INITIAL COMMENTS
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This report is a result of an on-site licensure renewal and methadone monitoring inspection conducted on August 17, 2023 through August 18, 2023, by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, Lebanon Treatment 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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704.7(b) LICENSURE Counselor Qualifications
704.7. Qualifications for the position of counselor.
(a) Drug and alcohol treatment projects shall be staffed by counselors proportionate to the staff/client and counselor/client ratios listed in 704.12 (relating to full-time equivalent (FTE) maximum client/staff and client/counselor ratios).
(b) Each counselor shall meet at least one of the following groups of qualifications:
(1) Current licensure in this Commonwealth as a physician.
(2) A Master's Degree or above from an accredited college with a major in chemical dependency, psychology, social work, counseling, nursing (with a clinical specialty in the human services) or other related field which includes a practicum in a health or human service agency, preferably in a drug and alcohol setting. If the practicum did not take place in a drug and alcohol setting, the individual's written training plan shall specifically address a plan to achieve counseling competency in chemical dependency issues.
(3) A Bachelor's Degree from an accredited college with a major in chemical dependency, psychology, social work, counseling, nursing (with a clinical specialty in the human services) or other related field and 1 year of clinical experience (a minimum of 1,820 hours) in a health or human service agency, preferably in a drug and alcohol setting. If a person's experience did not take place in a drug and alcohol setting, the individual's written training plan shall specifically address a plan to achieve counseling competency in chemical dependency issues.
(4) An Associate Degree from an accredited college with a major in chemical dependency, psychology, social work, counseling, nursing (with a clinical specialty in the human services) or other related field and 2 years of clinical experience (a minimum of 3,640 hours) in a health or human service agency, preferably in a drug and alcohol setting. If a person's experience was not in a drug and alcohol setting, the individual's written training plan shall specifically address a plan to achieve counseling competency in chemical dependency issues.
(5) Current licensure in this Commonwealth as a registered nurse and a degree from an accredited school of nursing and 1 year of counseling experience (a minimum of 1,820 hours) in a health or human service agency, preferably in a drug and alcohol setting. If a person's experience was not in a drug and alcohol setting, the individual's written training plan shall specifically address a plan to achieve counseling competency in chemical dependency issues.
(6) Full certification as an addictions counselor by a statewide certification body which is a member of a National certification body or certification by another state government's substance abuse counseling certification board.
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Observations
Based on a review of eight personnel records, it was determined that one employee hired as a counselor did not meet the qualification requirements for the position.
Employee #5 was hired as a counselor on February 20, 2023 and was current in that position at the time of the inspection. At the time of hire, the employee had a qualifying Bachelor ' s degree but not the required one year of clinical experience for a Bachelor ' s level counselor.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Employee will be listed as a counselor assistant. Employee had close supervision weekly from February to August for a total of 6 months Employee's training plan was adjusted to ensure required training within the first year of hire. CS will continue to monitor progress for the first full year to move her to counselor status.
When reviewing resumes for future counselor candidates, CS will work with CD to determine if each potential counselor meets all clinical qualifications for position.
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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.
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Observations
Based on a review of eleven client records, the facility failed to obtain an informed and voluntary consent to release information form from the client for the disclosure of information contained in two records reviewed.
Client # 6 was admitted on November 9, 2022 and was active at the time of the inspection. The record contained documentation of a release of information to the Department of Human Services on December 16, 2022; however, the consent to release information form to the agency was not signed by the client until December 19, 2022.
Client # 7 was admitted on April 25, 2022 and was discharged on April 27, 2023. The record contained documentation of a release of information in a nursing note with another treatment provider on March 31, 2023; however, the record contained no client signed consent to release information form for the provider.
These findings were discussed with facility staff during the licensing process.
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Plan of Correction
CD will conduct a training on Confidentiality in October to review how to complete a valid signed consent and when to complete them. CS will complete monthly chart audits and progress on this will be provided to CD monthly. |
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 eleven client records, the facility failed to ensure that informed and voluntary consent to release information forms included the specific information to be disclosed in one record reviewed.
