INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on May 4-5, 2022 by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, Williamsport Family Medical 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:
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Plan of Correction
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709.28 (c) (5) 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:
(5) Dated signature of witness.
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Observations
Based on the review of patient records, the facility failed to ensure a dated signature of a witness on the same date the patient signed in two out of eight records reviewed. Patient #1 was admitted on December 28, 2017 and was still active at the time of the inspection. There were consent to release information forms to four government agencies, a funding source and a transportation company signed by the patient on December 28, 2021 and by the witness on December 29, 2021. There were consent to release information forms to two hospitals signed by the patient on December 28, 2021 and by the witness on January 3, 2022. Additionally, there was a consent to release information form to a medical facility signed by the patient on March 22, 2022 and by the witness on March 23, 2022.Patient #2 was admitted on October 14, 2019 and was still active at the time of the inspection. There were consent to release information forms to two medical facilities signed by the patient on October 8, 2021 and by the witness on October 11, 2021.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
New releases were completed for patient #1 and patient #2. It was reviewed with all staff at our clinical meeting on 5/12/22 the importance of completing releases accurately and witnessing the consent at time of review. Going forward all releases will be checked for accuracy by the clinical supervisor during the chart review process to assure information is complete and reviewed appropriately so this does not continue in the future. |
715.19(1) LICENSURE Psychotherapy services
A narcotic treatment program shall provide individualized psychotherapy services and shall meet the following requirements:
(1) A narcotic treatment program shall provide each patient an average of 2.5 hours of psychotherapy per month during the patient 's first 2 years, 1 hour of which shall be individual psychotherapy. Additional psychotherapy shall be provided as dictated by ongoing assessment of the patient.
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Observations
Based on a review of patient records, the facility failed to provide patient with 2.5 hours of psychotherapy per month during the patient's first 2 years of treatment in one out of five applicable records reviewed. Patient # 7 was admitted on June 16, 2021 and was still active at the time of the inspection. In February 2022, the patient had 60 minutes of individual therapy and 0 hours of group therapy. In April, 2022, the patient had 96 minutes of individual therapy and 60 hours of group therapy. There was no documentation of client no shows or cancellations during those time periods.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
On 5//12/22 Executive Director provided re-training on managing caseloads to ensure that patients are receiving their required psychotherapy services as well as continuously documenting when patients do not attend group or individual sessions and attempts to re-engage into treatment. Executive Director and Clinical Supervisor will conduct monthly chart audits and review psychotherapy time to ensure that patients are receiving the required time in treatment. Executive Director will monitor the Monthly Requirements report from the EMR weekly to ensure that counselors are able to successfully manage their caseloads and ensure that the corrective action is implemented and patients are receiving their required psychotherapy time and/or there is copious documentation related to missed sessions and attempts to re-engage. |
709.92(b) LICENSURE Treatment and rehabilitation services
709.92. Treatment and rehabilitation services.
(b) Treatment and rehabilitation plans shall be reviewed and updated at least every 60 days.
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Observations
Based on a review of patient records, the facility failed to document treatment plan updates within the regulatory timeframe in four out of eight patient records reviewed.Patient #2 was admitted on October 14, 2019 and was still active at the time of the inspection. A treatment plan update was completed on January 31, 2022, and the next update was due no later than March 31, 2022; however, the next update was completed on April 7, 2022.Patient #5 was admitted on December 8, 2021 and was still active at the time of the inspection. A treatment plan update was completed on December 14, 2021 and the next update was due no later than February 14, 2021; however, the next update was completed on March 8, 2022.Patient #7 was admitted on June 16, 2021 and was still active at the time of the inspection. A treatment plan update was completed on November 15, 2021 and the next update was due no later than January 15, 2022; however, the next update was completed on March 1, 2022.Patient #8 was admitted on April 2, 2020 and was discharged on December 20, 2021. A treatment plan update was completed on June 29, 2021 and the next update was due no later than August 29, 2021; however, the next update was completed on September 29, 2021.These findings were reviewed with facility staff during the licensing process.This is a repeat citation from the May 19, 2021 licensing inspection.
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Plan of Correction
Based on these findings each counselor has found a way to track when their services are due. Each counselor has a spreadsheet with their caseload, this spreadsheet includes formulas to calculate the upcoming due dates of treatment plans as well as case consults and ASAMS. During each counselors individual supervision this spreadsheet is reviewed to assure all services are completed. This has begun as of June 1, 2022 and will continue on an ongoing basis. The Clinical Supervisors will assure the services are complete going forward during supervision. |