INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection and methadone monitoring inspection conducted on November 2-3, 2021 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 Medica lwas found not to be in compliance with the applicable chapters of 28 PA Code which pertain to the facility. The following deficiencies were identified during this inspection:
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Plan of Correction
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704.8(a) LICENSURE Qualifications-Counselor Assistant
704.8. Qualifications for the position of counselor assistant.
(a) A person who does not meet the educational and experiential qualifications for the position of counselor may be employed as a counselor assistant if the requirements of at least one of the following paragraphs are met. However, a project may not hire more than one counselor assistant for each employee who meets the requirements of clinical supervisor or counselor.
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Observations
Based on a review of personnel records and the facility staffing requirements facility summary report, the facility had a total of eleven counselor assistants and only ten employees who meet the requirements of clinical supervisor or counselor. These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
704.8(a) Licensure Qualifications-Counselor Assistant:
The facility failed to comply with regulation 704.8(a) related to a project may not hire more than one counselor assistant for each employee who meets the requirements of clinical supervisor or counselor. When posting for a counselor position, Program Director and Recruiting team are reviewing and identifying counselor and counselor assistant ratios. Qualifications are reviewed by Program Director and Recruitment team to ensure candidate meet the required minimum qualifications for the counselor position. Program Director and Clinical Supervisors are monitoring on a monthly basis the staffing ratios to ensure the facility is compliant with regulations. One counselor was promoted to Counselor as of 11/30/2021. Another counselor will be promoted to counselor on 12/28/2021. The facility is not going to hire anymore counselor assistant until the ratio is met.
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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.
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Observations
Based on ten of eleven applicable counselor assistant personnel records reviewed, the facility failed to provide documentation of weekly supervision to include one hour weekly of direct observation in personnel records # 11, 12, 14, 15, 16, 17, 18, 19, 20, 21.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
704.9(c) Licensure Supervised Period:
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 proper documentation required during supervision for all counselor assistants. Program Director will review documentation with Clinical Supervisor to ensure direct observations conducted weekly. Will be conducting direct observation in individual session setting with permission from client.
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709.28 (a) (1) LICENSURE Confidentiality
§ 709.28. Confidentiality.
(a) A written procedure shall be developed by the project director which shall comply with 4 Pa. Code § 255.5 (relating to projects and coordinating bodies: disclosure of client-oriented information). The procedure must include, but not be limited to:
(1) Confidentiality of client identity and records. Procedures must include a description of how the project plans to address security and release of electronic and paper records and identification of the person responsible for maintenance of client records.
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Observations
Based on medication administration, the facility failed to maintain confidentiality of all client identities as clients were observed throwing away take home bottles without blacking out each name and dose into a trash can by each dosing window.These findings were discussed with facility staff during the inspection process.This is a respeat citation from the January 20, 2021 annual licensing inspection.
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Plan of Correction
709.28(a)(1) Licensure Confidentiality:
The facility failed to comply with 709.28(a)(1) related to confidentiality to maintain security of client identity. Program Director implemented signs and placed them throughout the waiting room and dispensing area, notifying clients they must blackout any and all take home bottles returned to the facility. Medical team has been informed they must reinforce this procedure with clients to ensure identity is protected.
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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 one of eight client records reviewed, the facility failed to obtain an informed and voluntary consent from the client for the disclosure of information contained in the client record to include the specific information disclosed be limited to 255.5 (b) in client record # 3.Client # 3 was admitted on September 15, 2021 and was still active at the time of the inspection. An informed and voluntary consent from the client for the disclosure of information dated September 15, 2021 to a government agency allowed for the release of general records to include history and physical, physician, nurse, and other provider notes, social work/case management notes, psychiatric/mental health/developmental disabilities information, consultation reports, x-ray test and study results.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
709.28 Confidentiality (c)(2) Licensure Confidentiality:
The facility failed to comply with 709.28(c) related to confidentiality to include the specific information disclosed be limited to 255.5(b) in client record. Based on these findings the staff will be retrained on completing releases properly to limit information being disclosed. Any new clinical staff members employed will be trained thoroughly. Clinical Supervisors will review and monitor releases are being documented accurately.
