completed. The provider will meet with the client prior to the client receiving their medication. DON will track and monitor appointments to ensure implementation. |
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 document an annual evaluation of each ' s patient ' s status completed by the patient ' s counselor and reviewed, dated and signed by the medical director with all areas of regulation addressed, to include within the regulatory timeframe in three out of three applicable records reviewed.Patient #1 was admitted on October 22, 2020 and was still active at the time of the inspection. The annual clinical evaluation completed on October 25, 2023 was not dated and signed by the medical director.Patient #4 was admitted on November 26, 2021 and was still active at the time of the inspection. The annual clinical evaluation completed on November 26, 2023 was not dated and signed by the medical director.Patient #6 was admitted on January 9, 2019 and was discharged on March 21, 2024. The annual clinical evaluation completed on January 9, 2024 was not dated and signed by the medical director.These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
The Clinical Supervisor (CS) will conduct an audit of client charts to identify those who are past due for annual clinical evaluations by 10/31/2024. The Primary Counselor will then have a two-week period to then address those patients who have been identified as needing a clinical evaluation. Moving forward the Primary Counselors will be required to review their clients on a monthly basis to ensure that all client charts are clinically reviewed within 30 days of the anniversary of the client's admission to the facility. This will be monitored during the quarterly peer audit review process, as well as bi-weekly supervisions with the CS. |
709.92(a)(2) LICENSURE Treatment and rehabilitation services
709.92. Treatment and rehabilitation services.
(a) An individual treatment and rehabilitation plan shall be developed with a client. This plan shall include, but not be limited to, written documentation of:
(2) Type and frequency of treatment and rehabilitation services.
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Observations
Based on a review of the patient records, the facility failed to ensure that an individual treatment and rehabilitation plan shall be developed with the patient. This plan shall include but not limited to, written documentation of type and frequency of treatment and rehabilitation services in three out of five patient records reviewed. Patient #5 was admitted on May 24, 2024 and was still active at the time of the inspection. A comprehensive treatment plan was developed on June 4, 2024 with no type or frequency identified.Patient #7 was admitted on November 30, 2023 and was discharged on July 23, 2024. A comprehensive treatment plan was developed on December 15, 2024 with no type or frequency identified.Patient #8 was admitted on May 6, 2024 and was still active at the time of the inspection. A comprehensive treatment plan was developed on May 21, 2024 with no type or frequency identified.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Clinical Supervisor (CS) on 11/1/2024 will retrain the clinical staff on Treatment Planning. The CS will do a complete review of all existing client's charts and place a KIPU flag on those client charts to have type and frequency of services added to treatment plan. Moving forward the Primary Counselors will be required to include type and frequency when creating treatments plans. This will be monitored during the quarterly peer audit review process, as well as weekly by the CS during the quality assurance review process. |
709.92(a)(3) LICENSURE Treatment and rehabilitation services
709.92. Treatment and rehabilitation services.
(a) An individual treatment and rehabilitation plan shall be developed with a client. This plan shall include, but not be limited to, written documentation of:
(3) Proposed type of support service.
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Observations
Based on a review of client records, the facility failed to document proposed type of support service on individual treatment plans in three out of five records reviewed.Patient #5 was admitted on May 24, 2024 and was still active at the time of the inspection. A comprehensive treatment plan was developed on June 4, 2024. Patient #7 was admitted on November 30, 2023 and was discharged on July 23, 2024. A comprehensive treatment plan was developed on December 15, 2024. Patient #8 was admitted on May 6, 2024 and was still active at the time of the inspection. A comprehensive treatment plan was developed on May 21, 2024.These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
The Clinical Supervisor (CS) on 11/1/2024 will retrain the clinical staff Treatment Planning; to include identification and documentation of patient support services. The Primary Counselor will add support services to patient's treatment plan during next update. This will be monitored during the quarterly peer audit review process, as well as weekly by the CS during the quality assurance review process. |
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 a review of patient records, the facility failed to document treatment plan updates within the regulatory timeframe in three out of eight records reviewed. The facility has an exception to complete updates every 120 days for patient's who are stable and receiving counseling less than twice per month.Patient #4 was admitted on November 26, 2021 and was still active at the time of the inspection. A treatment plan update was completed on April 4, 2024 and an update was due no later than August 4, 2024; however, it was not completed until August 8, 2024. Patient #7 was admitted on November 30, 2023 and was discharged on July 23, 2024. A treatment plan was completed on February 28, 2024 and an update was due no later than April 29, 2024; however, it was not completed until May 22, 2024.Patient #8 was admitted on May 6, 2024 and was still active at the time of the inspection. A comprehensive treatment plan was completed on May 21, 2024 and the next update was due no later than July 21, 2024; however, it was not completed until September 25, 2024.These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
The Clinical Supervisor (CS) on 11/1/2024 will retrain the clinical staff on Treatment Planning. The CS will do a complete review of all existing client's charts and place a KIPU flag on patient chart in need of treatment plan update. Moving forward the Primary Counselors will be required to review their clients on a monthly basis to ensure that all client charts have a Treatment Plan completed every 60-120 days. This will be monitored during the quarterly peer audit review process, as well as weekly by the CS during the quality assurance review process. |