INITIAL COMMENTS
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This report is a result of an on-site licensure renewal and a methadone monitoring inspection conducted on October 22, 2019 through October 23, 2019 by staff from the Department of Drug and Alcohol Programs, Bureau of Quality Assurance for Prevention and Treatment. Based on the findings of the on-site inspection, Alliance Medical 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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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 seven patient records during an onsite licensing inspection on October 22-23, 2019, the program failed to provide patient #'s 6 and 7 with 2.5 hours of psychotherapy per month during the patient's first 2 years of treatment. Patient # 6 was admitted on March 12, 2019 and was current at the time of the inspection. The patient was missing one hour of psychotherapy in April 2019 and July 2019. The patient was also missing 45 minutes of psychotherapy in June 2019. There was no documentation of patient no shows or cancellations during those time periods.Patient #7 was admitted on April 16, 2018 and discharged on July 26, 2019. The patient was missing one hour of psychotherapy in April 2019. There was no documentation of patient no shows or cancellations during those time periods.These findings were reviewed with program staff during the licensing process.
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Plan of Correction
The facility failed to provide 2.5 hours of psychotherapy services for all patient records that were reviewed.
The facility will ensure that all patients receive the required of monthly psychotherapy. Monitoring of ongoing compliance with this regulation will be the responsibility of the Supervisory Staff through regular record review, clinical supervision, and utilization for Electronic Record reports.
Open counseling positions will be filled to help ease the burden on current counseling staff and provide additional counseling staff to when other staff are out of the building.
Supervisory Staff will meet with program staff in treatment team meeting and review all regulation requirements related to individualized psychotherapeutic needs.
Facility Staff will utilize Electronic Record reports to periodically check counseling compliance for their caseloads.
Supervisory staff will continue to conducted weekly chart reviews which does include this aspect of the patient file.
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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 the review of seven patient records during a licensing inspection conducted on October 22-23, 2019, it was determined that the program failed to appropriately transfer one patient's file that included 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 to the receiving narcotic treatment program.Patient #4 was admitted on October 4, 2019 and transferred to another program on October 4, 2019. The patient's transfer packet did not include the patient's psychosocial and medical history. These findings were reviewed with program staff during the licensing process.
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Plan of Correction
The facility failed to provide all the required documentation upon patients transfer to another narcotic treatment program.
The facility will ensure that all patients required documentation is transferred to narcotic treatment program when appropriate. The transferred documentation will also be imported into the electronic medical record.
When the facility has prior knowledge of potential patient transfers patient releases/consents will be completed in preparation to send required transfer documents.
However, if prior release/consents have not been completed the facility will only transfer documents covered under the release/consent provided by the transferring facility.
Supervisory staff will monitor this process and continue to conducted weekly chart reviews which does include this aspect of the patient file. |