INITIAL COMMENTS
|
This report is a result of an on-site licensure renewal and methadone monitoring inspection conducted on October 19, 2023, through October 20, 2023, by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, Pennsylvania Care LLC dba 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:
|
Plan of Correction
|
704.9(c) LICENSURE Supervised Period
704.9. Supervision of counselor assistant.
(c) Supervised period.
(1) A counselor assistant with a Master's Degree as set forth in 704.8 (a)(1) (relating to qualifications for the position of counselor assistant) may counsel clients only under the close supervision of a trained counselor or clinical supervisor for at least the first 3 months of employment.
(2) A counselor assistant with a Bachelor's Degree as set forth in 704.8 (a)(2) may counsel clients only under the close supervision of a trained counselor or clinical supervisor for at least the first 6 months of employment.
(3) A registered nurse as set forth in 704.8 (a)(3) may counsel clients only under the close supervision of a trained counselor or clinical supervisor for at least the first 6 months of employment.
(4) A counselor assistant with an Associate Degree as set forth in 704.8 (a)(4) may counsel clients only under the close supervision of a trained counselor or clinical supervisor for at least the first 9 months of employment.
(5) A counselor assistant with a high school diploma or GED equivalent as set forth in 704.8 (a)(5) may counsel clients only under the direct observation of a trained counselor or clinical supervisor for the first 3 months of employment. For the next 9 months, the counselor assistant may counsel clients only under the close supervision of a lead counselor or a clinical supervisor.
|
Observations
Based on a review of personnel records, the facility failed to maintain documentation that counselor assistants received direct observation as part of their close supervision, in five of five applicable records.Employee # 8 was hired by the facility on August 8, 2022 as a counselor assistant, prior to being promoted to the position of counselor on September 5, 2023. During the period of time the employee was a counselor assistant, the supervision notes provided at the time of the inspection did not indicate that direct observation of the provision of counseling services was a part of the close supervision. Employee # 11 was hired a counselor assistant on July 31, 2023 and was current in that position at the time of the inspection. The supervision notes provided at the time of the inspection did not indicate that direct observation of the provision of counseling services was a part of the close supervision. Employee # 12 was hired a counselor assistant on July 24, 2023 and was current in that position at the time of the inspection. The supervision notes provided at the time of the inspection did not indicate that direct observation of the provision of counseling services was a part of the close supervision. Employee # 13 was hired a counselor assistant on July 25, 2023 and was current in that position at the time of the inspection. The supervision notes provided at the time of the inspection did not indicate that direct observation of the provision of counseling services was a part of the close supervision. Employee # 14 was hired a counselor assistant on October 17, 2022 and was current in that position at the time of the inspection. The supervision notes provided at the time of the inspection did not indicate that direct observation of the provision of counseling services was a part of the close supervision. These findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
The facility failed to comply with regulation 704.9(c) requiring the facility to provide documentation of weekly direct observation in personnel records. Program Director will retrain clinical supervisors on 11/30/2023 on proper documentation required during supervision for all counselor assistants. Program Director will review documentation with Clinical Supervisor to ensure direct observations conducted at a minimum once a month. Will be conducting direct observation in individual session setting with permission from client. The clinical supervisors will document all supervision within the electronic record. |
704.11(c)(1) LICENSURE Mandatory Communicable Disease Training
704.11. Staff development program.
(c) General training requirements.
