INITIAL COMMENTS
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Based on the concerns arising from COVID-19, The Department of Drug and Alcohol Programs, Bureau of Quality Assurance for Prevention and Treatment, 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 October 15, 2020 by staff from the Department of Drug and Alcohol Programs, Bureau of Quality Assurance for Prevention and Treatment. 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, Polaris Renewal Services 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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709.24 (a) (3) LICENSURE Treatment/rehabilitation management.
§ 709.24. Treatment/rehabilitation management.
(a) The governing body shall adopt a written plan for the coordination of client treatment and rehabilitation services which includes, but is not limited to:
(3) Written procedures for the management of treatment/rehabilitation services for clients.
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Observations
Based on the review of the facility policy and procedure manual and review of client records, the facility failed to follow the policy and procedures for the development of the comprehensive treatment plan and case consultations.
The policy and procedure manual indicate comprehensive treatment plans to be developed with the client within thirty days of admission. Comprehensive treatment plans were not developed with the client within thirty days in client records # 1, 2, 3, 4, 5, 6 and 7.
The policy and procedure manual indicate case consultations are to be collaborative with the clinical supervisor and physician. Case consultations were not collaborative within client records # 1, 2, 4, 5, and 7.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Director changed the policies and procedures manual to reflect the treatment plan practice. The initial treatment plan will be developed with the patient at inttake/admission. The comprehensive treatment plan wil be developed with the patient within 60 days of admission.
Case consultations will indicate the staff members involved in the case consultation process. Staff have been instructed by the Director and supervisor to include stff names in the case consultation record. The clinical supervisor, during routine chart reviews, will check each consult to ensure that the staff participating in the consult are listed. |
709.28 (c) (2) 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:
(2) Specific information disclosed.
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Observations
Based on one of eight client records reviewed, the facility failed to keep disclosures of client identifying information within the limits established by 4 Pa. Code 255.5 (b) for releases of information in client record # 5.
Client # 5 was admitted on May 27, 2020 and was still active at the time of the inspection. A
consent form to a probation officer dated July 17, 2020 allowed for the release of "admission summary, treatment plans, drug and alcohol assessments, drug and alcohol treatment notes, dose history/current dose, and discharge summary".
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Director will provide training/retraining to all staff on completing releases of information and what information can be submitted, and to whom, according to 4 Pa. Code 255.5. Staff will also attend confidentiality trainings as available throug DDAP or other sources.
The counselor who inccorrectly completed that release for patient #5 was given individualized training/supervision about proper completion of consents to release information to comply with 4 Pa code 255.5 and what can and cannot be released.
The clinical supervisor as part of her regular chart review, will check all releases to ensure that they are completed according to 255.5 and that all disclosures are within the limits establisted by 5 Pa. Code 255.5.
As part of the peer review process, all consents to release information will be checked to make sure that they are completed in accordance with 255.5. Staff will be instructed to review disclosures with clinical supervisor or director prior to the release of any informatio. |
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 one of eight patient records reviewed, the facility failed to provide documentation of the physician making 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.
Patient # 1 was admitted on February 21, 2020 and was still active at the time of the inspection. The failed to provide documentation of the physician making a face to face determination of whether the patient is currently physiologically dependent upon a narcotic drug and has been physiologically dependent for at least 1 year prior to admission for maintenance treatment.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The digital signature for the doctor was listed as an invalid digital signature which was a glitch in the SMART management EMR system. As a plan of correction, the supervisor, during routine chart reviews, will ensure that all digital signatures in the EMR are viewable and valid. The Director will instruct all staff to confirm that their digital signatures are valid and viewable on all signed documents. If a digital signature is found to be invalid, the Polaris supervisor will contact SMART IT support to determine the cause of the problem. The document with the invalid signature will be printed and manually signed by the staff person delivering that service. The manually signed document will be uploaded in the stored images section of the patient record and a brief note will be placed in the case summary of the pt chart, explaining that the digital signature did not work and the document is manually signed and dated and located in stored images. |
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 two of eight patient records reviewed, the facility failed to provide the required 2.5 psychotherapy hours on patient records # 2 and # 5.
Patient # 2 was admitted on October 16, 2019 and was still active at the time of the inspection.
