INITIAL COMMENTS
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This report is a result of an on-site licensure renewal and methadone monitoring inspection conducted on December 15, 2022 through December 16, 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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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 personnel records, the facility failed to maintain documentation that counselor assistants receive direct observation of the provision of counseling services as part of their supervision, in one of one applicable record reviewed.
Employee # 6 was hired as a high school level counselor assistant by the facility on July 26, 2022. 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 weekly supervision.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
On 12/29/2022 THW Project Director worked with Director of Quality Assurance to update the form used for counselor supervision. THe form now includes a box to be selected for each time direct observation is performed.
A staff meeting was held on 12/29/22 where DQA introduced and trained supervisors to the new form. DQA will review all supervision documentation to ensure that appropriate dpcuemtnation is taking place. DQA will schedule direct observation of counseling assistants on a weekly basis, every Friday. |
704.12(a)(6) LICENSURE OutPatient Caseload
704.12. Full-time equivalent (FTE) maximum client/staff and client/counselor ratios.
(a) General requirements. Projects shall be required to comply with the client/staff and client/counselor ratios in paragraphs (1)-(6) during primary care hours. These ratios refer to the total number of clients being treated including clients with diagnoses other than drug and alcohol addiction served in other facets of the project. Family units may be counted as one client.
(6) Outpatients. FTE counselor caseload for counseling in outpatient programs may not exceed 35 active clients.
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Observations
Based on the review of the Staffing Requirements Facility Summary Report, the facility failed to keep client/staff ratios at or below the regulation limit of 35/1 for five of eleven applicable staff members.
The counselor Full Time Equivalent (FTE) is determined by dividing the total number of hours the counselor devotes to their clients by facility ' s work week. Then, in order to obtain the counselor's ratio, the total number of clients on the counselor's caseload is divided by the FTE.
Employee #5 was hired as a counselor assistant on December 21, 2022 and was current in that position at the time of the inspection. Employee #5 was reported to have 22 hours per week devoted to their 22 clients on their caseload.
The FTE counselor's caseload calculation is as follows: 22/40 = 0.55(FTE); 22/0.55 = 40, which equals to a client/counselor ratio of 40:1.
Employee #7 has been employed as a counselor since May 4, 2021 and was current in that position at the time of the inspection. Employee #7 was reported to have 22 hours per week devoted to their 22 clients on their caseload.
The FTE counselor's caseload calculation is as follows: 22/40 = 0.55(FTE); 22/0.55 = 40, which equals to a client/counselor ratio of 40:1.
Employee #8 has been employed as a counselor assistant since January 2022 and was current in that position at the time of the inspection. Employee #8 was reported to have 5 hours per week devoted to their 5 clients on their caseload.
The FTE counselor's caseload calculation is as follows: 5/40 = 0.12(FTE); 5/0.12 = 42, which equals to a client/counselor ratio of 42:1.
Employee #10 has been employed as a counselor since May 2, 2022 and was current in that position at the time of the inspection. Employee #10 was reported to have 24 hours per week devoted to their 24 clients on their caseload.
The FTE counselor's caseload calculation is as follows: 24/40 = 0.6(FTE); 24/0.6 = 40, which equals to a client/counselor ratio of 40:1.
Employee #11 has been employed as a counselor since December 14, 2020 and was current in that position at the time of the inspection. Employee #11 was reported to have 10 hours per week devoted to their 10 clients on their caseload.
The FTE counselor's caseload calculation is as follows: 10/40 = 0.25(FTE); 10/0.25 = 40, which equals to a client/counselor ratio of 40:1.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
On 12/29/2022 the board of directors reviewed the formula provided by DDAP for caseload equivalents and THW Project Director will now utilize the formula going forward to appropriately calculate the ratios and mark accordingly. Staff ratios were correct, the form was filled out wrong, which caused the ratios to come out dis-balanced. |
705.28 (d) (4) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(4) Maintain a written fire drill record including the date, time, the amount of time it took for evacuation, the exit route used, the number of persons in the facility at the time of the drill, problems encountered and whether the fire alarm or smoke detector was operative.
