INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection 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, Pennsylvania Associates, LLC dba as Miners Medical 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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709.24 (a) (3) LICENSURE Treatment/rehabilitation management.
§ 709.24. Treatment/rehabilitation management.
(a) The governing body shall adopt a written plan for the coordination of client treatment and rehabilitation services which includes, but is not limited to:
(3) Written procedures for the management of treatment/rehabilitation services for clients.
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Observations
Based on a review of client records, the facility failed to follow their written procedures for completion of an individual treatment and rehabilitation plan in three out of four applicable client records reviewed; case consultations in four out of seven applicable client records reviewed; and follow up contacts for clients in three out of three applicable client records reviewed.
The facility ' s policy and procedures manual states that the comprehensive treatment plan is due within thirty days of admission.
Client #1 was admitted on April 9, 2024 and was still active at the time of the inspection. An individual treatment and rehabilitation plan was due no later than May 9, 2024; however, it was not completed until July 5, 2024.
Client #7 was admitted on April 10, 2024 and was still active at the time of the inspection. An individual treatment and rehabilitation plan was due not later than May 10, 2024; however, it was completed on May 30, 2024.
Client #9 was admitted on March 14, 2024 and was still active at the time of the inspection. An individual treatment and rehabilitation plan was due no later than April 14, 2024; however, it was completed on April 16, 2024.
The facility ' s policy and procedures manual states that case consultations occur at three, six, nine months, one year and annually thereafter.
Client #1 was admitted on April 9, 2024 and was still active at the time of the inspection. A case consultation was due no later than July 9, 2024; however, there is no documentation that one was completed.
Client #3 was admitted on April 9, 2024 and was still active at the time of the inspection. A case consultation was due no later than July 9, 2024; however, it was completed on August 13, 2024.
Client #7 was admitted on April 10, 2024 and was still active at the time of the inspection. A case consultation was due no later than July 10, 2024; however, it was completed on July 16, 2024.
Client #10 was admitted on August 13, 2013 and was still active at the time of the inspection. A case consultation was due no later than August 13, 2024; however, it was completed on August 16, 2024.
The facility ' s policy and procedures manual states that follow up contacts occur at seven, thirty and sixty business days after discharge.
Client #4 was admitted on September 14, 2021 and discharged on May 22, 2024. A follow up contact was due no later than June 22, and July 22, 2024; however, it was completed on August 21, 2024.
Client #5 was admitted on May 27, 2020 and discharged on March 18, 2024. A follow up contact was due no later than March 27, 2024; however, it was completed on June 14, 2024.
Client #6 was admitted on December 9, 2020 and discharged on May 23, 2024. A follow up contact was due no later than June 23, 2024; however, it was completed on August 21, 2024.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The facility failed to comply with 709.24(a)(3) Treatment/rehabilitation management. The facility failed to complete the comprehensive treatment plan within thirty days of admission. The facility failed to complete case consultations within three, six, nine months, one year and annually. The facility failed to complete follow up contacts within seven, thirty and sixty days after discharge. Based on these findings, the clinical supervisors will monitor monthly during supervisions and complete all required follow up contacts after discharge. The Executive Director created a discharge spreadsheet for the clinical supervisors to monitor when to complete the follow up contacts after discharge. The clinical supervisors will also ensure all services are completed by the clinical staff members on time. Based on these findings the clinical supervisor will provide the clinical team with the treatment plan's due and overdue report every Monday from the Tableau Dashboard. The clinical supervisors will monitor weekly to ensure the services are completed. The clinical supervisor will also review monthly during supervision to ensure treatment plans are completed on time. Based on these findings the clinical supervisor will conduct monthly chart audits to ensure case consultations are completed before the due date and address during supervision. The Executive Director reviewed expectations on 10/28/2024 with the clinical team. |
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 facility failed to document what specific information could be disclosed in an informed and voluntary consent from the client in four out of ten records reviewed.
Client #1 was admitted on April 9, 2024 and was still active at the time of the inspection. Two informed and voluntary consent forms dated on April 9, 2024 for a medical provider and a mental health provider that had " other " marked with no further explanation. An informed and voluntary consent form dated on June 5, 2024 and September 25, 2024 for a drug and alcohol facility did not have the specific information identified that could be disclosed.
Client #3 was admitted on April 9, 2024 and was still active at the time of the inspection. An informed and voluntary consent form dated on April 9, 2024 for a social service provider and a medical provider that had " other " marked with no further explanation. Two informed and voluntary consent forms dated on April 9, 2024 and May 23, 2024 for a medical and mental health provider did not have the specific information identified that could be disclosed.
