INITIAL COMMENTS
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This report is a result of an on-site provisional license follow-up inspection conducted on July 6, 2022, 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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709.28 (c) (4) 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:
(4) Dated signature of client or guardian as provided for under 42 CFR 2.14(a) and (b) and 2.15 (relating to minor patients; and incompetent and deceased patients).
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Observations
Based on a review of eight patient records, the facility failed to obtain the dated signature of the patient on an informed and voluntary consent information form for the disclosure of information in one record reviewed.
Patient #2 was admitted on April 15, 2021 and was active at the time of the inspection. A consent to release information form to a physician signed by a witness on February 7, 2022, did not contain the patient ' s signature or date.
These findings were discussed with facility staff during the inspection process.
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Plan of Correction
On 8/1/2022 THW supervisory staff held a meeting with all employees at which time they reviewed the signatory process for paperwork. Clinicians/Witnesses must sign paperwork with the client present to ensure that both client and witness sign on each appropriate line. Prior to scanning documentation into our EMR system, the front desk coordinator will review each document for accuracy and efficiency. |
709.32 (c) (3) (i) - (v) LICENSURE Medication control
§ 709.32. Medication control.
(3) Inspection of storage areas that ensures compliance with State and Federal laws and program policy. The policy must include, but not be limited to:
(i) What is to be verified through the inspection, who inspects, how often, but not less than quarterly, and in what manner it is to be recorded.
(ii) Disinfectants and drugs for external use are stored separately from oral and injectable drugs.
(iii) Drugs requiring special conditions for storage to insure stability are properly stored.
(iv) Outdated drugs are removed.
(v) Copies of drug-related regulations are available in appropriate areas.
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Observations
Based on an inspection of medication storage areas on July 6, 2022, the facility was found to not be in compliance with their policy and procedures to only store, dispense, and dispose of Methadone, as a patient ' s expired personal medications were found in the medication storage area.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
On 8/9/2022 THW Board Members held a staff meeting at which time they designated the Medical Director responsible for overseeing the medication storage area inventory. As of 8/9/2022, the head nurse will conduct her inventory inspections with the Medical Director present so that there are two sets of eyes to ensure all policies are being met.
During monthly staff meetings, supervisors will reinforce to all staff that they are not to accept clients medications for disposal, and direct them to proper disposal resources. |
715.16(a)(3) LICENSURE Take-home privileges
(a) A narcotic treatment program shall determine whether a patient may be provided take-home medications.
(3) The narcotic treatment physician shall document in the patient record the rationale for permitting take-home medication.
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Observations
Based on a review of eight patient records, the facility failed to ensure that the narcotic treatment physician document in the patient record the rationale for permitting take-home medication in one patient record reviewed.
Patient #2 was admitted on April 15, 2021 and was active at the time of inspection. There was no documentation in the record from the narcotic treatment physician providing the rationale for permitting take-home medication on July 2, 2022.
The findings were reviewed with facility staff during the licensing process.
This is a repeat citation from the inspection conducted on January 18, 2022.
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Plan of Correction
As of 8/10/2022 THW Medical Director will ensure that take home rationale is expanded in the chart documentation. Take home rationale will include notating patients adherence in handling narcotic drugs, demonstrating satisfactory adherence to THW program rules as well as demonstrating substantial progress in rehabilitation.
Clinical supervisor will use monthly documentation reviews to ensure that documentation for take homes is current and sufficient. |
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 eight records, the facility failed to ensure an annual physical reevaluation was given by the narcotic treatment physician in one of four applicable records reviewed.
Patient # 8 was admitted on March 1, 2021 and was active at the time of the inspection. The most recent annual physical reevaluation was due no later than March 1, 2022; however, it was not documented in the patient record until March 31, 2022.
The findings were reviewed with facility staff during the licensing process.
This is a repeat citation from the inspection conducted on January 18, 2022.
