INITIAL COMMENTS
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Based on the concerns arising from COVID-19, The Department of Drug and Alcohol Programs, Bureau of Program Licensure, has implemented temporary procedures for conducting an annual renewal inspection. The inspection will be divided into two parts. 1, an abbreviated off-site inspection, will be conducted off site, and will require the submission of administrative information via email to a Licensing Specialist. 2, an abbreviated on-site inspection, will be conducted on-site at a later date and will include a review of client/patient records, and a physical plant inspection.This report is a result of Part 2, an abbreviated on-site inspection, conducted on March 15-16, 2021 by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Not all regulations were reviewed, the remainder of the regulations were reviewed during Part 1.Based on the findings of Part 2, an abbreviated 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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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
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Observations
Based on a review of doctor's hours and program census that took place on July 31, 2020, the narcotic treatment program was unable to provide documentation that the narcotic treatment physician provided services at least 1 hour per week onsite for every ten patients.The week of June 1-6, 2020 the program census was 374. The documented narcotic treatment physician hours were 34.5 rather than the required 37.4.The week of June 7-13, 2020 the program census was 372. The documented narcotic treatment physician hours were 36 rather than the required 37.2.The week of June 21-27, 2020 the program census was 367. The documented narcotic treatment physician hours were 34 rather than the required 36.7.The findings were reviewed with program staff during the licensing process. This was a repeat citation from a licensing inspection that took place on October 11, 2019.
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Plan of Correction
Lebanon Treatment Center has onboarded three new physicians and increased doctor time onsite to sufficiently cover required hours. Doctors are present a minimum of 16 hours weekly, with an additional 32 hours of coverage via physician's assistant. |
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 three out of fifteen patient records reviewed the narcotic treatment program 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. Patient #3 was admitted on June 21, 2019 and was active at the time of the inspection. The patient had two hours of group psychotherapy in December 2020, one hour of group and one hour of individual psychotherapy in January 2021 and two hours of group in February 2021. Patient #13 was admitted on March 23, 2019 and was discharged on December 11, 2020. The patient had one hour of individual psychotherapy in October 2020 and no further psychotherapy was documented in the records. Patient #14 was admitted on December 16, 2019 and was active at the time of the inspection. The patient had one hour of individual psychotherapy in October, November, and December 2020.These findings were reviewed with program staff during the licensing process.
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Plan of Correction
Lebanon Treatment Center management has conducted an in house meeting on 2/23 to review and address deficiencies in counseling services. All patients will be scheduled prior to the beginning of each month for required individual and group therapy sessions. Any missed sessions will result in a "hold" being placed on patient to address "no show" and patient will be rescheduled. Clinical staff will document "no shows" accordingly and ensure patients are receiving individual sessions monthly. Clinical supervisor will conduct reviews of patients that are non-compliant and follow up with primary counselors to ensure follow through. |