Client #9 was admitted on March 14, 2024 and was still active at the time of the inspection. An informed and voluntary consent form dated on March 14, 2024 for a funding source did not have the specific information identified that could be disclosed.
Client #10 was admitted on August 13, 2013 and was still active at the time of the inspection. Four informed and voluntary consent forms dated August 24, 2024 for two medical providers and two funding sources did not have the specific information identified that could be disclosed.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The facility failed to comply with regulation 709.28(c)(2) Confidentiality. The facility failed to document specific information to be disclosed with an informed and voluntary consent. Based on these findings the clinical staff were retrained by the Executive Director on 10/28/2024 in how to complete releases properly to include information being disclosed. All staff will complete the Confidentiality, ROI's and Coordination of Care Relias training by 11/8/2024. The clinical supervisors will review and monitor releases to ensure they are being documented accurately during monthly supervisions. |
709.28 (d) LICENSURE Confidentiality
§ 709.28. Confidentiality.
(d) A copy of a client consent shall be offered to the client and a copy maintained in the client record.
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Observations
Based on a review of the client records, the facility failed to document that a copy of a client informed and voluntary consent was offered to the client and a copy maintained in the client record in one out of ten client records reviewed.
Client #1 was admitted on April 9, 2024 and was still active at the time of the inspection. There was no documentation that a copy of an informed and voluntary consent to release information form for a funding source dated April 9, 2024 was offered to the client.
This finding was reviewed with the facility staff during the licensing process.
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Plan of Correction
The facility failed to comply with 709.28(d) related to Confidentiality. The facility failed to document that a copy of the client informed and voluntary consent was offered to the client. Based on these findings, the staff were retrained on 10/28/2024 on the importance of offering to the client a copy of the informed and voluntary consent by the Executive Director. All staff will complete the Confidentiality, ROI's and Coordination of Care Relias training by 11/8/2024. The clinical staff must indicate if a copy was offered. During monthly chart audits the clinical supervisors will review the charts to ensure the releases are properly documented to include pertinent information. The clinical supervisor will review any findings with the clinical team during monthly supervision. |
715.9(c) LICENSURE Intake
(c) If a patient was previously discharged from treatment at another narcotic treatment program, the admitting narcotic treatment program, with patient consent, shall contact the previous facility for the treatment history.
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Observations
Based on a review of patient records, the facility failed to ensure that a patient who was previously discharged from treatment at another narcotic treatment program, the admitting narcotic treatment program, with patient consent, shall contact the previous facility for the treatment history in one out of five applicable records reviewed.
Patient #9 was admitted on March 14, 2024 and was still active at the time of the inspection. Patient #9 had previous treatment at another narcotic treatment program; however, there is no documentation that the facility requested an informed and voluntary consent to release information for that provider to request the treatment records.
This finding was reviewed with the facility staff during the licensing process.
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Plan of Correction
The facility failed to comply with 715.9(c) Intake ensuring that a client who was previously discharged from treatment at another narcotic treatment program with the client consent to contact the previous facility for the treatment history. The Executive Director reviewed expectations with the clinical team during the staff meeting on 10/28/2024. The clinical supervisor will monitor all intakes and conduct weekly intake chart reviews. The clinical supervisor will ensure the staff are complying with regulation 715.9(c) Intake and have the clinical staff request client consent to contact previous facility. The clinical team will contact previous facility for treatment history and upload all requested documents to the electronic medical record. |
715.10(f) LICENSURE Pregnant patients
(f) The narcotic treatment program shall ensure that each female patient is fully informed of the possible risk to her or her unborn child from continued use of illicit drugs and from use of, or withdrawal from a narcotic drug administered or dispensed by the program in comprehensive maintenance or detoxification treatment.
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Observations
Based on a review of patient records, the facility failed to ensure that each female patient is fully informed of the possible risk to her or her unborn children from continued use of illicit drugs and from use of, or withdrawal from a narcotic drug administered or dispensed by the program in comprehensive maintenance or detoxification treatment in one out of three applicable records reviewed.
Patient #3 was admitted on April 9, 2024 and was still active at the time of the inspection. There is no documentation that the patient was informed of this risk.
This finding was reviewed with the facility staff during the licensing process.