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Observations
Based on a review of fire drill logs from January 2022 through October 2022, the facility failed to ensure that each fire drill log contained the exit route used, whether the smoke detector or fire alarm was operative, the number of persons in the facility at the time of the drill, and problems encountered in any of the drills.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
On 12/29/2022 The Project DIrector and DIrector of Quality Assurance updated our fire drill log form so that it will include the exit route used, whether the smoke detector or fire alarm was operative, the number of persons in the facility at the time of the drill, and problems encountered in any of the drills. The updated form will be utilized by the President of THW or the supervisor she designates if she is unable to to complete the fire drill (which would be the Director of Quality Assurance of Behavioral Heal Supervisor). DUring quarterly board of director meetings the fire drills of that quarter will be reivewed to ensure everything has been accurately documented. |
709.25 LICENSURE Fiscal Management
§ 709.25. Fiscal management.
The project shall obtain the services of an independent certified public accountant for an annual financial audit of activities associated with the project ' s drug/alcohol abuse services, in accordance with generally accepted accounting principles which include reference to the drug and alcohol treatment activities.
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Observations
Based on a review of facility tax returns submitted as a requirement of the exception to this regulation, the project failed to demonstrate that their revenue associated with the project's drug/alcohol abuse services did not exceed the amount specified in their exception request approval letter. Therefore, the facility failed to obtain the services of an independent certified public accountant for an annual financial audit of activities associated with the project's drug/alcohol abuse services, in accordance with generally accepted accounting principles which include reference to the drug and alcohol treatment activities.
These findings were reviewed with the project staff during the licensing process.
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Plan of Correction
On 12/29/2022 The Board of Directors met and decided that going forward THW Vice President will request that THW accountant differentiate the drug and alcohol revenue from the revenue of their other programs and activities in order to differentiate and clarify the drug and alcohol revenue amount.THW Vice President will hire an independent certified account by 3/1/23 to conduct an audit for THWs previous 2021 record. Going forward THW Vice President will utilize the accountant for a yearly independent audit unless the previous year shows under 500,00 revenue for D&A programs, in which case THW Vice President will apply for excpetion. |
709.28 (c) (6) 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:
(6) Date, event or condition upon which the consent will expire.
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Observations
Based on a review of eight client records, the facility failed to ensure that consent to release information forms included the date, event, or condition upon which the consent will expire in one record reviewed.
Client #5 was admitted on May 19, 2022 and was discharged on August 4, 2022. The record contained a consent to release information form to a treatment provider signed by the client on July 26, 2022, that was missing the date, event, or condition upon which the consent will expire.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
On 2/27/22 THW will begin utilizing a new software, consent forms will be electronic and will not be allow saving until all the selected boxes are appropriately checked. This will minimize such clerical errors and ensure our documentation is consistent and appropriate.
On 12/29/22 THW held a staff meeting to ensure that prior to the new software initation, counselors will review all consent forms for accuracy after they have been completed by patient. Prior to scanning forms into our current software, the administrative assistant will double check that all forms are filled out efficiently. |
709.28 (d) LICENSURE Confidentiality
§ 709.28. Confidentiality.
(d) A copy of a client consent shall be offered to the client and a copy maintained in the client record.
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Observations
Based on a review of client records, the facility failed to assure that a copy of a client consent was offered to the client and a copy maintained in the client record in one of eight client records reviewed.
Client #5 was admitted on May 19, 2022 and was discharged on August 4, 2022. The record contained a consent to release information form to a treatment provider signed by the client on July 26, 2022, that did not indicate a copy was offered to the client.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
On 2/27/22 THW will begin utilizing a new software, consent forms will be electronic and will not be allow saving until all the selected boxes are appropriately checked. This will minimize such clerical errors and ensure our documentation is consistent and appropriate.
On 12/29/22 THW held a staff meeting to ensure that prior to the new software initation, counselors will review all consent forms for accuracy after they have been completed by patient. Prior to scanning forms into our current software, the administrative assistant will double check that all forms are filled out efficiently. |
715.9(a)(4) LICENSURE Intake
(a) Prior to administration of an agent, a narcotic treatment program shall screen each individual to determine eligibility for admission. The narcotic treatment program shall:
(4) Have a narcotic treatment physician make a face-to-face determination of whether an individual is currently physiologically dependent upon a narcotic drug and has been physiologically dependent for at least 1 year prior to admission for maintenance treatment. The narcotic treatment physician shall document in the patient 's record the basis for the determination of current dependency and evidence of a 1 year history of addiction.
