INITIAL COMMENTS
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This report is a result of an on-site licensure renewal and methadone monitoring inspection conducted on November 30, 2023 through December 1, 2023, by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, The Healing Way 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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704.9(c) LICENSURE Supervised Period
704.9. Supervision of counselor assistant.
(c) Supervised period.
(1) A counselor assistant with a Master's Degree as set forth in 704.8 (a)(1) (relating to qualifications for the position of counselor assistant) may counsel clients only under the close supervision of a trained counselor or clinical supervisor for at least the first 3 months of employment.
(2) A counselor assistant with a Bachelor's Degree as set forth in 704.8 (a)(2) may counsel clients only under the close supervision of a trained counselor or clinical supervisor for at least the first 6 months of employment.
(3) A registered nurse as set forth in 704.8 (a)(3) may counsel clients only under the close supervision of a trained counselor or clinical supervisor for at least the first 6 months of employment.
(4) A counselor assistant with an Associate Degree as set forth in 704.8 (a)(4) may counsel clients only under the close supervision of a trained counselor or clinical supervisor for at least the first 9 months of employment.
(5) A counselor assistant with a high school diploma or GED equivalent as set forth in 704.8 (a)(5) may counsel clients only under the direct observation of a trained counselor or clinical supervisor for the first 3 months of employment. For the next 9 months, the counselor assistant may counsel clients only under the close supervision of a lead counselor or a clinical supervisor.
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Observations
Based on a review of eight personnel records, the facility failed to maintain documentation that counselor assistants received direct observation as part of their close supervision, in one of one applicable record.
Employee # 8 was hired by the facility as a counselor assistant on January 6, 2023. The supervision notes provided at the time of the inspection did not indicate that direct observation of the provision of counseling services was a part of the close supervision in each week reviewed.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
After last years inspection, THW changed our supervision form to include a selection for direct observation. As of 1/2/2024, CEO and COO have revised the supervision form so that once the selection of direct observation is made, the section is expanded to include: client ID, observations made, recommendations given.
On 1/2/2024, CEO and COO met with all managerial and supervisory level staff to review the form and ensure that it is accurately and adequately documented for counselor assistants going forward.
As of 1/2/24 COO will review all supervision notes on a monthly basis to ensure that requirements are met. |
704.10 LICENSURE Counselor Asst Promotion
704.10. Promotion of counselor assistant.
(a) A counselor assistant who satisfactorily completes one of the sets of qualifications in 704.7 (relating to qualifications for the position of counselor) may be promoted to the position of counselor.
(b) A counselor assistant shall document to the facility director that he is working toward counselor status. This information shall be documented upon completion of each calendar year.
(c) A counselor assistant shall meet the requirements for counselor within 5 years of employment. A counselor assistant who has accumulated less than 7,500 hours of employment during the first 5 years of employment will have 2 additional years to meet the requirements for counselor.
(d) A counselor assistant who cannot meet the time requirements in subsection (c) may submit to the Department a written petition requesting an exception. The petition shall describe the circumstances that make compliance with subsection (c) impracticable and shall be approved by both the clinical supervisor or lead counselor and the project director. Granting of the petition will be within the discretion of the Department.
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Observations
Based on a review of personnel records, the facility failed to ensure that a counselor assistant satisfactorily completed one of the sets of qualifications in 704.7 prior to being promoted to the position of counselor in one of one applicable record reviewed.
Employee # 7 was hired as a counselor assistant on December 21, 2020 and was promoted to the position of counselor on December 20, 2022. At the time of promotion, the employee did not possess a qualifying degree as specified in 704.7.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
As of 1/2/2024, employee #7 will no longer work with drug and alcohol clientele.
As of 1/2/2024, CEO and COO updated THWs job description of counselor so that a selection must be made from a listing of qualifying degrees.
Executive and Supervisory staff was trained on 1/2/2024 on the new job description to ensure that a selection is made when a new hire is reviewing and signing their onboarding documents, which includes the job description.
