INITIAL COMMENTS
|
This report is a result of an on-site complaint investigation conducted on July 1, 2021 through July 2, 2021 by staff from the Bureau of Program Licensure. Based on the findings of the on-site complaint investigation, Pennsylvania Associates, LLC dba Mount Pocono Medical was found not to be in compliance with the applicable chapters of 28 PA Code which pertain to the facility.
|
Plan of Correction
|
705.22 (2) LICENSURE Building exterior and grounds.
705.22. Building exterior and grounds.
The nonresidential facility shall:
(2) Keep the grounds of the facility clean, safe, sanitary and in good repair at all times for the safety and well being of clients, employees and visitors. The exterior of the building and the building grounds or yard shall be free of hazards.
|
Observations
During the complaint investigation conducted on July 1-2, 2021, the facility failed to keep the facility in good repair.
The group room where this Program Representative was seated had carpet that was worn & stained and there was a big hole located behind the door.
|
Plan of Correction
The Facility Director reviewed the citation. The Facility Director will ensure compliance by completing monthly building checks to keep the grounds of the facility clean, safe, sanitary and in good repaid at all times for the safety and well being of patients.
The facility director will scheduled a time for a contractor to come in to give an estimate to repair the carpet and fix the door knob size hole behind the door. The estimate will be submitted to the corporate office, and schedule the repair to be completed by 9/30/21. Contractor will provide all supplies required for the repair.
The facility director will ensured the facility will be in good repair by 9/30/21.
Interior and exterior will be checked by the facility director daily for compliance
|
705.26 (2) LICENSURE Heating and cooling.
705.26. Heating and cooling.
The nonresidential facility:
(2) May not permit in the facility heaters that are not permanently mounted or installed.
|
Observations
During the complaint investigation conducted on July 1- 2, 2021, the facility failed to ensure that all heaters are permanently mounted or installed. There was a heater observed in the Facility Director's office.
|
Plan of Correction
The Facility Director reviewed the citation. To safeguard against any safety issues and to be in compliance with PA regulation 705.26, portable heaters used as a fan will not be used within the facility. Only air conditioning units that are permanently mounted or installed will be utilized.
The Facility Director will ensure compliance by observing the interior of the building on a daily basis.
The facility director removed the portable unit from the office.
The facility director will remove all portable heaters/fans from the facility. |
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.
|
Observations
Based on a review of client records during the complaint investigation on July 1-2, 2021, the facility failed to ensure that the client was seen every 2.5 hours monthly in client records, #1 and 2.
Client #1 was admitted on 10/15/20. The client was seen during the following months:
12/14/20 - 35min
2/5/21 - 1hr
2/22/21 - 30mim
3/19/21 - 30min
4/13/21 - 30min
4/16/21 - 30min
6/29/21 - 15min
NO shows:
1/15/21
1/25/21
1/28/21
2/12/21
3/12/21
Client #2 was admitted on 11/10/20. The client was seen during the following months:
12/24/20 - 1hr
1/21/21 - 1hr
5/24/20 - 15min
6/25/21 - 1hr
NO shows:
12/15/20
6/2/21
|
Plan of Correction
The Facility Director reviewed the citation. To ensure patients are attending 2.5 hours of psychotherapy per month, the Clinical Supervisors will conduct a training by 8/31/2021 on how to utilize the EHR to assist patients in meeting monthly counseling requirements.
The Clinical Supervisors will train clinicians to use dose holds (a dose hold is an alert in the EHR that stops the patient when checking indicating the patient is required to see a counselor), Scheduled Events reports, and Daily Activities in the EHR (Methasoft)to reach required monthly counseling. Non-compliance will be addressed during supervision.
The Clinical Supervisors will conduct monthly chart audits to monitor compliance and address any issues in supervision. |
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.
|
Observations
Based on a review of client records during the complaint investigation on July 1-2, 2021, the facility failed to ensure that the treatment plans were updated every 60 days in records, #1 and 2.
Client #1 who is still an active client, the last treatment plan was documented on 2/5/21 and the next one was to be completed by 4/5/21 as of the date of the investigation one was not completed.
