INITIAL COMMENTS
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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 16-17, 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, Mazzitti and Sullivan Counseling Services, 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:
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Plan of Correction
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709.82(b) LICENSURE Treatment and rehabilitation services
709.82. Treatment and rehabilitation services.
(b) Treatment and rehabilitation plans shall be reviewed and updated at least every 30 days.
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Observations
Based on a review of partial hospitalization clients records, the faciltiy failed to review and update treatment and rehabilitation plans at least every 30 days in one out of two client records.
Client #1 was admitted on October 12, 2020 and was discharged on December 23, 2020. Client #1 had a preliminary treatment plan dated October 14, 2020 and a comprehensive treatment plan dated October 14, 2020. Client #1 had no further treatment plans documented in the record.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Facility director will develop and introduce training on 3/16/21 outlining established documentation guidelines, specifically those related to treatment plan updates at the PHP level of care. Training will be completed by clinical supervisor with all staff on 3/23/21 and documented in supervision notes. Clinical supervisor will continue to complete their monthly chart audits paying special attention to established timelines regarding treatment planning and offer support and accountability to counselors as needed. |
709.82(d)(1) LICENSURE Treatment and rehabilitation services
709.82. Treatment and rehabilitation services.
(d) Counseling shall be provided to a client on a regular and scheduled basis. The following services shall be included and documented:
(1) Individual counseling, at least twice weekly.
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Observations
Based on a review of partial hospitalization clients, the facility failed to ensure that two out of two clients received individual counseling at least twice a week.
Client # 1 was admitted on October 12, 2020 and was discharged on December 23, 2020. Client #1 did not receive individual counseling twice a week for the following weeks: October 12, 2020, October 19, 2020, October 26, 2020, November 2, 2020, November 9, 2020, November 16, 2020, November 23, 2020, November 30, 2020, December 7, 2020, December 14, 2020 and December 21, 2020.
Client # 2 was admitted on December 28, 2020 and was discharged on January 29, 2021. Client #2 did not receive individual counseling twice a week for the following weeks: December 28, 2020, January 4, 2021, January 11, 2021, January 18, 2021 and January 25, 2021.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Facility director will develop and introduce training on 3/16/21 outlining established guidelines pertaining to frequency of individual sessions at the PHP level of care. Clinical supervisor will conduct a training with all staff on 3/25/21 regarding the frequency of individual sessions at the PHP level of care and record in supervision notes. The program was previously aware of this deficiency and has since replaced the clinician that was responsible for these specific citations. Clinical supervisor will continue to complete monthly chart audits to provide support and accountability to the program clinicians and quickly identify and correct any deviations from established guidelines. |
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 three client records on February 16, 2021, the narcotic treatment 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.
Patient #3 was admitted on August 3, 2020 and was current at the time of the inspection. Patient #3 did not have any individual psychotherapy for the months of: December 2020, January 2021 and February 2021.
Patient #4 was admitted on November 4, 2020 and was discharged on December 22. 2020. Patient #4 did not have any individual psychotherapy for the months of November 2020 and December 2020.
Patient #5 was admitted on November 30, 2020 and was current at the time of the inspection. Patient # 5 did not have any individual psychotherapy for the months of:
December 2020, January 2021 and February 2021.
These findings were reviewed with program staff during the licensing process.
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Plan of Correction
Facility director will develop and introduce training on 3/16/21 outlining established guidelines pertaining to the frequency of counseling sessions including the minimal requirements for individual psychotherapy hours with an emphasis on client participating in MAT. Clinical supervisor will conduct a training with all staff on 3/25/21 reviewing the established guidelines of minimal requirements related to frequency of visits including individual psychotherapy and document in supervision notes. Clinical supervisor will continue to complete monthly chart audit to provide support and accountability to program clinicians and identify any deviation from the established guidelines that clients should have no less than 2.5 hours of psychotherapy per month, 1 hour of which shall be individual psychotherapy. |