As of 1/2/2024, all new hire job descriptions will be reviewed and signed off by COO to ensure that qualifying degree is selected and appropriate. |
715.12(1-5) LICENSURE Informed patient consent
A narcotic treatment program shall obtain an informed, voluntary, written consent before an agent may be administered to the patient for either maintenance or detoxification treatment. The following shall appear on the patient consent form:
(1) That methadone and LAAM are narcotic drugs which can be harmful if taken without medical supervision.
(2) That methadone and LAAM are addictive medications and may, like other drugs used in medical practices, produce adverse results.
(3) That alternative methods of treatment exist.
(4) That the possible risks and complications of treatment have been explained to the patient.
(5) That methadone is transmitted to the unborn child and will cause physical dependence.
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Observations
Based on a review of patient records, the facility failed to obtain an informed, voluntary, written consent before an agent was administered in one of three applicable records reviewed.
Patient # 8 was admitted on April 4, 2023 and was active at the time of the inspection. The patient was initially administered an agent on April 6, 2023; however, the informed, voluntary, written consent did not contain the patient ' s signature.
This is a repeat citation from the December 15, 2022 through December 16, 2022 annual licensing renewal inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
THW changed our electronic healthcare record system in 2023. Unfortunately after our "go live date" all requests for changes were wait listed in order received. This clients consent was electronically signed, and the signature stamp which includes their name and the date and time of signature was on the ROI and was on time and correct. The physical portion of their captured signature is what was missing and was resolved during the time of the inspection.
On 1/2/2024 THW CEO and COO held a staff meeting and explained that if any technical glitches preclude a signature from appearing on the consent form, the clinician is to print the form out, have the client sign the form, and scan it into their E-Chart. After which, our EHR system can be emailed by the clinician to notify of the technical error so that they may rectify it on their end. COO must be copied on the error emails, and must be informed of any technical errors to ensure that live signatures are captured in person. |
715.15(d) LICENSURE Medication dosage
(d) A narcotic treatment program shall label all take-home medication with the patient 's name and the narcotic treatment program 's name, address and telephone number and shall package all take-home medication as required by Federal regulation.
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Observations
During an observation of medication administration on December 1, 2023 at 07:15 a.m., a patient was observed taking a take-home bottle from the facility that did not include the narcotic treatment program ' s name, address or telephone number as required by Federal regulation.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
On 1/2/2024, a roll of pre-printed labels was created to keep under lock in the dispensing station. On 1/2/24 CEO and COO held a staff meeting, and instructed nursing that if going forward the label printers are down, the nurses are to use a pre-printed label to apply on take home bottles.
To enhance compliance, the medical director will sit in to observe dosing on a monthly basis beginning January 2024. |
715.16(a)(2) LICENSURE Take-home privileges
(a) A narcotic treatment program shall determine whether a patient may be provided take-home medications.
(2) The narcotic treatment physician shall make this determination after consultations with staff involved in the patient's care.
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Observations
During an observation of medication administration on December 1, 2023 at 07:15 a.m., a patient took seven take-home bottles from the facility when the order signed by the physician only allowed for six days. The allowance for the seventh take-home was not determined by the physician.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
During 1/2/2024 staff meeting, policies and procedures were reviewed by Medical Director, CEO and COO with nursing. Included in the review were dispensing regulations, that each patient must take their days dose at the dosing window in presence of the nurse. No patient will receive any bottles additional from what is prescribed and determined by the physician. To enhance compliance, the medical director will sit in to observe dosing on a monthly basis beginning January 2024. |
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 that medication orders were complete according to the project's policy and procedures in one of eight records reviewed. According to the project's policy on medication orders, nursing staff may only administer and dispense methadone orders as written by the Medical Director.
Patient # 5 was admitted on January 20, 2023 and was discharged on August 18, 2023. Medication administration began on January 23, 2023; however, the record documented the initial order was not entered until January 30, 2023.
During an observation of medication administration on December 1, 2023 at 07:15 a.m., the medication dose ordered for onsite administration was prepared in a take-home bottle and given to the patient for off-site administration. The patient was not observed when ingesting the agent.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
THW changed our electronic healthcare records and dispensing system in March of 2023. In our new system, medication administration cannot proceed until an order is documented and signed by the physician, which will prevent any similar occurrence in the future.