(1) Staff persons and volunteers shall receive a minimum of 6 hours of HIV/AIDS and at least 4 hours of tuberculosis, sexually transmitted diseases and other health related topics training using a Department approved curriculum. Counselors and counselor assistants shall complete the training within the first year of employment. All other staff shall complete the training within the first 2 years of employment.
|
Observations
Based on a review of fourteen personnel records and the facility's Staffing Requirement Facility Summary Report (SRFSR) form, the facility failed to ensure that two employees received the minimum of 4 hours of TB/STD and 6 hours of HIV/AID training within the regulatory timeframe.Employee # 7 was hired as a counselor on August 22, 2022 and was due to have the communicable disease trainings no later August 22, 2023. However, there was no documentation of the completion of the HIV/AIDS or TB/STD trainings as of the date of the inspection.Employee # 14 was hired as a counselor on October 17, 2022 and was due to have the communicable disease trainings no later October 17, 2023. However, there was no documentation of the completion of the TB/STD training as of the date of the inspection.The findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
The facility failed to comply with regulation 704.11 (b)(1) requiring the facility to maintain licensure individual training plan. The clinical supervisor will meet with counselors on 11/30/2023 during the staff meeting to discuss the required training for employment. Clinical Supervisor will conduct monthly audits to ensure required training are completed within the first year of employment. If an employee does not have the required trainings completed within the first year of employment. The employee may be subjected to an internal corrective action plan if not completed by 1/30/2024 or later when the facility is in full compliance with the regulation. |
705.26 (2) LICENSURE Heating and cooling.
705.26. Heating and cooling.
The nonresidential facility:
(2) May not permit in the facility heaters that are not permanently mounted or installed.
|
Observations
Based on a physical plant inspection on October 19, 2023, the facility failed to ensure that heaters were permanently mounted as a space heater was found in a counselor office in the back hallway of the facility. These findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
The facility failed to comply with regulation 705.26 (2) ensuring no space heaters in the facility. The Facility Director reviewed the citation. The Clinical Supervisor will review with the clinical team during the staff meeting. To safeguard against any safety issues or concerns, heating will be provided by a permanent mounted unit. The Facility Director will ensure compliance by maintaining a functional internal heating unit and checking the interior of the building for space heaters monthly. |
705.28 (d) (5) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(5) Prepare alternate exit routes to be used during fire drills.
|
Observations
Based on a review of fire drill logs from December 2022 through August 2023, the facility failed to prepare alternate exit routes as the same exit route was documented in each drill.The findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
The facility failed to comply with regulation 705.28 (d) (5) ensuring to utilize the alternative exit route during fire drills. The fire safety officer will be trained by the Executive Director on 11/30/2023 in the utilization of the alternative exit route and ensure all staff use both exit routes during fire drills. The fire safety officer will ensure the alternative exit route is utilized periodically. The fire safety officer will document the fire safety drill within the electronic record. |
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 seven client records, the facility failed to obtain an informed and voluntary consent from the client for the disclosure of information in one record reviewed. Client # 1 was admitted on September 20, 2022 and was discharged on July 20, 2023. The record contained documentation that medication history, UDS results, history and physical were released to another treatment provider on June 27, 2023. The consent to release information form to the provider signed by the client on June 12, 2023, did not allow for the release of that information.These findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
The facility failed to comply with 709.28(c) related to confidentiality to include the specific information disclosed for the client record. Based on these findings the clinical staff will be retrained by the clinical supervisors on 11/30/2023 in how to complete releases properly to include information being disclosed. The clinical supervisors will review and monitor releases to ensure they are being documented accurately. |
709.28 (c) (1) 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:
(1) Name of the person, agency or organization to whom disclosure is made.
|
Observations
Based on a review of seven client records, the facility failed to document the name of the person, agency, or organization to whom disclosure is made on consent to release information forms in one client record reviewed. Client # 6 was admitted on March 1, 2023 and was discharged on June 29, 2023. The release of information form to an emergency contact was signed and dated by the client on March 1, 2023; however, the form did not include the name of the person, agency, or organization to whom the disclosure would be made. This finding was reviewed with facility staff during the licensing process.
|
Plan of Correction
The facility failed to comply with 709.28(c) (1) related to Confidentiality to proper document an informed and voluntary consent. Based on these findings, the staff will be retrained on 11/30/2023 on the proper way to complete releases and how these releases are used to protect the client's confidentiality. The clinical supervisors will review the charts to ensure the releases are properly documented to include pertinent information. |
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.
