INITIAL COMMENTS
|
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 February 4, 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, Addiction Medicine and Health Advocates, Inc. 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:
|
Plan of Correction
|
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.
|
Observations
Based on the review of client records, the project failed to obtain an informed and voluntary consent from the client for the disclosure of information contained in the client record in three of eight client records reviewed.
Client #1 was admitted on November 30, 2018 and was a current client at the time of the inspection. The last valid release of information form for the funding source was signed and dated by client on December 18, 2019 and expired on December 18, 2020. An updated release of information form was not documented in the client record at the time of the inspection.
Client #3 was admitted on September 29, 2016 and was a current client at the time of the inspection. The last valid release of information form for the funding source was signed and dated by client on September 9, 2019 and expired on September 9, 2020. An updated release of information form was not documented in the client record at the time of the inspection.
Client #4 was admitted on January 5, 2017 and was a current client at the time of the inspection. The last valid release of information form for the funding source was signed and dated by client on January 13, 2021 and expired on January 13, 2021. An updated release of information form was not documented in the client record at the time of the inspection.
These findings were reviewed with project staff during the licensing process.
|
Plan of Correction
The clinical supervisors will complete a review of all active patient records to ensure that the release of information forms for any entity with which AMHA is still having communication are current and complete. This includes the patients' funding source. If an updated release form is found to be needed, the patient's assigned counselor will be asked to obtain one immediately. The clinical supervisors will review the records to make sure this task is completed. The Clinical Program Manager will be responsible for overseeing this process and ensuring that all releases are current and complete. |
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 the review of patient records, the 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 in four of eight applicable patient records reviewed.
Patient #1 was admitted on November 30, 2018 and was a current patient at the time of the inspection. The patient was missing 2.5 of the 2.5 psychotherapy hours required for the month of August 2020 and 1.5 of the 2.5 psychotherapy hours required for the month of September 2020.
Patient #5 was admitted on September 9, 2019 and was discharged on February 12, 2020. The patient was missing .75 hours of the 1 individual psychotherapy hour required for the month of October 2020 and .5 hours of the 1 individual psychotherapy hour required for the months of November 2020 and December 2020.
Patient #7 was admitted on January 11, 2018 and was discharged on January 7, 2020. The patient was missing 2.5 of the 2.5 psychotherapy hours required for the months of November 2020 and December 2020 and 1.0 of the 2.5 psychotherapy hours required for the month of September 2020.
Patient #8 was admitted on August 14, 2020 and was a current patient at the time of the inspection. The patient was missing 2.5 of the 2.5 psychotherapy hours required for the month of December 2020 and 2.0 of the 2.5 psychotherapy hours required for the month September 2020.
These findings were reviewed with program staff during the licensing process.
This is a repeat citation from last year's licensure renewal inspection.
|
Plan of Correction
A staff meeting will be held to review the regulations pertaining to minimum monthly psychotherapy requirements. Each counselor will be required to review their patient caseload and create a chart or spreadsheet to identify the required number of psychotherapy hours each patient needs. They will then be required to track obtained therapy hours each week to ensure that the patient received their required number of hours prior to the end of the month. The clinical supervisors will monitor the development of these systems and adherence to them. The Clinical Program Manager will have overall responsibility for monitoring compliance. |
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.
|
Observations
Based on the review of patient records, the program failed to provide each patient at least one hour per month of group or individual psychotherapy during the third and fourth year of treatment in one of eight applicable patient records reviewed.
Patient #4 was admitted on January 5, 2017 and was a current patient at the time of the inspection. The patient was missing 1.0 of the 1.0 psychotherapy hours required for the months January 2021 and July 2020 and .5 of the 1.0 psychotherapy hours required for the months August 2020, September 2020, and November 2020.
These findings were reviewed with program staff during the licensing process.
|
Plan of Correction
A staff meeting will be held to review the regulations pertaining to minimum monthly psychotherapy requirements. Each counselor will be required to review their patient caseload and create a chart or spreadsheet to identify the required number of psychotherapy hours each patient needs. They will then be required to track obtained therapy hours each week to ensure that the patient received their required number of hours prior to the end of the month. The clinical supervisors will monitor the development of these systems and adherence to them. The Clinical Program Manager will have overall responsibility for monitoring compliance. |
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.
|
Observations
Based on the review of patient records, the program failed to document the results of all annual physical examinations given by the narcotic treatment program, including an annual reevaluation by the narcotic treatment physician in three of eight applicable patient records reviewed.
Patient #1 was admitted on November 30, 2018 and was a current patient at the time of the inspection. The last annual physical examination was documented in the patient record on December 5, 2019 and the next annual physical examination was due no later than December 5, 2020; however, there was no recent annual physical examination documented in the patient record at the time of the inspection.
Patient #3 was admitted on September 29, 2016 and was a current patient at the time of the inspection. The last annual physical examination was documented in the patient record on September 24, 2018 and the next annual physical examination was due no later than September 24, 2019 and the next no later than September 24, 2020; however, there was no recent annual physical examination documented in the patient record at the time of the inspection.
Patient #4 was admitted on January 5, 2017 and was a current patient at the time of the inspection. The last annual physical examination was documented in the patient record on January 9, 2020 and the next annual physical examination was due no later than January 9, 2021; however, there was no recent annual physical examination documented in the patient record at the time of the inspection.
These findings were reviewed with program staff during the licensing process.
|
Plan of Correction
The Nursing Supervisor and Clinical Program Manager have met to review this citation. The Nursing Manager will identify all patients who are overdue for a physical exam as well as those due in each month of 2021. Patients will then be scheduled for appointments with one of our physicians to catch up on overdue physical exams and to remain current for ones coming due. A system will be developed to remain current with physical exams moving forward by putting a reminder in the electronic health record at least one month prior to the due date for the next scheduled exam for each patient. The Nursing Supervisor will be responsible for developing, executing and monitoring compliance with this process. |