INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on November 15-16, 2016 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Pennsylvania Associates, LLC dba Mount Pocono Medical 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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704.11(b)(1) LICENSURE Individual training plan.
704.11. Staff development program.
(b) Individual training plan.
(1) A written individual training plan for each employee, appropriate to that employee's skill level, shall be developed annually with input from both the employee and the supervisor.
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Observations
Fourteen personnel records were reviewed on November 15-16, 2016. The facility failed to document a complete individual training plan that included input from both the employee and the supervisor in employee records # 2, 3, 4, 5, 6, 7, 8, 9, 10, 13, and 14.
This finding was reviewed with facility staff during the licensing inspection.
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Plan of Correction
The Facility Director reviewed the citation and acknowledged that although all individual training plans were done, all were not completed to include input from both the employee and the supervisor. Moving forward, all individual training plans will include input from both parties. The training forms will be completed by the Supervisor and submitted to the Facility Director to ensure compliance. All staff have been informed. |
704.11(f)(2) LICENSURE Trng Hours Req-Coun
704.11. Staff development program.
(f) Training requirements for counselors.
(2) Each counselor shall complete at least 25 clock hours of training annually in areas such as:
(i) Client recordkeeping.
(ii) Confidentiality.
(iii) Pharmacology.
(iv) Treatment planning.
(v) Counseling techniques.
(vi) Drug and alcohol assessment.
(vii) Codependency.
(viii) Adult Children of Alcoholics (ACOA) issues.
(ix) Disease of addiction.
(x) Aftercare planning.
(xi) Principles of Alcoholics Anonymous and Narcotics Anonymous.
(xii) Ethics.
(xiii) Substance abuse trends.
(xiv) Interaction of addiction and mental illness.
(xv) Cultural awareness.
(xvi) Sexual harassment.
(xvii) Developmental psychology.
(xviii) Relapse prevention.
(3) If a counselor has been designated as lead counselor supervising other counselors, the training shall include courses appropriate to the functions of this position and a Department approved core curriculum or comparable training in supervision.
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Observations
Fourteen personnel records were reviewed on November 15-16, 2016. The facility failed to document the completion of 25 clock hours of annual training required for the counselor position, in employee record # 5.
Employee # 5 was hired as a counselor on 10/18/13 and their record documented 23.25 hours of training for the 2015 training year.
This finding was reviewed with facility staff during the licensing inspection.
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Plan of Correction
The Facility Director acknowledged this shortage of training hours. The Facility Director will ensure all staff complete their required training hours on or before the deadline, by enforcing all staff to submit their proof of completion on or before the deadline. There will be quarterly checks done by the Facility Director to ensure this is taking place throughout the year. |
709.28 (c) 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.
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Observations
Six client records were reviewed on November 15-16, 2016. The facility failed to obtain an informed and voluntary consent in client records # 1 and 2.
Client # 1 was admitted into treatment on 1/25/16 and was discharged on 8/7/16. The client's record documented that the facility forwarded a letter to a county children and youth services agency on 7/13/16, reporting the client's presence in treatment. The consent to release information documented in the client's record, for that county agency, was not signed and dated by the client until 7/14/16.
Client # 2 was admitted into treatment on 8/26/15 and was discharged on 1/29/16. The client's record documented that the facility forwarded a letter to a county children and youth services agency on 12/31/15. The consent to release information documented in the client's record, signed and dated by the client on 12/31/15, did not properly document the information to be disclosed and the purpose of disclosure.
These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
The Facility Director reviewed the records in question. All clinical staff have been reminded of state regulations in addition to internal policy and procedure related to confidentiality. Current clinical staff have been informed that no information is to be released without prior signed consent. Future staff will be trained during orientation. The Lead Counselor, Supervisor and Facility Director will ensure compliance is maintained through internal chart audits. The facility's new computerized system should prevent documentation lacking any information. |
709.33 (a) LICENSURE Notification of termination.
§ 709.33. Notification of termination.
(a) Project staff shall notify the client, in writing, of a decision to involuntarily terminate the client ' s treatment at the project. The notice shall include the reason for termination.
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Observations
Six client records were reviewed on November 15-16, 2016. The facility failed to document that the client was notified, in writing, of a decision to involuntarily terminate the client's treatment at the facility in client record # 4.
Client # 4 was admitted into treatment on 5/25/16 and was involuntarily terminated from treatment on 9/9/16. The client's record failed to document written notification of the facility's decision to involuntarily terminate treatment.
This finding was reviewed with facility staff during the licensing inspection.