|
Observations
Based on a review of seven client records, the facility failed to document that the client was notified, in writing, of the facility's decision to involuntarily terminate the client's treatment at the project in one of one applicable record reviewed.Client # 4 was admitted on August 22, 2019 and was involuntarily discharged on June 12, 2023. There was no documentation that the client was notified, in writing, of the facility's decision to involuntarily terminate.The findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
The facility failed to comply with 709.33(a) to notify a client of an involuntary termination. The clinical supervisors will be trained by the Executive Director on 11/30/2023 on the proper documentation that needs to be sent to a client being involuntarily terminated. The letter will be uploaded to the client's electronic record once completed and mailed to the client's home. The Executive Director will ensure the involuntary termination letter has been uploaded to the patients electronic medical record. |
715.6(a)(2) LICENSURE Physician staffing
(a) A narcotic treatment program shall designate a medical director to assume responsibility for administering all medical services performed by the narcotic treatment program.
(2) When a narcotic treatment program is unable to hire a medical director who meets the qualifications in paragraph (1), the narcotic treatment program may hire an interim medical director. The narcotic treatment program shall develop and submit to the Department for approval a training plan for the interim medical director, addressing the measures to be taken for the interim medical director to achieve minimal competencies and proficiencies until the interim medical director meets qualifications identified in paragraph (1)(i), (ii) or (iii). The interim medical director shall meet the qualifications within 36 months of being hired.
|
Observations
Based on an administrative review, the facility failed to develop and submit to the Department for approval a training plan for the interim medical director. The interim medical director has been in the position since August 1, 2023.These findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
The facility failed to comply with 715.6(a)(2) when a narcotic treatment program medical director meets the qualifications for interim medical director and submits a training plan to DDAP. The physician recruiter will monitor the qualifications of the medical director candidate. If the qualifications do not meet the standards of DDAP a training plan will be submitted to DDAP for approval. The current Medical Director Training Plan was completed on 2/21/2023 and submitted to RA-licensuredivision. The facility expects to have the training plan approved by DDAP before or after 12/31/2023. |
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
|
Observations
Based on the review of physician and certified registered nurse practitioner timesheets, the facility failed to provide at least one hour of physician time a week on site for every ten patients in each of the 16 weeks reviewed. During the week of June 5, 2023 through June 11, 2023, the patient census was 650. The facility was required to provide at least 65 physician hours. There were only 53.8 hours documented.During the week of June 12, 2023 through June 18, 2023, the patient census was 650. The facility was required to provide at least 65 physician hours. There were only 56.03 hours documented.During the week of June 19, 2023 through June 25, 2023, the patient census was 650. The facility was required to provide at least 65 physician hours. There were only 38.08 hours documented.During the week of June 26, 2023 through July 2, 2023, the patient census was 643. The facility as required to provide at least 64.3 physician hours. There were only 53.62 hours documented.During the week of July 3, 2023 through July 9, 2023, the patient census was 640. The facility was required to provide at least 64 physician hours. There were only 45 hours documented.During the week of July 10, 2023 through July 16, 2023, the patient census was 633. The facility was required to provide at least 63.3 physician hours. There were only 43.33 hours documented.During the week of July 17, 2023 through July 23, 2023, the patient census was 633. The facility was required to provide at least 63.3 physician hours. There were only 45.85 hours documented.During the week of July 24, 2023 through July 30, 2023, the patient census was 628. The facility was required to provide at least 62.8 physician hours. There were only 37.03 hours documented.During the week of July 31, 2023 through August 6, 2023, the patient census was 608. The facility was required to provide at least 60.8 physician hours. There were only 45.13 hours documented.During the week of August 7, 2023 through August 13, 2023, the patient census was 617. The facility was required to provide at least 61.7 physician hours. There were only 53.25 hours documented.During the week of August 14, 2023 through August 20, 2023, the patient census was 616. The facility was required to provide at least 61.6 physician hours. There