INITIAL COMMENTS
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This report is a result of an on-site licensure renewal and methadone monitoring inspection conducted on March 10-11, 2022 by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, Center for Behavioral Health - PA d/b/a Discovery House - PA 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) (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 the review of patient records, the facility failed to document a completed consent to release information form in one out of seven records reviewed.
Patient #4 was admitted on August 23, 2021 and was still active at the time of the inspection. A consent form dated August 16, 2021 to another treatment facility had "other" checked for information to be disclosed without specifying what additional information was permitted to be released.
The finding was reviewed with facility staff during the licensing inspection.
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Plan of Correction
We reviewed how to complete a release correctly in the team meeting on 4/13/22. All staff were present and new staff will be trained in the area of releases. Patient # 4 the release has been updated and signed. Clinical Supervisor will review releases in individual supervision monthly and in clinical meetings. Clinical Supervisor will review in monthly Clinical and Medical audits and Clinical Quality Reviews. Director will review in Chart to Charge Audits. |
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 the review of physician timesheets, the facility failed to provide at least one hour of physician time a week, onsite for every ten patients.
During the week of October 17-23, 2021, the patient census was 448. The facility was required to provide at least 44.8 physician hours. There were 40 physician hours documented.
During the week of November 21-27, 2021, the patient census was 438. The facility was required to provide at least 43.8 physician hours. There were 39 physician hours documented.
During the week of December 26, 2021 - January 1, 2022, the patient census was 424. The facility was required to provide at least 42.4 physician hours. There were 39 physician hours documented.
The findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
We will plan to have a backup Nurse Practitioner that can fill in on hours and have the coverage with our Medical Directors.
Director will monitor hours on a weekly basis to ensure that we have enough Medical hours to meet our census weekly. |
715.13(a) LICENSURE Patient identification
(a) A narcotic treatment program shall use a system for patient identification for the purpose of verifying the correct identity of a patient prior to administration of an agent.
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Observations
Based on the observation of medication administration, the facility failed to properly verify the correct identity of a patient prior to administration of an agent. Section 6.1.1, #7d of the facility's policy and procedures manual states "patients will present at the dispensing window without hats or sunglasses. There was one observed occurrence where the patient was not asked to remove their hat prior to dosing.
The findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
This policy reviewed with all nursing and will ensure that all patients are asked to remove their hats. New medical staff will be trained upon hire.
Nurse Manager will train all new medical staff and will review this yearly with all existing staff. Nurse Manager will also monitor weekly to ensure compliance. |
715.14(b) LICENSURE Urine testing
(b) A narcotic treatment program shall develop and implement policies and procedures to ensure that urine collected from patients is unadulterated. These policies and procedures shall include random observation which shall be conducted professionally, ethically and in a manner which respects patient privacy.
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Observations
Based on direct observation of urinalysis collection procedures, the facility failed to follow their policy and procedures manual to ensure that urine collected from patients is unaltered. Policy 5.12.1 states the staff person will use appropriate temperature tools to ensure specimen is appropriate temperature. Temperature tools were not used during one patient's urine collection process.
The findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
This policy reviewed with all nursing and will ensure that all patients will have their drug screen samples tested. New medical staff will be trained upon hire.
Nurse Manager will train all new medical staff and will review this yearly with all existing staff. Nurse Manager will also monitor weekly to ensure compliance. |
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 patients with 2.5 hours of psychotherapy per month during the patient's first two years of treatment, one hour of which shall be individual psychotherapy, in one out of four applicable records reviewed.
Patient #2 was admitted on December 3, 2020 and was still active at the time of the inspection. In December 2021, the patient did not receive any individual psychotherapy sessions. In February 2022, the patient received 30 minutes of individual psychotherapy.
The findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
During this time period we were down counselors and Clinical Supervisor and Director were handling higher caseloads and patients were attending more groups. We are now full staffed and all patients will attend the required counseling monthly including the 1 hour in individual sessions.
Clinical Supervisor will review weekly in supervision and monthly in clinical meetings. Clinical Supervisor will train all new clinical staff in this area. |
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 document an annual physical examination within the regulatory timeframe in one out of two applicable records.
Patient #2 was admitted on December 3, 2020 and was still active at the time of the inspection. The annual physical examination was due December 3, 2021; however, it was completed on December 14, 2021.
The finding was reviewed with facility staff during the licensing inspection.
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Plan of Correction
All patients have their physical exams completed annually on the month that they were admitted. We will ensure that when patients schedule their physicals that they schedule them in advance of their anniversary day.
Clinical Supervisor and Clinic Director will review monthly and quarterly in audits. |
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 a review of patient records, the facility failed to document an annual clinical evaluation within the regulatory timeframe in two out of three applicable records.
Patient #2 was admitted on December 3, 2020 and was still active at the time of the inspection. The annual clinical evaluation was due on December 4, 2021; however, it was completed on December 6, 2021.
Patient #3 was admitted on January 10, 1995 and was still active at the time of the inspection. The annual clinical evaluation was due on January 10, 2022; however, it was completed on January 26, 2022.
The findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
This was reviewed with the counselors during the clinical meeting on 4/7/22. Patients will be scheduled early to complete the paperwork, if a no show counselor will complete the annual clinical form and review in next session with patient.
Clinical Supervisor and Clinic Director will review monthly and quarterly in audits. Clinical Supervisor will also spot check during individual supervision. |
709.92(a) LICENSURE Treatment and rehabilitation services
709.92. Treatment and rehabilitation services.
(a) An individual treatment and rehabilitation plan shall be developed with a client. This plan shall include, but not be limited to, written documentation of:
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Observations
Based on the review of patient records, the facility failed to complete the comprehensive treatment plan within 30 days of admission as required in their policy and procedures manual in two out of three applicable records.
Patient #2 was admitted on December 3, 2020 and was still active at the time of the inspection. A comprehensive treatment plan was due on January 3, 2021; however, it was not completed until January 29, 2021.
Patient #4 was admitted on August 23, 2021 and was still active at the time of the inspection. A comprehensive treatment plan was due on September 23, 2021; however, it was not completed until October 1, 2021.
These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
During the Clinical Meeting on 4/21/22 all counselors will be trained on this process of completing the treatment plans before the due date instead of completing them all by the end of the month. Clinical Supervisor will review due dates and spot check in supervision. All new clinical staff will be trained on this process.
Clinical Supervisor and Clinic Director will review monthly and quarterly in audits. |