INITIAL COMMENTS
|
Based on the concerns arising from COVID-19, The Department of Drug and Alcohol Programs, Bureau of Quality Assurance for Prevention and Treatment, has implemented temporary procedures for conducting an annual renewal inspection.
The inspection will be divided into two parts.
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.
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 November 17, 2020 by staff from the Department of Drug and Alcohol Programs, Bureau of Quality Assurance for Prevention and Treatment. 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, The Guidance 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:
|
Plan of Correction
|
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.
|
Observations
Based on a review of client records, the facility failed to document a written, informed and voluntary consent from the client for the disclosure of information contained in the record in three of seven client records reviewed on November 17, 2020.
The facility obtained prior authorization for drug and alcohol treatment services without a consent for the funding entity in the following client records.
Client # 2 was admitted August 14, 2020.
Client # 4 was admitted January 15, 2019.
Client # 5 was admitted December 23, 2019 and discharged March 27, 2020.
The findings were reviewed with facility staff during the licensing process.
This is a repeat citation from the 2018 and 2019 licensing inspections.
|
Plan of Correction
In response to this, we have taken several steps:
(A)Drug and Alcohol Treatment staff were provided an overview of the findings on 11/17/2020 during team meeting.
(B) All Drug and Alcohol Treatment staff completed a Retraining on completing consents in accordance with 709.28 on 12/01/2020
(C)Drug and Alcohol Facility & Project Director met with agency Fiscal Director on 11/19/2020 and reviewed the need to communicate any changes with client's insurances to treatment staff so consents can be updated. New processes have been implemented as of 12/01/2020 so alerts in changes can be noted.
(D) Drug & Alcohol Facility & Project Director reviewed with agency Director of Program Evaluation the findings on 12/01/2020. The Quality and Compliance Department will begin conducting routine and random audits of Drug and Alcohol client charts to monitor compliance of consent completion. This process is targeted to begin 12/10/2020.
(E) Updated consents for the Insurance companies for Clients 2 and 4 will be obtained at their next scheduled appointments. Clients 2 is scheduled for 12/04/20 and Client 4 is scheduled for 12/08/20. |
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.
|
Observations
Based on a review of patient records, the facility failed to document a random monthly drug-screening urinalysis in three of four patient records reviewed on November 17, 2020.
Patient # 1 was admitted January 17, 2020. No drug screens were documented for May, June and September 2020.
Patient # 3 was admitted June 5, 2019 and discharged April 22, 2020. No drug screen was documented for July 2019.
Patient # 4 was admitted January 15, 2019. No drug screens were documented for December 2019 and February, March, April and June 2020.
The findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
Due to the lack of resources in rural communities because of COVID 19 demands, it was challenging to have clients meet the requirement for monthly urinalyses as it required them to go to labs that were already stretched to capacity. Some clients were also very fearful of going into hospitals for testing. For individuals who did not have regular labs, notation was completed in their client record.
The findings from the 11/17/2020 DDAP review were shared by the Program and Facility Director with the prescribing psychiatrists and MAT nurse during the team meeting on 11/17/2020.
Prior to this date, prescribers had resumed the practice that all individuals will be required to have labwork even with COVID 19 restrictions in place at facilities.
Additionally, we have taken the following steps: (a) Providers will adjust their schedules as of 12/01/2020 so that labs and visits can be completed within the same calendar month, rather than within 30 days (b) MAT nurse will ensure clients are notified of their scheduled labs each month and document this in the chart in a daily note. (c) Completion of lab work will be monitored during weekly Drug and Alcohol Team Meetings. These meetings are held on Tuesday starting at 4 pm. (d) Spreadsheets with required clinical lab information and results are updated weekly by the MAT nurse for physician review.
|
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.
|
Observations
Based on a review of patient records, the facility failed to document for each patient an average of 2.5 hours of psychotherapy per month in four of four patient records reviewed on November 17, 2020.
Patient # 1 was admitted January 17, 2020.
Patient # 2 was admitted August 14, 2020.
Patient # 3 was admitted June 5, 2019 and April 22, 2020.
Patient # 4 was admitted January 15, 2019.
The findings were reviewed with facility staff during the licensing process.
This is a repeat citation from the 2019 licensing inspection.
|
Plan of Correction
In response to this citation, we have taken several steps:
(A)Drug and Alcohol Treatment staff were provided an overview of the findings on 11/17/2020 during team meeting.
(B) All Drug and Alcohol Treatment staff completed a retraining on 12/01/2020 regarding the requirements for psychotherapy in accordance to regulation 715.19.
(C) Drug & Alcohol Facility & Project Director reviewed with agency Director of Program Evaluation the findings on 12/01/2020. The Quality and Compliance Department will begin conducting routine and random audits of Drug and Alcohol client charts to monitor compliance of psychotherapy requirements. This process is targeted to begin 12/10/2020.
(D) Drug and Alcohol Therapy staff will be "scheduling out" their suboxone clients enough sessions per month to meet the required number of therapeutic minutes. This process was reviewed with the clinical staff during team meeting on 12/01/2020. Staff were asked to begin new process on same date.
(E) Therapists will be provided with ongoing supervision and education on methods for keeping clients engaged during telehealth sessions
(F) Tracking methods were updated to include monthly minutes rather than visits on the MAT client spreadsheet that is reviewed weekly during Drug and Alcohol Treatment team meetings.
(G) It is a goal of the Drug and Alcohol Department to develop Psychotherapy groups. Target time for these groups to begin is mid January 2021. Groups are being presented as an additional access to therapy. |