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Plan of Correction
The Facility Director reviewed this citation. The medical staff will meet with all patients facing involuntary discharge. All necessary information, including reason for discharge, schedule of taper and actual discharge date will be reviewed with patient and documented. Patients will sign as proof of notification. This will be kept on file in each patient's record in the facility's new computerized system. Patient will receive a copy of written notification; this will be documented in patient's record. Staff have been made aware that this will need to take place for each patient facing involuntary discharge. In addition, to ensure compliance is being met, the Facility Director will follow up prior to the discharge date via chart audits. |
709.34 (c) (1) LICENSURE Reporting of unusual incidents
§ 709.34. Reporting of unusual incidents.
(c) To the extent permitted by State and Federal confidentiality laws, the project shall file a written unusual incident report with the Department within 3 business days following an unusual incident involving:
(1) Physical or sexual assault by staff or a client.
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Observations
The facility's documentation of unusual incidents were reviewed on November 16, 2016. The facility failed to report to the Department a documented event that involved a physical assault by clients. This event occurred on 8/21/16, at approximately 9:20-9:40 am.
This finding was reviewed with facility staff during the licensing inspection.
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Plan of Correction
Although the incident was internally documented, the Facility Director will ensure that all future unusual incidents are reported to the Department within the specified time frame. Management have been made aware of incidents qualifying as an unusual incident. In addition, management have been informed of the process of submitting reports to ensure there are no delays in the absence of the Facility Director. |
715.6(d) LICENSURE Physician Staffing
(d) A narcotic treatment program shall provide narcotic treatment physician services at least 1 hour per week onsite for every ten patients
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Observations
An onsite licensing inspection was conducted on November 15-16, 2016. Based on the review of administrative documentation, the facility failed to consistently provide narcotic treatment physician services at least one hour per week onsite for every ten clients.
During the licensing process, weekly physician time sheets were reviewed for the time period of 6/5/16 - 8/27/16. Insufficient onsite physician hours were provided for ten weeks out of the time period reviewed.
During the week of June 5-11, 2016, the average patient census was 369.85. The facility was required to provide at least 36.98 physician hours onsite. There were 35.95 onsite physician hours documented, including hours provided by the certified registered nurse practitioner.
During the week of June 19-25, 2016, the average patient census was 374.71. The facility was required to provide at least 37.47 physician hours onsite. There were 37.33 physician hours documented, including hours provided by the certified registered nurse practitioner.
During the week of July 3-9, 2016, the average patient census was 377. The facility was required to provide at least 37.7 physician hours onsite. There were 29.5 physician hours documented, including hours provided by the certified registered nurse practitioner.
During the week of July 10-16, 2016, the average patient census was 379.42. The facility was required to provide at least 37.94 physician hours onsite. There were 37.33 physician hours documented, including hours provided by the certified registered nurse practitioner.
During the week of July 17-23, 2016, the average patient census was 383.85. The facility was required to provide at least 38.38 physician hours onsite. There were 37.5 physician hours documented, including hours provided by the certified registered nurse practitioner.
During the week of July 24-30, 2016, the average patient census was 385.14. The facility was required to provide at least 38.51 physician hours onsite. There were 25.5 physician hours documented, including hours provided by the certified registered nurse practitioner.
During the week of July 31-August 6, 2016, the average patient census was 384.55. The facility was required to provide at least 38.45 physician hours onsite. There were 29.37 physician hours documented, including hours provided by the certified registered nurse practitioner.
During the week of August 7-13, 2016, the average patient census was 384. The facility was required to provide at least 38.4 physician hours onsite. There were 37.5 physician hours documented, including hours provided by the certified registered nurse practitioner.
During the week of August 14-20, 2016, the average patient census was 383. The facility was required to provide at least 38.3 physician hours onsite. There were 37.5 physician hours documented, including hours provided by the certified registered nurse practitioner.
During the week of August 21-27, 2016 the average patient census was 384.28. The facility was required to provide at least 38.42 physician hours onsite. There were 37.5 physician hours documented, including hours provided by the certified registered nurse practitioner.
These findings were reviewed with project staff during the licensing process.
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Plan of Correction
The CRNP hours were being tracked online in which the system automatically deducted 30 minutes each shift whether or not a lunch break was taken. Moving forward, the Facility Director will track these hours on paper to accurately document onsite hours to ensure compliance. Additional medical staff will be hired to ensure appropriate coverage. |
715.6(e) LICENSURE Physician Staffing
(e) A physician assistant or certified registered nurse practitioner may perform functions of a narcotic treatment physician in a narcotic treatment program if authorized by Federal, State and local laws and regulations, and if these functions are delegated to the physician assistant or certified registered nurse practitioner by the medical director, and records are properly countersigned by the medical director or a narcotic treatment physician. One-third of all required narcotic treatment physician time shall be provided by a narcotic treatment physician. Time provided by a physician assistant or certified registered nurse practitioner may not exceed two-thirds of the required narcotic treatment physician time.