were only 33 hours documented.During the week of August 21, 2023 through August 27, 2023, the patient census was 616. The facility was required to provide at least 61.6 physician hours. There were only 40.05 hours documented.During the week of August 28, 2023 through September 3, 2023, the patient census was 610. The facility was required to provide at least 61 physician hours. There were only 56.07 hours documented.During the week of September 4, 2023 through September 10, 2023, the patient census was 605. The facility was required to provide at least 60.5 physician hours. There were only 48.8 hours documented.During the week of September 11, 2023 through September 17, 2023, the patient census was 602. The facility was required to provide at least 60.2 physician hours. There were only 40.69 hours documented.During the week of September 18, 2023 through September 24, 2023, the patient census was 608. The facility was required to provide at least 60.8 physician hours. There were only 57.13 hours documented.This is a repeat citation from the November 9, 2022 annual licensing renewal inspection.These findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
Miners Medical failed to comply with 715.6(d) ensuring to provide the required number of hours onsite for the physician and certified registered nurse practitioner. The Assistant Regional Director will monitor the census ongoing and ensure accurate physician coverage hours at one for every ten clients of the required physician time is provided to the facility. The Assistant Regional Director will locate coverage in the absence of a provider or as needed. |
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.
|
Observations
Based on the review of 16 weeks of physician time sheets, the facility failed to provide the required number of hours onsite for the physician based on the census during 11 of the weeks reviewed. A physician must provide one-third of the required hours, with a certified registered nurse practitioner or physician's assistant providing the remaining two-thirds of the required hours. During the week of June 5, 2023 through June 11, 2023, the patient census was 650. The physician was required to provide one-third of the 65 hours, which equals to 21.6 hours. The physician provided 14 hours. During the week of June 19, 2023 through June 25, 2023, the patient census was 650. The physician was required to provide one-third of the 65 hours, which equals to 21.6 hours. The physician provided 14 hours. During the week of June 26, 2023 through July 2, 2023, the patient census was 643. The physician was required to provide one-third of the 64.3 hours, which equals to 21.4 hours. The physician provided 14 hours. During the week of July 10, 2023 through July 16, 2023, the patient census was 633. The physician was required to provide one-third of the 63.3 hours, which equals to 21.1 hours. The physician provided 10 hours. During the week of July 24, 2023 through July 30, 2023, the patient census was 628. The physician was required to provide one-third of the 62.8 hours, which equals to 20.9 hours. The physician provided 3 hours. During the week of August 14, 2023 through August 20, 2023, the patient census was 616. The physician was required to provide one-third of the 61.6 hours, which equals to 20.5 hours. The physician provided 0 hours. During the week of August 21, 2023 through August 27, 2023, the patient census was 616. The physician was required to provide one-third of the 61.6 hours, which equals to 20.5 hours. The physician provided 8.3 hours. During the week of August 28, 2023 through September 3, 2023, the patient census was 610. The physician was required to provide one-third of the 61 hours, which equals to 20.3 hours. The physician provided 16.11 hours. During the week of September 4, 2023 through September 10, 2023, the patient census was 605. The physician was required to provide one-third of the 60.5 hours, which equals to 20.1 hours. The physician provided 16.58 hours. During the week of September 11, 2023 through September 17, 2023, the patient census was 602. The physician was required to provide one-third of the 60.2 hours, which equals to 20 hours. The physician provided 8.38 hours. During the week of September 18, 2023 through September 24, 2023, the patient census was 608. The physician was required to provide one-third of the 60.8 hours, which equals to 20.2 hours. The physician provided 16.76 hours. This is a repeat citation from the November 9, 2022 annual licensing renewal inspection.These findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
Miners Medical failed to comply with 715.6(e) ensuring to provide the required number of hours onsite for the physician. The Assistant Regional Director will monitor the census ongoing and ensure accurate physician staffing/scheduling for at least one third of the required physician time is provided to the facility. The Assistant Regional Director will locate coverage in the absence of a provider or as needed. |
715.16(a)(3) LICENSURE Take-home privileges
(a) A narcotic treatment program shall determine whether a patient may be provided take-home medications.