Client # 4 was admitted on December 11, 2018 and was discharged on May 16, 2023. The record contained a consent to release information form to a treatment provider signed by the client on December 12, 2022, that was missing the specific information to be disclosed.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
CD will conduct a training on Confidentiality in October to review how to complete a valid signed consent and when to complete them. CS will complete monthly chart audits and progress on this will be provided to CD monthly. |
709.32 (b) LICENSURE Medication control
§ 709.32. Medication control.
(b) Verbal orders for medication can be given only by a physician or other medical professional authorized by State and Federal law to prescribe medication and verbal orders may be received only by another physician or medical professional authorized by State and Federal law to receive verbal orders. When a verbal or telephone order is given, it has to be authenticated in writing by a physician or other medical professional authorized by State and Federal law to prescribe medication. In detoxification levels of care, written authentication shall occur no later than 24 hours from the time the order was given. Otherwise, written authentication shall occur within 3 business days from the time the order was given.
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Observations
Based on a review of ten client records, the facility failed to ensure that verbal orders were authenticated in writing by a physician or other medical professional within three business days in four records reviewed.
Client # 1 was admitted on September 23, 2022 and was active at the time of the inspection. A verbal order was given on May 18, 2023 but was not authenticated in writing until May 24, 2023. A verbal order was given on August 9, 2023 but was not authenticated in writing until August 14, 2023.
Client # 3 was admitted on May 19, 2023 and was active at the time of the inspection. A verbal order was given on May 19, 2023 but was not authenticated in writing until May 24, 2023. A verbal order was given on June 29, 2023 but was not authenticated in writing until July 5, 2023.
Client # 5 was admitted on May 31, 2023 and was active at the time of the inspection. A verbal order was given on August 11, 2023 but was not authenticated in writing until August 16, 2023.
Client # 10 was admitted on March 17, 2023 and was active at the time of the inspection. A verbal order was given on August 4, 2023 but was not authenticated in writing until August 9, 2023.
This is a repeat citation from the August 29, 2023 through August 30, 2023 annual licensing renewal inspection.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Physician will be provided a laptop for access to approve orders. CD will provide computer and Nurse Supervisor and Physician assistant will contact doctor to ensure that orders are signed. |
709.34 (c) (1) LICENSURE Reporting of unusual incidents
§ 709.34. Reporting of unusual incidents.
(c) To the extent permitted by State and Federal confidentiality laws, the project shall file a written unusual incident report with the Department within 3 business days following an unusual incident involving:
(1) Physical or sexual assault by staff or a client.
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Observations
Based on a review of client records and a discussion with facility staff, the project failed to file a written unusual incident report with the Department within three business days following an unusual incident involving a physical assault by a client.
There was documentation of a patient assault on November 2, 2022; however, there was no documentation that a written unusual incident report was filed with the Department.
These findings were reviewed with project staff during the licensing process.
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Plan of Correction
CD completed report to DDAP for said incident 9/22/2023. CD will report internal incident reporting and will have this reviewed by Quality Assurance prior to submission. All completed unusual incident reports are printed out and submitted to internal QA reporting. All incident reports will be submitted to DDAP by CD within 24 hours of incident. |
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.
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Observations
Based on a review of administrative documents and a discussion with facility staff, the facility failed to ensure that all State laws and regulations were followed to allow the physician ' s assistant to perform functions of a narcotic treatment physician. The facility failed to ensure there was a written agreement between the physician ' s assistant and supervising physician, which included delegated functions of the physician ' s assistant.
This is a repeat citation from the August 29, 2022 through August 30, 2022 annual licensing renewal inspection.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Physican Assistants Collaborative Agreement was filed in March of 2022. This was reviewed with PA and submitted for revision to DOH in September of 2023. Once approved by DOH this will be kept on site for future reference. CD will monitor weekly to ensure completed. |
715.9(a)(2) LICENSURE Intake
(a) Prior to administration of an agent, a narcotic treatment program shall screen each individual to determine eligibility for admission. The narcotic treatment program shall:
(2) Verify the individual 's identity, including name, address, date of birth, emergency contact and other identifying data.