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Observations
Six client records were reviewed on November 15-16, 2016. The facility failed to document the countersignature of the medical director or narcotic treatment physician on records pertaining to functions conducted by the certified registered nurse practioner, in client records # 1, 2, and 5.
Client # 1 was admitted into treatment on 1/25/16 and was discharged on 8/7/16. The client's record indicated that documentation of opiate addiction was completed by the certified registered nurse practioner on 1/25/16. This documentation did not include the countersignature of the medical director or narcotic treatment physician. Additionally, the client's record documented that a physical exam was conducted by the certified registered nurse practitioner on 1/25/16. This documentation did not include the countersignature of the medical director or narcotic treatment physician.
Client # 2 was admitted into treatment on 8/26/15 and was discharged on 1/29/16. The client's record indicated that documentation of opiate addiction was completed by the certified registered nurse practioner on 8/26/15. Additionally, the client's record documented that a physical exam was conducted by the certified registered nurse practitioner on 8/26/15, This documention did not include the countersignature of the medical director or narcotic treatment physician.
Client # 5 was admitted into treatment on 6/3/13 and was active in treatment. The client's record documented that a semi-annual review of dosage level was completed by the certified registered nurse practitioner on 11/10/16. This documentation did not include the countersignature of the medical director or narcotic treatment physician. Additionally, the client's record documented that an annual physical exam was conducted by the certified registered nurse practitioner on 5/5/16. This documentation did not include the countersignature of the medical director or narcotic treatment physician.
These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
The medical staff have been made aware of countersignatures needed for documentation signed by either a CRNP or PA. The Medical Director will countersign on the necessary documentation. The Facility Director will follow up via internal chart audits to ensure compliance. |
715.13(b) LICENSURE Patient identification
(b) A narcotic treatment program shall maintain onsite a photograph of each patient which includes the patient 's name and birth date. The narcotic treatment program shall update the photograph every 3 years.
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Observations
Six client records were reviewed on November 15-16, 2016. The facility failed to maintain a photograph of the client that included the client's name and birthdate in client record # 4.
Client # 4 was admitted into treatment on 5/25/16 and was discharged on 9/9/16. A photograph that included the client's name and birthdate was not documented in the client's record.
This finding was reviewed with facility staff during the licensing inspection.
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Plan of Correction
Photographs including name and date of birth are currently obtained prior to admission. Follow up takes place during the intake chart audit. These audits are conducted by either the Lead Counselor, Clinical Supervisor, or the Facility Director. Due to the facility's new computerized system's capability to upload documentation, all photographs with name and date of birth are now uploaded into each patient's record to avoid it ever being misplaced once filed. |
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
Six client records were reviewed on November 15-16, 2016. As the referring narcotic treatment program, the facility failed to document the transfer of all required patient files in client record # 6.
Client # 6 was admitted into treatment on 10/25/10 and discharged on 3/28/16, to transfer to another narcotic treatment program. The client's record documented that the results of the client's annual physical exam and TB test were forwarded to the receiving narcotic treatment program on 3/22/16. The client's record failed to also document the transfer of the following patient files: psychosocial summaries, dosage level, and urinalysis reports or summary.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
Clinical staff are responsible for sending requested documentation to the receiving facility. Clinical staff have been informed to list each document on the fax cover sheet and/or file together a copy of all documents being sent. To ensure compliance, internal chart audits will be conducted by Lead Counselor, Clinical Supervisor and Facility Director. |
709.94(g) LICENSURE Project management services
709.94. Project management services.
(g) Outpatient projects which receive reimbursement under the medical assistance program shall have a current, signed provider agreement with the Department of Public Welfare and comply with 55 Pa. Code Part III (relating to Medical Assistance Manual).
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Observations
Six client records were reviewed on November 15-16, 2016. The facility failed to document a physician signature on treatment plans in client records # 1, 3, and 6. Treatment for these clients was funded through the Medical Assistance program.
Client # 1 was admitted into treatment on 1/25/16 and was discharged on 8/7/16. A treatment plan update documented in the client's record, dated 6/25/16, was not signed by a physician.
Client # 3 was admitted into treatment on 3/4/16 and was discharged on 4/25/16. The master treatment plan documented in the client's record, dated 4/6/16, was not signed by a physician.
Client # 6 was admitted into treatment on 10/25/10 and was discharged on 3/28/16. Treatment plan updates documented in the client's record, dated 11/13/15, 1/13/16, and 3/11/16, were not signed by a physician.
These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
As of late August 2016 with the implementation of the facility's new computerized system, all treatment plans remain in a pending status until signed by all parties. All parties who are required to review and sign treatment plans have been trained in this area. The Facility Director will periodically review status to ensure compliance. |