(3) The narcotic treatment physician shall document in the patient record the rationale for permitting take-home medication.
|
Observations
Based on a review of seven patient records, the narcotic treatment physician failed to document in the patient record the rationale for permitting take-home medication in one of two applicable records reviewed. Patient # 3 was admitted on October 3, 2022 and was active at the time of the inspection. The patient received take-home medication on August 24, 2023 and the rationale for take-home medication was not signed by the physician until September 11, 2023.These findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
The facility failed to comply with 715.16(a)(3) ensuring the narcotic treatment physician to document the rationale for permitting take home medication. The medical staff will be trained on 11/30/2023 to ensure the physician documents a rationale for take home medication. If one is not stated, the take home medication will not be granted. The nursing supervisor will be reviewing take home medication request to ensure the rationale is inputted. |
715.17(c)(1)(i-vi)) LICENSURE Medication control
(c) A narcotic treatment program shall develop and implement written policies and procedures regarding the medications used by patients which shall include, at a minimum:
(1) Administration of medication.
(i) A narcotic treatment physician shall determine the patient 's initial and subsequent dose and schedule. The physician shall communicate the initial and subsequent dose and schedule to the person responsible for the administration of medication. Each medication order and dosage change shall be written and signed by the narcotic treatment physician.
(ii) An agent shall be administered or dispensed only by a practitioner licensed under the appropriate Federal and State laws to dispense agents to patients.
(iii) Only authorized staff and patients who are receiving medication shall be permitted in the dispensing area.
(iv) There shall be only one patient permitted at a dispensing station at any given time.
(v) Each patient shall be observed when ingesting the agent.
(vi) Administering and dispensing shall be conducted in a manner that protects the patient from disruption or annoyance from other individuals.
|
Observations
Based on a review of patient records, the facility failed to ensure that medication orders were completed according to the facility's policy and procedures in one of seven records reviewed. According to the project's policy on medication orders, complete medication orders contain the signature of the physician. Patient # 6 was admitted on March 1, 2023 and was discharged on June 29, 2023. A medication order was entered on March 1, 2023, and was not signed by a prescriber until March 20, 2023. A medication order was entered on March 2, 2023, and was not signed by a prescriber until March 20, 2023. A medication order was entered on March 9, 2023, and was not signed by a prescriber until March 20, 2023. These findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
The facility failed to comply with 715.17(c)(1) (i-vi) ensuring the narcotic treatment physician completion of the medication order. The narcotic treatment physician will be retrained on 11/30/2023 on checking the electronic medical record daily to ensure all signatures are completed on time. The nursing supervisor will monitor to ensure the signature of the physician are completed on time. |
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 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, in two of four applicable records.Patient # 1 was admitted on March 13, 2023 and was active at the time of the inspection. The patient was required to have at least 2.5 hours of psychotherapy a month. The patient did not receive any psychotherapy hours for the months of June and July 2023. Patient # 3 was admitted on October 3, 2022 and was active at the time of the inspection. The patient was required to have at least 2.5 hours of psychotherapy a month. The patient did not receive any psychotherapy hours for the months of July 2023, and did not receive 1 hour of individual therapy hours for the month of June 2023. These findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
The facility failed to comply with 715.19(1) ensuring each client was provided an average of 2.5 hours of psychotherapy per month. Miners Medical is currently hiring counselors to ensure services are completed on time. Once all positions are filled all patients will be assigned to a clinical staff member. The clinical supervisors will ensure all required services are completed monthly. The clinical supervisors will review with each clinical staff member on 11/30/2023 compliancy requirements bi-weekly to ensure patients are scheduled. |
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.