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Observations
Based on a review of eight patient records, the facility failed to have a narcotic treatment physician make a face-to-face determination of whether an individual is currently physiologically dependent upon a narcotic drug and has been for at least one year in one record reviewed.
Patient #1 was admitted on July 18, 2022 and was active at the time of the inspection. There was no documentation of determination of physiological dependency made by a physician during the intake process.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
An individual seeking admission to the program will have a face to face intake appointment with the narcotic treatment physician. During this appointment, the physician will make a determination of whether the individual is currently physiologically dependent upon a narcotic drug and has been for at least one year. The physician will document accorindingly in the patient chart. THW Project Director will develop a policy that defines the discharge types in order to ensure that the admission process is efficient for individuals seeking re-admission.
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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 eight patient records, the facility failed to obtain an informed, voluntary, written consent before an agent was administered in one record reviewed.
Patient #1 was admitted on July 18, 2022 and was active at the time of the inspection. The patient was initially administered an agent on July 18, 2022; however, the informed, voluntary, written consent was not signed in the patient record.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
An individual seeking admission to the program will have an intake appointment with the counselor. During this appointment, the individual will sign an informed consent form with the counselor as witness prior to seeing the narcotic treatment physician for their medical evalution. THW Project Director will develop a policy that defines the discharge types in order to ensure that the admission process is efficient for individuals seeking re-admission, and that the informed consent form is signed and effective for re-admitted patients. |
715.15(a) LICENSURE Medication Dosage
(a) The narcotic treatment physician shall review the dosage levels at least twice a year, with each review occurring at least 2 months apart, to determine a patient 's therapeutic dosage.
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Observations
Based on a review of eight patient records, the facility failed to ensure that the narcotic treatment physician reviewed the dosage levels at least twice a year in one patient record.
Patient #6 was admitted on October 7, 2019 and was active at the time of the inspection. The patient record contained documentation of a dose review on August 29, 2022, with the previous one being completed on August 21, 2021.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
On 12/29/22 THW held a staff meeting discussing appointments. Upon intake, patient will be scheduled for a semi annual dose review follow up review appointment by our administrative assistant. At the semi-annual follow up appointment they will be scheduled by administrative assistant for their annual physical. At the annual; physical they will be scheduled for their next semi annual in 6 months.
Our new EHR system, which will be effective 2/27/22 will send automative reminders to patients for their medical appointments, which will help ensure they keep the appointments in a timely fashion.
Until the new software is implemented the Clinical Supervisor will ensure that all clients are scheduled for semi annual dose review by reviewing facility caseload vs. scheduled appointments on the first Monday of every month. If a client mistakenly does not have an appt, this will allow ample time for them to be scheduled and reviewed with the doctor in a time efficient manner. |
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 with the required number of individual and group psychotherapy hours in two records reviewed.
Patient #4 was admitted on September 13, 2021 and was discharged on October 24, 2022. The patient was required to have at least two and a half hours of individual and group psychotherapy per month. During the 2022 month of July, the patient received no documented psychotherapy hours. For the 2022 month of September, the patient only received one hour of individual psychotherapy and no documented group therapy.
Patient #7 was admitted on September 15, 2022 and was active at the time of the inspection. The patient was required to have at least two and a half hours of psychotherapy per month. During the 2022 months of October and November, the patient only received 2.25 hours of therapy per month.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
On 2/27/2022 THW will implement our new software which will automatically alert our counselors if their clients are falling short on counseling units 7 days prior to the month ending.
Appointment types will also be pre-established based on their duration so that clerical errors such as 2.25 will be avoided.
During staff meeting on 12/29/2022, THW Project Director and Director of Quality Assurance discussed the importance of no-show notes to document when a client misses their session or their scheduled group. If a client misses their scheduled counseling, the counselor will hace 48 hours to contact the client to reschedule their session in order to ensure that all efforts are made for our clients to recieve their therapeutic support. |
715.20(1) LICENSURE Patient transfers
A narcotic treatment program shall develop written transfer policies and procedures which shall require that the narcotic treatment program transfer a patient to another narcotic treatment program for continued maintenance, detoxification or another treatment activity within 7 days of the request of the patient.
(1) The transferring narcotic treatment program shall transfer patient files which include admission date, medical and psychosocial summaries, dosage level, urinalysis reports or summary, exception requests, and current status of the patient, and shall contain the written consent of the patient.