During 1/2/2024 staff meeting, policies and procedures were reviewed by Medical Director, CEO and COO with nursing. Included in the review were dispensing regulations, that each patient must take their days dose at the dosing window in presence of the nurse. No patient will receive any bottles additional from what is prescribed and determined by the physician. To enhance compliance, the medical director will sit in to observe dosing on a monthly basis beginning January 2024. |
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 one of four applicable records.
Patient # 8 was admitted on April 4, 2023 and was active at the time of the inspection. The patient did not receive any individual therapy hours for the month of July 2023.
This is a repeat citation from the December 15, 2022 through December 16, 2022 annual licensing renewal inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
In our new EHR system, a tracker was added that displays the clients counseling compliance for the month. This tracker is displayed at check-in, during all appointments, and every time a patients chart is accessed, to ensure that each patient receives the services needed.
During a 1/1/2024 staff meeting, CEO and COO reminded all clinical staff that is a patient does not keep their appointment, a no-show note must be entered. Going forward, the last Friday of every month the COO will print a tracker list of all patients for the month to verify that all sessions were made and no show notes were documented. |
715.23(b)(11) LICENSURE Patient records
(b) Each patient file shall include the following information:
(11) Counselor notes regarding patient progress and status.
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Observations
Based on a review of eight patient records, the facility to ensure that each patient file included counselor notes regarding patient progress and status.
Patient # 2 was admitted on December 19, 2018 and was discharged on March 16, 2023. The patient was placed on a 10-day administrative detox on March 10, 2023. The patient was discharged on March 16, 2023, prior to the conclusion of the 10-day taper; however, the record contained no documentation describing why the taper was not completed and the patient ' s status at discharge.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Patient #2 was discharged on day 9 of his taper as he was scheduled for intake with another clinic to transfer. All transfer documentation was scanned into his chart accordingly, but he was not accepted in the other clinic and chose to go inpatient instead of returning to THW, however we did not have documentation to verify that he went inpatient.
On 1/2/2024, CEO and COO held a staff meeting during which time policies and procedures were reviewed including termination and administrative detox procedures. If a patient on a detox were to choose to transfer to another clinic or go inpatient, all documentation will be entered into his chart for verification. If the patient denies providing verification, that denial will be documented as well.
Going forward as of 1/2/2024, all administrative detoxes will be approved and monitored by the CEO to ensure that documentation is adequately logged.
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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 four of four applicable records reviewed.
Patient # 2 was admitted on December 19, 2018 and was discharged on March 16, 2023. The record did not contain documentation of an annual evaluation.
Patient # 3 was admitted on July 12, 2018 and was discharged on October 18, 2023. The annual evaluation completed on August 17, 2023 was not signed by the medical director.
Patient # 6 was admitted on October 6, 2016 and was active at the time of the inspection. The annual evaluation completed on August 16, 2023 was not signed by the medical director.
Patient # 7 was admitted on July 22, 2019 and was active at the time of the inspection. The annual evaluation completed on September 25, 2023 was not signed by the medical director.
This is a repeat citation from the January 18, 2022, July 6, 2022, and December 16, 2022 licensing inspections.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
THW changed our electronic healthcare record system in 2023. Unfortunately after our "go live date" all requests for changes to forms and documentation were wait listed in order received. On October 16, 2023 our EHR finally accepted our waitlisted ticket to revise our clinical evaluation so that it is automatically sent to the medical director once it is signed by the clinician.
On 1/2/2024 staff meeting, CEO and COO instructed clinical staff that if technical errors or malfunctions were to occur in the future that could prevent the medical signature of the annual evaluation, the clinician is to print it out, have the medical director manually sign it, and scan it into the patients E chart. |
709.91(b)(6) LICENSURE Intake and admission
709.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(6) Psychosocial evaluation.
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Observations
Based on a review of client records and the facility's policies and procedures, the facility failed to document a psychosocial evaluation within thirty days of admission, per policy, in two of four applicable records reviewed.