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Plan of Correction
The facility failed to comply with 715.10(f) Pregnant Patients ensuring that each female client was informed of the possible risk to her or her unborn children from continued use of illicit drugs and from use of, or withdrawal from a narcotic drug administered or dispensed by the program in comprehensive maintenance. The Executive Director reviewed the expectations with the medical staff on 10/28/2024. The Medical Director and Nurse Practitioner were informed to communicate with the nursing staff of upcoming appointments with any pregnant patients. The Medical Director and Nurse Practitioner were informed to ensure each pregnant female client of the possible risk to her or her unborn children from continued use of illicit drugs and from use of, or withdrawal from a narcotic drug administered or dispensed by the program in comprehensive maintenance. The nursing staff will monitor to ensure the form is signed and completed before the client receives the dose of methadone. The medical staff will utilize the pregnancy protocol. The Executive Director will meet with the medical team bi-weekly to ensure all issues are being addressed. |
715.12(1-5) LICENSURE Informed patient consent
A narcotic treatment program shall obtain an informed, voluntary, written consent before an agent may be administered to the patient for either maintenance or detoxification treatment. The following shall appear on the patient consent form:
(1) That methadone and LAAM are narcotic drugs which can be harmful if taken without medical supervision.
(2) That methadone and LAAM are addictive medications and may, like other drugs used in medical practices, produce adverse results.
(3) That alternative methods of treatment exist.
(4) That the possible risks and complications of treatment have been explained to the patient.
(5) That methadone is transmitted to the unborn child and will cause physical dependence.
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Observations
Based on a review of patient records, the facility failed to obtain an informed and voluntary consent prior to administering an agent in one out of five applicable records.
Patient #3 was admitted on April 9, 2024 and was still active at the time of the inspection. There was no documentation that an informed and voluntary consent was signed.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
715.12(1-5) Informed patient consent
The facility failed to comply with 715.12(1-5) Informed patient consent. The facility failed to comply with obtaining an informed and voluntary consent prior to administering an agent. The Executive Director reviewed the expectations with the medical team on 10/28/2024 during the staff meeting. The Medical Director and Nurse Practitioner were informed on the importance of discussing and obtaining the patient signature on the Informed Patient Consent. The nursing staff review all intakes prior to the client receiving the first dose of methadone to ensure the Informed Patient Consent is completed and signed. The Clinical Supervisors will conduct weekly intake chart audits to ensure all intake documentation is completed accurately. |
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 physical examination by the narcotic treatment physician within the regulatory timeframe in two out of three applicable records reviewed.
Patient #8 was admitted on January 4, 2015 and was still active at the time of the inspection. An annual physical was due no later than January 4, 2024; however, it was completed on January 9, 2024.
Patient #10 was admitted on August 13, 2013 and was still active at the time of the inspection. An annual physical was due no later than August 13, 2024; however, it was completed on August 14, 2024.
This is a repeat citation from the November 9, 2022 and October 20, 2023 licensing inspections.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The facility failed to comply with 715.23(b)(5) Patient records. The facility failed to document an annual physical examination by the narcotic treatment physician. The narcotic treatment physicians were retrained by the Executive Director on 10/28/2024 on the importance of completing all annual physical examinations within the scheduled time slot. The narcotic treatment physician will check their schedule within the electronic medical records to ensure all annual physicals are scheduled and completed. The clinical supervisor will review all annual physical examinations during monthly chart audits to ensure they are completed before the due date. |
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 a review of patient records, the facility failed to document an annual evaluation in two out of three applicable records.
Patient #6 was admitted on December 9, 2020 and discharged on May 23, 2024. An annual evaluation was due no later than December 9, 2023; however, it was completed on January 25, 2024.
Patient #10 was admitted on August 13, 2013 and was still active at the time of the inspection. An annual evaluation was due no later than August 13, 2024; however, there was no documentation that one was completed.
This is a repeat citation from the October 21, 2023 licensing inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The facility failed to comply with 715.23(c)(1-7) Patient records. The facility failed to document an annual evaluation by the patient's counselor. The clinical staff members were retrained by the Executive Director on 10/28/2024 on the importance of completing all annual evaluations before the scheduled due date. Based on these findings the clinical supervisor will provide the clinical team with the annual evaluations due and overdue report every Monday from the Tableau Dashboard. The clinical supervisors will monitor weekly to ensure the services are completed. The clinical supervisors will also review during monthly supervision. |
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 client records, the facility failed to document treatment plan updates within the regulatory timeframe in five out of nine applicable records reviewed.
Client #4 was admitted on September 14, 2021 and discharged on May 22, 2024. A treatment plan update was completed on December 5, 2023, and the next update was due no later than February 5, 2024; however, there was no documentation that one was completed.
Client #5 was admitted on May 27, 2020 and discharged on March 18, 2024. A treatment plan update was completed on November 29, 2023, and the next update was due no later than January 29, 2024; however, there was no documentation that one was completed.