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Observations
Based on a review of patient records, the facility failed to ensure that urinalysis reports or summary were included in the transfer paperwork to another treatment program in one record reviewed.
Patient #2 was admitted on June 16, 2022 and was transferred on September 20, 2022. The record contained no documentation that urinalysis reports or summaries were sent with the transfer paperwork.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
On 12/29/22 THW held a staff meeting discussing the transfer process. Going forward Clinical supervisor wil be responsible for any and all client;s transfer paperwork, and will use a newly created cover sheet to identify and ensure that each piece of requested information is included in the transfer packet, including urine analysis reports. |
715.20(4) LICENSURE Patient transfers
A narcotic treatment program shall develop written transfer policies and procedures which shall require that the narcotic treatment program transfer a patient to another narcotic treatment program for continued maintenance, detoxification or another treatment activity within 7 days of the request of the patient.
(4) The receiving narcotic treatment program shall document in writing that it notified the transferring narcotic treatment program of the admission of the patient and the date of the initial dose given to the patient by the receiving narcotic treatment program.
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Observations
Based on a review of patient records, the facility failed ensure that the transferring narcotic treatment program was notified of the admission of the transferring patient and the date of the initial dose in one record reviewed.
Patient #7 was admitted on September 15, 2022 and was active at the time of the inspection. The record contained no documentation that the transferring treatment program was notified of the initial dose.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
On 12/29/2022 THW held a staff meeting to discuss the transer process. Clinical Supervisor will be responsible for all transfer paperwork, both in and out. Clinical SUpervisor will ensure that when a client is succesfully transferred to THW, the referring clinic will be sent via fax a services rendered report for the client, the day that their dosing begins. The report will be signed by the clinical supervisor, and the confirmation fax print out will be scanned, together with the cover sheet and services rendered report, directly into the patients file, by the clinical supervisor once the fax is completed. |
715.23(b)(4) LICENSURE Patient records
(b) Each patient file shall include the following information:
(4) The results of an initial intake physical examination.
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Observations
Based on a review of patient records, the facility failed to ensure each patient file included the results of an initial intake physical examination in one of three applicable records reviewed.
Patient #1 was admitted on July 18, 2022 and was active at the time of the inspection. The record did not contain documentation of an initial physical examination.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
An individual seeking admission to the program will have a face to face appointment with the narcotic treatment physician. During this appointment, the physician will complete a physical evluation of the patient. The physician will document accorindingly in the patient chart. THW Project Director will develop a policy that defines the discharge types in order to ensure that the admission process is efficient for individuals seeking re-admission. |
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 ensure an annual physical reevaluation was documented in one of three applicable records reviewed.
Patient #4 was admitted on September 13, 2021 and discharged on October 24, 2022. The initial physical examination was completed on September 13, 2021, and the annual physical evaluation was due no later than September 13, 2022; however, there was no documentation of an annual physical examination at the time of the inspection.
This is a repeat citation from the January 17-18, 2022 annual licensing inspection.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
On 2/27/22 THW will implement a new software which will automatically alert the treating phyisician as well as the counselor to any clients that over due for any appointments.
On 12/29/22 THW held a staff meeting to discuss ensuring everyone recieves their physical on time, even if they are set for treatment completion shortly after their annual due date. During intake all clients will be scheduled for semi annual dose review and at the dose review all clients will be scheduled for annual physical. Administrative assistant will do all the scheduling, and will schedule each client 2-3 weeks prior to their due date to allow the occurance of rescheduling if necessary while ensuring everything is still completed on time. |
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 an annual evaluation by the counselor signed by the medical director in two of two applicable records.
Patient #4 was admitted on September 13, 2021 and was discharged on October 24, 2022.
Patient #6 was admitted on October 7, 2019 and was active at the time of the inspection.
This is a repeat citation from the January 17-18, 2022 and July 6, 2022 licensing inspections.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
On 2/27/22 THW will implement a new software that will require the signature of the medical director on the counselors annual justifications. Our current software has a backlog of 6 months for requested work and will not be able to make amendments in time.
On 12/29/22 THW held a staff meeting to discuss an interim solution. Until our new software is active, the medical director will document on her annual justification form that she reviewed the counselors annual justification form. |