Client # 8 was admitted on April 4, 2023 and was active at the time of the inspection. The psychosocial evaluation was not completed until November 14, 2023.
Client # 9 was admitted on May 10, 2023 and was active at the time of the inspection. The client record did not contain a psychosocial evaluation.
These finding were discussed with facility staff during the licensing process.
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Plan of Correction
On 1/2/2024, CEO and COO held a staff meeting to review policies and procedures including acceptable timelines for completion signature on documentation. Job descriptions were updated to include the timeframes for THW documentation, and new staff will review the time frames on their job description with their direct supervisor during onboarding. Bio-psychosocial was one of the documentation time frames included on the discussion list.
Clinical Supervisor will review all newly admitted patient charts on a quarterly basis to ensure compliance, first quarter to be reviewed 4/1/2024.
The clinician responsible for the records in question was fired from THW on 12/15/2023, after three signed warnings in her personnel fire for late documentation. |
709.92(a)(3) 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:
(3) Proposed type of support service.
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Observations
Based on a review of client records, the facility failed to document the proposed type of support services on the individual treatment and rehabilitation plan in four of four applicable client records reviewed.
Client # 4 was admitted on May 22, 2023 and was discharged on August 28, 2023. The individual treatment and rehabilitation plan was completed on June 21, 2023; however, the plan did not include documentation of the proposed type of support services.
Client # 5 was admitted on January 20, 2023 and was discharged on August 18, 2023. The individual treatment and rehabilitation plan was completed on February 14, 2023; however, the plan did not include documentation of the proposed type of support services.
Client # 8 was admitted on April 4, 2023 and was active at the time of the inspection. The individual treatment and rehabilitation plan was completed on July 14, 2023; however, the plan did not include documentation of the proposed type of support services.
Client # 9 was admitted on May 10, 2023 and was active at the time of the inspection. The individual treatment and rehabilitation plan was completed on June 8, 2023; however, the plan did not include documentation of the proposed type of support services.
These finding was reviewed with facility staff during the licensing process.
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Plan of Correction
On 1/2/2024, CEO and COO held a staff meeting during which time we discussed and reviewed with all staff our THW resource binder for local support services including but not limited to AA meetings, NA meetings, access to peer specialists, access to case management, local AL-ANON meetings, vocational and education resources, housing resources, etc.
All clinical staff was instructed as of 1/2/2024 to include support services on the treatment plan as appropriate per client.
Clinical Supervisor will review randomized patient charts on a quarterly basis for compliance and quality assurance, first quarter to be reviewed 4/1/2024. |
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.
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Observations
Based on a review of client records, the facility failed to ensure that treatment and rehabilitation plans were reviewed and updated at least every 60 days in four of seven applicable records reviewed.
Client # 1 was admitted on September 28, 2017 and was discharged on August 9, 2023. A treatment plan update was completed on April 14, 2023, and the next treatment plan update was due to be completed by June 14, 2023; however, the next treatment plan update was not completed until June 21, 2023.
Client # 3 was admitted on July 12, 2018 and was discharged on October 18, 2023. A treatment plan update was completed on June 5, 2023, and the next treatment plan update was due to be completed by August 5, 2023; however, the next treatment plan update was not completed until September 28, 2023.
Client # 6 was admitted on October 6, 2016 and was active at the time of the inspection. A treatment plan update was completed on March 29, 2023, and the next treatment plan update was due to be completed by May 29, 2023, however, the next treatment plan update was not completed until July 31, 2023.
Client # 7 was admitted on July 22, 2019 and was active at the time of the inspection. A treatment plan update was completed on January 17, 2023, and the next treatment plan update was due to be completed by March 17, 2023, however, the next treatment plan update was not completed until March 27, 2023. A subsequent treatment plan update was completed on July 21, 2023, and the next treatment plan update was due to be completed by September 21, 2023, however it was not completed until October 11, 2023.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
In our new EHR system, a tracker was added that displays the clients counseling and documentation compliance for the month. This tracker is displayed at check-in, during all appointments, and every time a patients chart is accessed, to ensure that each patient receives the services needed.