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715.16(e) LICENSURE Take-home priveleges
(e) With an exception granted under subsection (d), a narcotic treatment program may not permit a patient to receive more than a 2-week take-home supply of medication.
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Observations
Based on one of one applicable patient records reviewed, documentation indicated patient. # 3 was receiving a thirty-day take-home. There was no documentation of an exception approval from the department.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
715.16(e) Licensure Take Home Privileges:
The facility failed to comply with 715.16(e) related to not completing exception documentation for take home privileges over two weeks supply of medication. Medical Director will submitted exception request to SAMSHA and Blanket Exception form to the Department of Drug and Alcohol for approval before the patient is admitted into the facility. Once approved, Executive Director will review and set up appointment date and time for the patient to be admitted. Federal officers will sign chain of custody form every time take home medications are dispensed.
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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.
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Observations
Based on five of six applicable patient records reviewed, the facility failed to have a narcotic treatment physician determine the patient 's initial and subsequent dose and schedule with each dosage change written and signed by the narcotic treatment physician. Patient # 1 was admitted on December 5, 2017 and was still active at the time of the inspection. A dose review/change was determined by the CRNP on June 3, 2021 without documentation of a verbal order by the physician.Patient # 2 was admitted on March 18, 2021 and was still active at the time of the inspection. The initial dose was determined by the CRNP on March 18, 2021. A subsequent dose change was determined by the CRNP on March 23, 26, 30, May 5, 27, and June 2, 2021 without documentation of a verbal order by the physician. Patient # 6 was admitted on May 20, 2021 and was discharged on August 3, 2021. There was no documentation of an order for the initial dose in the client record. A dose increase from 30 mg to 40 mg occurred on May 21, 2021 by the CRNP without a verbal order documented by the physician. A dose change occurred on June 1 and June 7 by the CRNP without a verbal order documented by the physician.Patient # 7 was admitted on June 10, 2020 and was discharged on August 3, 2021. A dose review/change was determined by the CRNP on March 4, May 21, June 1, and June 4, 2021 without documentation of a verbal order by the physician.Patient # 8 was admitted on February 24, 2020 and was discharged on April 8, 2021. A dose review/change was determined by the CRNP on February 26, 2021 without documentation of a verbal order by the physician.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
715.17(c)(1)(i-vi) Licensure Medication Control:
The facility failed to comply with regulation 715.17(c)(1)(i-vi) in regards to medication control. The Nurse Practitioner has been educated on the importance of checking off the verbal order tab. Medical Director has been informed to check documentation completed by Nurse Practitioner to ensure information is correct and sign off on any required documents.
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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 two of four applicable patient records reviewed, the facility failed to provide documentation of an annual evaluation by the counselor.Patient # 7 was admitted on June 10, 2020 and discharged on August 3, 2021. An annual evaluation was due no later than June 10, 2021 however, there was no annual evaluation documented in the patient record.Patient # 8 was admitted on February 24, 2020 and discharged on April 8, 2021. An annual evaluation was due no later than February 24, 2021 however, there was no annual evaluation documented in the patient record.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
715.23(c)(1-7) Licensure Patient Records:
The facility failed to comply with regulation 715.23(c)(1-7) related to patient records to provide documentation of an annual evaluation by the counselor. Clinical Supervisor will retrain clinical staff members on properly completing annual evaluations. Clinical Supervisors will provide clinical staff with a tracking grid for client services due. Clinical Supervisors will monitor services due doing supervision and when conducting chart audits.
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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.
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Observations
Based on two of two applicable client records reviewed, the facility failed to provide documentation of follow-up information in accordance with the facility policy and procedure manual. The facility policy and procedure manual indicate a follow-up to the client occur by phone within set intervals. The first seven days, three months, and twelve months if not being referred to an outside resource.Client # 5 was admitted on May 19, 2020 and discharged on August 17, 2021. There was no follow-up information documented in the client record. Client # 8 was admitted on February 24, 2020 and discharged on April 8, 2021. There was no follow-up information documented in the client record. These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
709.93(a)(11) Licensure Client Records:
The facility failed to comply with regulation 709.93(a)(11) related to client rights in reference to discharge follow up information. Clinical Supervisor will provide an in house training to all clinical staff members to ensure documentation is completed. Clinical Supervisors will monitor compliancy through on-going chart audit reviews.
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