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Plan of Correction
As of 8/10/2022, THW front desk coordinator will schedule clients three weeks prior to their one year mark to ensure compliance in keep their set annual review appointments. On the last Friday of every month, THW Medical Director will provide the front desk with a list of annuals due in two months to ensure everyone is scheduled promptly. THW Medical Director will complete annual physical by the annual due date, and will document reason and/or exception if the client is late for their physical.
Counselor will be responsible to re-affirm annual appointment with client, as they are due for their annual justification as well. Counselor will be responsible to ensure that client is aware of the importance of attending set appointment, and that appointment cannot be rescheduled. |
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 eight patient records, the facility failed to ensure that the patient's counselor completed an annual evaluation and included the areas of employment, legal standing, substance abuse, financial management abilities, physical and emotional health, fulfillment of treatment objectives, and family and community support in one of five records reviewed.
Patient # 8 was admitted on March 1, 2021 and was active at the time of the inspection. The annual evaluation was due no later than March 1, 2022; however, it was not documented in the patient record until March 14, 2022.
The findings were reviewed with facility staff during the licensing process.
This is a repeat citation from the inspection conducted on January 18, 2022.
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Plan of Correction
As of 8/10/2022, Clinical Supervisor instructed THW front desk coordinator to schedule clients three weeks prior to their one year mark to ensure compliance in keep their set annual review appointments. On the last Friday of every month, THW Medical Director will provide the front desk with a list of annuals due in two months to ensure everyone is scheduled promptly.
Counselor will be responsible to re-affirm annual appointment with client. Counselor will be responsible to ensure that client is aware of the importance of attending set appointment, and that appointment cannot be rescheduled. |
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 patient records, the facility failed to ensure that treatment and rehabilitation plans were reviewed and updated at least every 60 days in five of seven applicable records reviewed.
Patient #2 was admitted on April 15, 2021 and was active at the time of inspection. A treatment plan update was completed on March 11, 2022 and a treatment plan update was due by May 11, 2022; however, the next update was not completed until May 23, 2022.
Patient #3 was admitted on March 14, 2016 and was active at the time of inspection. A treatment plan update was completed on March 31, 2022 and a treatment plan update was due by May 31, 2022; however, the next update was not completed until June 19, 2022.
Patient #4 was admitted on May 29, 2018 and was active at the time of the inspection. A treatment plan update was completed on April 4, 2022 and a treatment plan update was due by June 4, 2022; however, no additional updates were completed prior to the date of the inspection.
Patient #7 was admitted on February 14, 2021 and was discharged on May 26, 2022. A treatment plan update was completed on February 14, 2022 and a treatment plan update was due by April 14, 2022; however, no additional updates were completed prior to the patient ' s discharge.
Patient #8 was admitted on March 1, 2021 and was active at the time of inspection. A treatment plan update was completed on March 11, 2022 and a treatment plan update was due by May 11, 2022; however, the next update was not completed until June 17, 2022.
The findings were reviewed with facility staff during the licensing process.
This is a repeat citation from inspections conducted on January 18, 2022, November 19, 2020, January 15, 2020, November 22,2019, and December 28, 2018.
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Plan of Correction
THW Supervisory staff will continue to hold monthly staff meetings, at which time supervisory staff will continuously enforce the importance of clinicians scheduling individual sessions with their clients ONE WEEK prior to treatment plan due date.This will ensure that if the client is unable to keep the session, it can be rescheduled and kept in time for the treatment plan to be updated on schedule. The monthly staff meeting will also be used to review treatment plan due dates for each counselor for the upcoming month.
During monthly documetnation review the clinical supervisor will review treatment plans to ensure that counselors are managing punctual submission.
THW supervisory staff will continue to hold yearly refresher training for staff which includes documentation specifications. |
709.93(a)(8) 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:
(8) Case consultation notes.
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Observations
Based on a review of patient records, the facility failed to follow their procedures for case consultation notes in that the procedure states "patients should receive a case consultation quarterly within the first year and yearly after that." In three of six applicable records reviewed there were no case consultation notes documented per policy and procedure.
Patient #5 was admitted on November 15, 2021 and was discharged on February 25, 2022. The patient record did not contain documentation of case consultation notes.