In June 2020 the patient had .5 hours of individual sessions and no groups.
In July 2020 the patient had 1 hour of individual sessions and no groups.
In August 2020 the patient had 2 hours of individual sessions and no groups.
In September 2020 the patient had 0 hours of individual sessions and no groups.
Patient # 5 was admitted on May 27, 2020 and was still active at the time of the inspection.
In June 2020 the patient had 2 hours of individual sessions and no groups.
In August 2020 the patient had 2 hours of individual sessions and no groups.
In September 2020 the patient had 1 hour of individual sessions and no groups.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
All patients will receive their required 2.5 hours per month of psychotherapy during their first two years of treatment. This will be documented in the patient record and reviewed by the clinical supervisor using chart reviews and administrative services reports. Any patient who does not complete their required monthly therapy hours will be placed on a corrective action plan.
Patient #2 was discharged and admitted on the same day, October 16, 2020. Pt's previous time in treatment warranted that he is eligible for reduced counseling for an average of 1 hour per month, not 2.5 hours. Based on average time of monthly counseling and reduced counseling status, pt is deficient .5 hours. At that time, Polaris had extended an offer of employment and had a counselor scheduled to start. The counselor did not show up for his first day of employment, which left pt #2 without a primary cs for 1 month. Polaris was actively seeking a new counselor to fill that vacancy, this patient was monitored by the clinical supervisor but did not meet the required average of reduced 1.0 hours of psychotherapy for the identified months. Polaris will make every effort to recruit and retain qualified counseling staff to ensure that all patients are meeting their monthly required therapy hours.
The clinical supervisor will review service reports with each counselor mid month and at the end of each month to make sure their patients are on track to receive their required counseling.
Patient # 5. This patient had documented missed counseling sessions in June and August. This patient's counselor in new and started in May 2020. The primary counselor did not provide the required 2.5 hours of required monthly psychotherapy. This was identified by the clinical supervisor and addressed during supervision.
The clinical supervisor will review service reports with each counselor mid month and at the end of each month to make sure their patients are on track to receive their required counseling.
The director will review the service reports with the clinical supervisor to ensure compliance with required psychotherapy requirements.
Any patient who missed counseling sessions will be placed on a behavioral contract by their primary cs and will be reviewed by clincial supervisor during supervision and chart reviews.
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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 two of eight patient records reviewed, the facility failed to provide documentation of transferring patient files which include admission date, medical and psychosocial summaries, dosage level, urinalysis reports or summary, exception requests, and current status of the patient transferred to the receiving facility.
Patient # 6 was admitted on December 12, 2019 and transferred out of the facility on March 2, 2020. There was no documentation of required information being sent to the receiving facility.
Patient # 6 was admitted on January 23, 2020 and transferred out of the facility on February 25, 2020. There was no documentation of required information being sent to the receiving facility.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
A written notice of documentation that transferring patient files which include admission date, medical and psychosocial summaries, dose level, urinalysis reports or summary, exception requests and current status of the patient transferring, was sent to the receiving facility. and will be contained in all charts of patients transferring from Polaris to a and initial dose of all transfers from Polaris will be contained in their record. The primary counselor will complete the transfer checklist for each tranferring patient. The counselor is responsible for sending over all required documentation to the receiving facility via fax. The counselor will then give all faxed documentation, the checklist, and fax confirmation to the office administrator, who will upload the documentation into the patient record. The supervisor will conduct chart reviews on each discharge chart to make sure the notifications were completed, sent, and contained in the patient chart within 7 days of transfer. |
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 one of eight patient records reviewed, the facility failed to provide documentation 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.
Patient # 8 was transferred in on January 23, 2020 and was transferred out on February 25, 2020. There was no documentation of admission or initial dose by the receiving facility in the patient record.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
A written notice of admission and initial dose of all transfers to Polaris will be contained in their record. The office administrator will complete and fax the notice of admission and first dose to the referring clinic of each patient within 7 days of patient admission. The notification letter and fax confirmation will be uploaded by the administrator into the patient record. The supervisor will conduct chart reviews on each admission chart to make sure the notifications were completed, sent, and contained in the patient chart. |