Client #2 who is still an active client, treatment plan updates dated 1/21/21, 2/26/21 and 6/1/21 that facility failed to document an update, just stated the same goals. Additionally, the treatment plan update dated 6/1/21 was late since the last one documented before this one was dated for 2/26/21.
|
Plan of Correction
The Facility Director reviewed the citation. To safeguard against treatment plans not being completed in a timely manner the clinical supervisors will retrain clinicians by 8/31/2021 on how to utilize the EHR alert system to identify when treatment plans are due, review and develop the plan with the patient in either counseling or telehealth counseling sessions, and on the process of stopping the patient while checking in at the kiosk to obtain a signature if needed prior to the plans end date.
The clinical supervisor will have a face to face training with all clinicians on DDAP regulations pertaining to updating treatment plans every 60 days, she will offer time management suggestions and give instructions on how to review reports in Methasoft what will allow them to work ahead of schedule to ensure tx plans are completed in a timely manner. She will show the clinicians what reports to use in EHR that show the dates tx plans are due. She will give the clinicians samples of completed plans and will review reports daily for compliance
The clinical supervisors will retrain the clinicians on using the flag delay at the kiosk that alerts the patient on check-in that their signature could be required. The clinicians will learn how to use the daily activities option and scheduled events report in the EHR to determine when treatment plans are due allowing them to be completed in a timely manner.
The clinical supervisors will audit charts on a monthly basis for compliance and addressing any issues in supervision.
|
709.92(c) LICENSURE Treatment and rehabilitation services
709.92. Treatment and rehabilitation services.
(c) The project shall assure that counseling services are provided according to the individual treatment and rehabilitation plan.
|
Observations
Based on a review of client records during the complaint investigation on July 1-2, 2021, the facility failed to assure that counseling was provided in client records, #1 and 2.
Client #1's treatment plans dated 11/13/20, 2/5/21 and 2/5/21 states that the client will be seen for individual sessions 4 hrs monthly. Client was admitted on 10/15/20. The client was seen during the following months:
12/14/20 - 35min
2/5/21 - 1hr
2/22/21 - 30mim
3/19/21 - 30min
4/13/21 - 30min
4/16/21 - 30min
6/29/21 - 15min
NO shows:
1/15/21
1/25/21
1/28/21
2/12/21
3/12/21
Client #2's treatment plans dated 11/10/20, 1/21/21, 2/26/21 and 6/1/21 states that the client will be seen every week for 60 min. sessions. Client was admitted on 11/10/20. The client was seen during the following months:
12/24/20 - 1hr
1/21/21 - 1hr
5/24/20 - 15min
6/25/21 - 1hr
NO shows:
12/15/20
6/2/21
|
Plan of Correction
The Facility Director reviewed the citation. To ensure that counseling services are provided according to the individual treatment plan, the Clinical Supervisors will conduct a training by 8/31/2021 on how to utilize the EHR to assist patients in meeting monthly counseling requirements.
The Clinical Supervisors will train clinicians to use dose delay (a dose delay is an alert in the EHR that stops the patient when checking indicating the patient is required to see a counselor), review current treatment plans, scheduled events reports, and the daily activities option in the EHR (Methasoft)to reach required monthly counseling. Non-compliance will be addressed during supervision.
The Clinical Supervisors will conduct monthly chart audits to monitor compliance and address any issues in supervision. |
709.92(d) LICENSURE Treatment and rehabilitation services
709.92. Treatment and rehabilitation services.
(d) Counseling shall be provided to a client on a regular and scheduled basis.
|
Observations
Based on a review of client records during the complaint investigation on July 1-2, 2021, the facility failed to assure that counseling was provided on a regular schedule bases in client record, #2.
Client #2's treatment plans dated 11/10/20, 1/21/21, 2/26/21 and 6/1/21 states that the client will be seen every week for 60 min. sessions. Client was admitted on 11/10/20. The facility failed to provide him a counselor during the months of February 2021 through May 2021. He did not have a counselor until 5/24/20.
|
Plan of Correction
The Facility Director reviewed the citation pertaining to 709.92 (d) counseling shall be provided to a patient on a regular and scheduled basis.
The clinical supervisors will retrain clinicians by 8/31/2021 on determining appropriate methods and interventions on treatment plans that indicate the amount of counseling required based on progress and length of time in treatment.
Compliance will be monitored on a monthly basis via chart audits. Non-compliance issues will be addressed in supervision. |