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Observations
Based on a review of ten patient records, the facility failed to ensure that emergency contact information was obtained in one record reviewed.
Patient # 2 was admitted on July 11, 2022 and was discharged on November 2, 2022. The record did not contain emergency contact information.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Each Counselor is required to complete an emergency contact consent with each new patient. All new intake consents will be reviewed by CS with a chart review that checks for this consent. CS will review ongoing with chart reviews after admitting into program. |
715.9(a)(4) LICENSURE Intake
(a) Prior to administration of an agent, a narcotic treatment program shall screen each individual to determine eligibility for admission. The narcotic treatment program shall:
(4) Have a narcotic treatment physician make a face-to-face determination of whether an individual is currently physiologically dependent upon a narcotic drug and has been physiologically dependent for at least 1 year prior to admission for maintenance treatment. The narcotic treatment physician shall document in the patient 's record the basis for the determination of current dependency and evidence of a 1 year history of addiction.
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Observations
Based on a review of ten patient records, the facility failed to have a narcotic treatment physician make a face-to-face determination of whether an individual is currently physiologically dependent upon a narcotic drug and has been for at least one year in three records reviewed.
Patient # 3 was re-admitted to the facility on May 19, 2023 and was active at the time of the inspection. The initial face-to-face interview was made by a physician's assistant on May 19, 2023.
Patient # 6 was admitted on November 9, 2022 and was active at the time of the inspection. The initial face-to-face determination of physiological dependency was made by a physician's assistant on November 9, 2022.
Patient # 10 was transferred to the facility on March 17, 2023 and was active at the time of the inspection. The initial face-to-face interview was made by a physician's assistant on March 17, 2023.
This is a repeat citation from the August 29, 2023 through August 30, 2023 annual renewal licensing inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
CD and PA reviewed current Collaborative agreement on DOH website approved 3/29/2022 which permitted PA to complete face to face. CD, Medical Director and PA to complete an updated collaborative agreement to be more specific with PA's duties which specifically includes DDAP verbiage. Once the agreement is approved, CD will keep on file for future reference. |
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 a review of patient records, the facility failed to ensure the narcotic treatment physician determined the subsequent dose and schedule. It was documented in patient records that the facility's physician ' s assistant rather than the narcotic treatment physician, determined the initial and subsequent doses in for two of three applicable patients.
Patient # 6 was admitted on November 9, 2022 and was active at the time of the inspection. Medication orders were written and signed by the physician ' s assistant on November 10, 2022 and November 11, 2022.
Patient # 9 was admitted on November 22, 2019 and was discharged on May 5, 2023. Medication orders were written and signed by the physician ' s assistant on October 7, 2022 and October 13, 2022.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
CD and PA reviewed current Collaborative agreement on DOH website approved 3/29/2022 which give permission for PA to do face to face, initial doses and subsequent doses. CD, Medical Director and PA to complete an updated collaborative agreement to be more specific with PA's duties which will include the ability to complete a face-to-face admission for MAT, initial and subsequent doses. Once the agreement is approved, CD will keep on file for future reference. |
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 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 four out of four applicable records.
Patient # 1 was admitted on September 23, 2022 and was active at the time of the inspection. The patient was required to have at least one hour of individual psychotherapy per month. The patient did not receive any individual therapy during the months of July, June, May, and April 2023.
Patient # 2 was admitted on July 11, 2022 and was discharged on November 2, 2022. The patient was required to have at least one hour of individual psychotherapy per month. The patient did not receive any individual therapy during the month of October 2022.
Patient # 3 was admitted on May 19, 2023 and was active at the time of the inspection. The patient was required to have at least one hour of individual psychotherapy per month. The patient did not receive any individual therapy during the month of July 2023.
Patient # 6 was admitted on November 9, 2022 and was active at the time of the inspection. The patient was required to have at least one hour of individual psychotherapy per month. The patient did not receive any individual therapy during the month of May 2023. The patient only received 0.75 hours of individual therapy during the month of April 2023.