|
Observations
Based on a review of patient records, the facility failed to ensure an annual physical examination was given by the narcotic treatment program which includes an annual reevaluation by the narcotic treatment physician in two of two applicable records reviewed.Patient # 3 was admitted on October 3, 2022 and was active at the time of the inspection. The annual physical examination was due no later than October 3, 2023; however, it was not documented in the patient record until October 12, 2023. Patient # 5 was admitted on May 14, 2019 and was discharged on June 27, 2023. The annual physical examination was due no later than May 14, 2023; however, the most recent annual physical was completed on April 14, 2022. This is a repeat citation from the November 9, 2022 annual licensing renewal inspection.The findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
The facility failed to comply with 715.23(b)(5) to ensure an annual physical examination was completed by the narcotic treatment physician. The narcotic treatment physician will be retrained on 11/30/2023 on the importance of completing all annual physical examinations. The narcotic treatment physician will check their schedule within the electronic medical records to ensure all annual physicals are scheduled and completed. |
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.
|
Observations
Based on a review of patient records, the facility failed to ensure an annual evaluation of each patient's status was completed by the patient's counselor in one of two applicable records reviewed. Patient # 3 was admitted on October 3, 2022 and was active at the time of the inspection. An annual evaluation was due to be completed by October 3, 2023, however, the record did not contain documentation of annual evaluation.These findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
The facility failed to comply with 715.23(c)(1-7) ensuring all annual evaluations were completed by the clinical team. The clinical supervisors will monitor monthly during supervision to ensure annual evaluations are being completed. The clinical staff will monitor caseload due dates to ensure services are completed on time. The clinical supervisors will discuss expectations during staff meeting on 11/30/2023. |
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.
|
Observations
Based on a review of seven client records, the facility failed to document treatment plan updates within the regulatory timeframe in five of seven applicable records reviewed.Client # 1 was admitted on March 13, 2023 and was active at the time of the inspection. A treatment plan update was completed on May 6, 2023, and the next plan update was due no later than July 6, 2023; however, no treatment plan updates were completed prior to the date of the inspection. Client # 3 was admitted on October 3, 2022 and was active at the time of the inspection. The individual treatment and rehabilitation plan was completed on December 22, 2022, and the treatment plan update was due no later than February 22, 2023; however, the update was not completed until March 2, 2023. Additionally, a treatment plan update was completed on April 27, 2023, and next update was due no later than June 27, 2023; however, the update was not completed until August 31, 2023.Client # 4 was admitted on August 22, 2019 and was discharged on June 12, 2023. A treatment plan update was completed on October 18, 2022, and the next update was due no later than December 18, 2022; however, the next update was not completed until December 28, 2022. Client # 5 was admitted on May 14, 2019 and was discharged on June 27, 2023. A treatment plan update was completed on September 16, 2022, and the next update was due no later than November 16, 2022; however, the next update was not completed until May 26, 2023. Client # 7 was admitted on December 14, 2022 and was discharged on August 21, 2023. A treatment plan update was completed on April 27, 2023, and the next update was due no later than June 27, 2023; however, the next update was not completed until July 28, 2023. These findings were discussed with facility staff during the inspection process.
|
Plan of Correction
The facility failed to comply with 709.92(b) to complete treatment plan at the specific due date. Based on these findings the clinical supervisor will monitor monthly during supervision to ensure treatment plans are completed on time. The clinical staff will monitor caseload due dates to ensure services are completed on time. The clinical supervisors will discuss expectations during staff meeting on 11/30/2023. |
709.93(a)(8) LICENSURE Client records
709.93. Client records.
(a) There shall be a complete client record on an individual which includes information relative to the client's involvement with the project. This shall include, but not be limited to, the following:
(8) Case consultation notes.