On 1/2/2024, CEO and COO held a staff meeting to review policies and procedures including acceptable timelines for completion signature on documentation. Job descriptions were updated to include the timeframes for THW documentation including treatment plan due dates, and new staff will review the time frames on their job description with their direct supervisor during onboarding.
The clinician responsible for all the records in question was fired from THW on 12/15/2023, after three signed warnings in her personnel fire for late documentation.
Clinical Supervisor will review all randomized patient charts on a quarterly basis to ensure time frame compliance, first quarter to be reviewed 4/1/2024.
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709.93(a)(5) LICENSURE Client records
709.93. Client records.
(a) There shall be a complete client record on an individual which includes information relative to the client's involvement with the project. This shall include, but not be limited to, the following:
(5) Progress notes.
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Observations
Based on a review of client records and the facility's policy and procedure manual, the facility failed to ensure a complete client record included information relative to the client's involvement with the project to include progress notes entered within 48 hours of the date of service, per the facility's policy, in four of nine applicable records reviewed.
Client # 6 was admitted on October 6, 2016 and was active at the time of the inspection. The record contained a progress note for a group session occurring on September 29, 2023, that was not completed until November 17, 2023.
Client # 7 was admitted on July 22, 2019 and was active at the time of the inspection. The record contained a progress note for an individual session occurring on October 16, 2023, that was not completed until November 7, 2023.
Client # 8 was admitted on April 4, 2023 and was active at the time of the inspection. The record contained a progress note for an individual session occurring on June 16, 2023 and a group note occurring on September 29, 2023, that were not completed until November 21, 2023 and November 17, 2023, respectively.
Client # 9 was admitted on May 10, 2023 and was active at the time of the inspection. The record contained a progress note for a group session occurring on September 29, 2023, that was not completed until November 17, 2023.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
In our new EHR system, a tracker was added that displays the clients counseling compliance for the month. This tracker is displayed at check-in, during all appointments, and every time a patients chart is accessed, to ensure that each patient receives the services needed.
On 1/2/2024, CEO and COO held a staff meeting to review policies and procedures including acceptable timelines for completion signature on documentation. Job descriptions were updated to include the timeframes for THW documentation, and new staff will review the time frames on their job description with their direct supervisor during onboarding.
Clinical Supervisor will review randomized patient charts on a quarterly basis to ensure compliance, first quarter to be reviewed 4/1/2024.
The clinician responsible for the records in question was fired from THW on 12/15/2023, after three signed warnings in her personnel fire for late documentation.
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709.17(a)(3) LICENSURE Subchapter B.Licensing Procedures.Refusal/rev
709.17. Refusal or revocation of license.
(a) The Department may revoke or refuse to issue a license for any of the following reasons:
(3) Failure to comply with a plan of correction approved by the Department, unless the Department approves an extension or modification of the plan of correction.
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Observations
Based on a review of patient records, the facility failed to comply with plans of correction that were approved by the Department.
A plan of correction to ensure that counselors completed an annual evaluation that was signed by the medical director was submitted and approved by the Department for the January 18, 2022, July 6, 2022, and December 16, 2022 licensing inspections. Annual evaluations were again found to be a deficiency in the November 30, 2023 through December 1, 2023 annual licensing inspection.
A plan of correction to ensure that patients provided written informed consent prior to the administration of an agent was submitted and approved by the Department for the December 16, 2022 licensing inspection. Patient informed consent was again found to be a deficiency in the November 30, 2023 through December 1, 2023 annual licensing inspection.
A plan of correction for ensuring that required clients received 2.5 hours of psychotherapy per month was submitted and approved by the Department for the December 16, 2022 annual licensing inspection. Psychotherapy hours were again found to be a deficiency in the November 30, 2023 through December 1, 2023 annual licensing inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
On 12/1/2023 a new staff member was hired in order to restructure and support Quality Assurance measures of THW. This role will exclusively ensure that all POCs are followed. Said staff member spent 30 days onboarding THW policies and procedures. The staff member was active in our staff meeting of 1/2/2024 to ensure that all measures are followed through as planned. |