This is a repeat citation from the August 29, 2022 through August 30, 2022 annual licensing renewal inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
CS will review policy regarding counseling requirements each month. All missed sessions will be documented in a no-show note demonstrated that the patient was offered a group/individual session but declined to show. |
715.19(2) LICENSURE Psychotherapy services
A narcotic treatment program shall provide individualized psychotherapy services and shall meet the following requirements:
(2) A narcotic treatment program shall provide each patient at least 1 hour per month of group or individual psychotherapy during the third and fourth year of treatment. 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 each patient at least 1 hour per month of group or individual psychotherapy during the third and fourth year of treatment in one applicable record reviewed.
Patient # 9 was admitted on November 22, 2019 and was discharged on May 5, 2023. The patient was required to have at least one hour of group or individual psychotherapy per month. The patient only received one half hour of therapy during the month of February 2023.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
CS will review policy regarding counseling requirements each month. All missed sessions will be documented in a no-show note demonstrated that the patient was offered a group/individual session but declined to show. |
715.20(3) LICENSURE Patient transfers
A narcotic treatment program shall develop written transfer policies and procedures which shall require that the narcotic treatment program transfer a patient to another narcotic treatment program for continued maintenance, detoxification or another treatment activity within 7 days of the request of the patient.
(3) The transferring narcotic treatment program shall document what materials were sent to the receiving narcotic treatment program.
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Observations
Based a review of patient records, the transferring facility failed to document what materials were sent to the receiving facility in one of one applicable record reviewed.
Patient # 7 was admitted on April 25, 2022 and transferred to another narcotic treatment program on April 27, 2023.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
CS will review transfer in policy with counselors in October. All transfer in our out staff will attempt to make contact by completing a consent and reaching out to the transferring facility. All attempts for contact will be documented in patient charts. |
715.20(4) LICENSURE Patient transfers
A narcotic treatment program shall develop written transfer policies and procedures which shall require that the narcotic treatment program transfer a patient to another narcotic treatment program for continued maintenance, detoxification or another treatment activity within 7 days of the request of the patient.
(4) The receiving narcotic treatment program shall document in writing that it notified the transferring narcotic treatment program of the admission of the patient and the date of the initial dose given to the patient by the receiving narcotic treatment program.
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Observations
Based on a review of patient records, the receiving narcotic treatment program failed to document in writing that it notified the transferring narcotic treatment program of the admission of the patient and the date of the initial dose in one of one applicable record reviewed.
Patient # 10 was transferred to the facility on March 17, 2023 and was active at the time of the inspection.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
CS will review the transfer policy with counselors in October. Each counselor is required to complete transfer acknowledgments for each patient received or referred out of our facility. |
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 a review of patient records, the facility failed to ensure an annual physical reevaluation in two of eight applicable records reviewed.
Patient # 4 was admitted on December 11, 2018 and was discharged on May 16, 2023. The most recent annual physical evaluation was due no later than December 13, 2022; however, it was not documented in the patient record until January 13, 2023.
Patient # 9 was admitted on November 22, 2019 and was discharged on May 5, 2023. The most recent annual physical evaluation was due no later than November 22, 2022; however, it was not documented in the patient record until December 16, 2022.
This is a repeat citation from the August 29, 2022 through August 31, 2022 annual licensing renewal inspection.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Nursing supervisor will put holds on each patient within the electronic health record to ensure that patient is notified of their appointment for annuals one month in advance to plan appropriately. |
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 the review of patient records, the facility failed to document a completed annual evaluation signed by the medical director in two of eight applicable records.
Patient # 8 was admitted on May 18, 2016 and was active at the time of the inspection. The annual evaluation completed on May 16, 2023 was not signed by the medical director.
Patient # 9 was admitted on November 22, 2019 and was discharged on May 5, 2023. The annual evaluation completed on October 31, 2022 was not signed by the medical director.
This is a repeat citation from the August 29, 2022 through August 31, 2022 annual licensing renewal inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
CD will review with medical director in September. CD and NS will monitor medical director completing all required clinical annual evaluations. |