|
Observations
Based on a review of client records and the facility ' s policy and procedure manual, the facility failed to ensure a complete client record included information relative to the client's involvement with the project, to include case consultation information quarterly for the first year and annually thereafter, in four of seven records reviewed. Client # 2 was admitted on September 20, 2022 and was discharged on July 20, 2023. The record did not contain documentation of case consultation information. Client # 3 was admitted on October 3, 2022 and was active at the time of the inspection. The first case consultation was due to be completed by January 3, 2023, however, it was not completed until September 15, 2023.Client # 6 was admitted on March 1, 2023 and was discharged on June 29, 2023. The record did not contain documentation of case consultation information. Client # 7 was admitted on December 14, 2022 and was discharged on August 21, 2023. A case consultation was documented on January 30, 2023, and the next case consultation was due to be completed by June 14, 2023, however, no additional case consultation information as documented. These findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
The facility failed to comply with 709.93(a)(8) to ensure case consultations are being completed. On 11/30/2023 the clinical supervisors will review with clinical staff the importance of completing case consultations on time. The clinical supervisors will monitor monthly during supervision to ensure case consultations are completed on time. The clinical staff will monitor caseload due dates to ensure services are completed on time. |
709.93(a)(11) LICENSURE Client records
709.93. Client records.
(a) There shall be a complete client record on an individual which includes information relative to the client's involvement with the project. This shall include, but not be limited to, the following:
(11) Follow-up information.
|
Observations
Based on a review of client records and the facility ' s policy and procedure manual, the facility failed to ensure a complete client record included information relative to the client's involvement with the project, to include follow-up notes within 30 and 120 days of discharge, in two of five applicable records reviewed. Client # 4 was admitted on August 22, 2019 and was discharged on June 12, 2023. The first follow-up was due to be completed by July 12, 2023, however, it was not completed until July 25, 2023.Client # 7 was admitted on December 14, 2022 and was discharged on August 21, 2023. The record did not contain documentation of follow-up notes. This is a repeat citation from the November 9, 2022 and November 3, 2021 annual licensing renewal inspections.These findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
The facility failed to comply with 709.93(a)(11) to ensure follow up calls are completed. The clinical supervisors will be retrained on 11/30/2023. Clinical supervisors will complete follow up calls and complete documentation on the follow up call within the electronic medical record. An attempt will be made to follow up the patient's progress and status. This contact will be attempted by phone within set intervals 30 days and 120 days. The purpose of these contacts will be to offer continued therapeutic support and encouragement to the patient, to assess the patient's progress, and to suggest other services. |
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.
|
Observations
Based on a review of client records and administrative documents, the facility failed to comply with plans of correction that were approved by the Department. A plan of correction for including follow-up information in the client record was submitted and approved by the Department for the November 9, 2022, and November 3, 2021, annual licensing inspections. Completing follow-up information was again found to be a deficiency in the October 19, 2023 through October 20, 2023 licensing inspection. A plan of correction for ensuring narcotic treatment physician services at least 1 hour per week onsite for every ten patients was submitted and approved by the Department for the November 9, 2022 annual licensing inspection. Physician services was again found to be a deficiency in the October 19, 2023 through October 20, 2023 licensing inspection. A plan of correction for ensuring at least one third of all required physician hours was provided by a narcotic treatment physician was submitted and approved by the Department for November 9, 2022 annual licensing inspection. Physician hours was again found to be a deficiency in the October 19, 2023 through October 20, 2023 licensing inspection. A plan of correction for completing annual physical examinations was submitted and approved by the Department for November 9, 2022 annual licensing inspection. Completing annual physical examinations was again found to be a deficiency in the October 19, 2023 through October 20, 2023 licensing inspection. These findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
The facility director will ensure the plans of correction is implemented by the corrective action date and clinical supervisor will assist in the monitoring process. Clinical supervisor will monitor progress of the plan and quarterly reviews of plans of correction implantation will occur during staff/supervision meetings. Additional monitoring will occur monthly through chart audits completed by the PTC compliance team and if deficiencies are noted they will be reviewed within the month. If the plan of correction appears to be not working as written, a supervisory meeting will occur to adjust the current plan. The facility director will report to the project director the findings each quarter during PTCs regional operations meeting. |