Patient #7 was admitted on February 14, 2021 and was discharged on May 26, 2022. The patient record did not contain documentation of case consultation notes.
Patient #8 was admitted on March 1, 2021 and was active at the time of inspection. The patient record did not contain documentation of any case consultation notes since 12/22/21.
These findings were reviewed with facility staff during the licensing process.
This is a repeat citation from the inspection conducted on January 18, 2022.
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Plan of Correction
THW Supervisory staff will use monthly staff meetings to complete and review the upcoming months due dates for case consultations with counselors. During the meeting counselors will schedule their case consultations with one another and/or their supervisor. Clinical supervisor will use supervision sessions with counselors to ensure that case consults are being completed in a punctual manner. |
709.93(a)(11) 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:
(11) Follow-up information.
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Observations
Based on a review of client records, the facility failed to ensure a complete client record included information relative to the client's involvement with the project to include follow-up information in two of three applicable records reviewed.
Client #6 was admitted on March 3, 2022 and discharged on April 11, 2022. The client record did not contain documentation of follow-up information.
Client #7 was admitted on February 14, 2021 and was discharged on May 26, 2022. The client record did not contain documentation of follow-up information.
These findings were reviewed with facility staff during the licensing process.
This is a repeat citation from the inspection conducted on January 18, 2022.
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Plan of Correction
As of 8/10/2022, THW clinicians will use their microsoft outlook calendar to monitor discharges and follow ups. When a client is discharged, the clinician will schedule in outlook for 30 days later to contact the discharged client for follow up.
THW Clinicial Supervisor will use monthly staff meetings to remind clinicians to schedule and complete their follow ups. On a quarterly basis, Clinical Supervisor will review the quarter's discharge to ensure follow ups were completed. |
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 eight patient records, the facility failed to comply with plans of correction that were approved by the Department.
A plan of correction to ensure treatment and rehabilitation plans were updated at least every 60 days was submitted and approved by the Department for the January 18, 2022, November 19, 2020, January 15, 2020, November 22, 2019, and December 28, 2018 annual licensing inspections. Treatment plan updates completed every 60 days was again found to be a deficiency in the July 6, 2022 licensing inspection.
A plan of correction to ensure that the narcotic treatment physician documented in the patient record the rationale for permitting take-home medication privileges was submitted and approved by the Department for the January 18, 2022 annual licensing inspection. Documentation of the rationale for permitting take-home privileges was again found to be a deficiency in the July 6, 2022 licensing inspection.
A plan of correction to ensure that physical exams were completed annually was submitted and approved by the Department for the January 18, 2022 annual licensing inspection. Annual physical evaluations completed within the regulatory timeframe was again found to be a deficiency in the July 6, 2022 licensing inspection.
A plan of correction to ensure that patient counselors completed an annual evaluation was submitted and approved by the Department for the January 18, 2022 annual licensing inspection. Annual evaluations by counselors within the regulatory timeframe was again found to be a deficiency in the July 6, 2022 licensing inspection.
A plan of correction to ensure that case consultations were completed according to the facility policy and procedures was submitted and approved by the Department for the January 18, 2022 annual licensing inspection. Case consultations documented according to policy and procedure was again found to be a deficiency in the July 6, 2022 licensing inspection.
A plan of correction to ensure that documentation of follow-up information was completed according to the facility policy and procedures was submitted and approved by the Department for the January 18, 2022 annual licensing inspection. Documentation of follow-up information was again found to be a deficiency in the July 6, 2022 licensing inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
THW Board of DIrectors will use quarterly Board Meetings to monitor progress and adherence to plan of corrections. Supervisory staff will attend board meetings prepared with updates and reports to present to the Board to ensure that proper protocols are being followed. Supervisory staff will present changes during their monthly staff meeting, and will use the monthly staff meeting to review upcoming due dates of annual physicals and justifications, case consultations, treatment plans, discharges, and follow ups. THW will hold bi-annual refresher training on documentation standards and THW policies, rather than annually. The next board meeting will be 9/6/2022. |