Client #8 was admitted on January 4, 2015 and was still active at the time of the inspection. A treatment plan update was completed on May 13, 2024, and the next update was due no later than July 13, 2024; however, it was not completed until July 29, 2024.
Client #9 was admitted on March 14, 2024 and was still active at the time of the inspection. A treatment plan was completed on May 15, 2024, and the next update was due no later than July 15, 2024; however, it was not completed until July 25, 2024.
Client #10 was admitted on August 13, 2013 and was still active at the time of the inspection. A treatment plan update was completed on April 13, 2024, and the next update was due no later than June 13, 2024; however, it was not completed until June 22, 2024.
This is a repeat citation from the October 20, 2023 licensing inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The facility failed to comply with 709.92(b) Treatment and rehabilitation services. The facility failed to document treatment plan updates within the regulatory timeframe. Based on these findings the clinical supervisor will provide the clinical team with the treatment plan's due and overdue report every Monday from the Tableau Dashboard. The clinical supervisors will monitor weekly to ensure the services are completed. The clinical supervisor will also review monthly during supervision to ensure treatment plans are completed on time. The Executive Director discussed expectations during the staff meeting on 10/28/2024. |
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 a review of client records, the facility failed to ensure that the clients received counseling services according to their individual treatment plan in five out of ten applicable records reviewed.
Client #1 was admitted on April 9, 2024 and was still active at the time of the inspection. The treatment plan dated July 5, 2024, indicated two and half hours per month with one hour of individual therapy. In July 2024, the client received only one hour of group and one hour of individual therapy.
Client #2 was admitted on July 16, 2024 and was still active at the time of the inspection. The treatment plan dated July 16, 2024, indicated one hour of group and one hour of individual therapy a month. In August 2024, the facility canceled a group session and did not reschedule the group therapy.
Client #3 was admitted on April 9, 2024 and was still active at the time of the inspection. The treatment plan dated April 10, 2024, indicated two and half hours per month with one hour being individual therapy. In June 2024, the client received only two hours of group and fifteen minutes of individual therapy.
Client #4 was admitted on September 14, 2024 and discharged on May 22, 2024. The treatment plan dated December 5, 2023, indicated two and half hours per month with one hour being individual therapy. In April 2024, there was no documented therapy sessions and in March 2024, there was no documentation that the client was offered therapy other than one session in which the client did not attend.
Client #7 was admitted on April 10, 2024 and was still active at the time of the inspection. The treatment plan dated July 3, 2024, indicated weekly individual counseling and one and half hours of group sessions weekly. In July 2024, the client received only one hour of group therapy and in August 2024, the client received only one hour and fifteen minutes of induvial therapy.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The facility failed to comply with 709.92(c) Treatment and rehabilitation services. The facility failed to ensure that the clients received counseling services according to their individual treatment plan. Based on these findings the Executive Director reviewed expectations during the staff meeting on 10/28/2024, informing them of the need to provide the required counseling services in accordance with the client's treatment plan. The clinical supervisors will monitor the scheduler to ensure clients are scheduled for sessions. The clinical supervisor will monitor Tableau Dashboard weekly for face-to-face services. The clinical supervisor will review face to face services during monthly supervision to ensure the services are completed with the clients. |
709.17(a)(3) LICENSURE Subchapter B.Licensing Procedures.Refusal/rev
709.17. Refusal or revocation of license.
(a) The Department may revoke or refuse to issue a license for any of the following reasons:
(3) Failure to comply with a plan of correction approved by the Department, unless the Department approves an extension or modification of the plan of correction.
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Observations
Based on a review of client records, the facility failed to comply with plans of correction that were approved by the Department.
A plan of correction for ensuring that the annual physical examination by the narcotic treatment physician was submitted and approved by the Department for the November 9, 2022 and October 20, 2023 annual licensing inspection.
Completing the annual physical examination by the narcotic treatment physician was again found to be a deficiency in the September 30 & October 1, 2024 licensing inspection.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
709.17 Refusal or revocation of license
The facility failed to comply with plans of correction that were approved by the Department. The facility failed to ensure that all plans of corrections were being followed. The Executive Director reviewed the expectations with all of the staff members on 10/28/2024. The facility will monitor that all of the plans of corrections are being followed with the Clinical Supervisor conducting weekly and monthly chart audits. The Clinical Supervisors will review progress and/or areas needing improvement with the clinical team during monthly supervision. The Clinical Supervisors will conduct quarterly clinical team meetings to ensure staff stay in compliance with all of the plans of corrections. |