INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on July 24, 2017 by staff from the Department of Drug and Alcohol Programs, Bureau of Quality Assurance for Prevention and Treatment, Program Licensure Division. Based on the findings of the on-site inspection, PHMC Pathways to Recovery 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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704.12(a)(5) LICENSURE Partial Hosp Ratio
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.
(5) Partial hospitalization. Partial hospitalization programs shall have a minimum of one FTE counselor who provides direct counseling services to every ten clients.
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Observations
The Staffing Requirements Facility Summary Report (SRFSR) form was completed and reviewed during the licensing process. The form listed four counselors and a clinical supervisor as clinical staff. Based on the total number of hours per week that the facility reported the employees devoted to their clients and the total number of active drug and alcohol clients, as of the date of the inspection, the facility exceeded the allowable maximum 10:1 full time equivalent (FTE) client to counselor ratio for a partial hospitalization program.The FTE ratio is determined by dividing the total number of hours the facility devotes to the clients by 35. The result is the facility's FTE. Then, in order to obtain the facility's client/counselor ratio, the total number of clients the facility currently has is divided by the facility FTE.The number of hours per week devoted by the entire facility, as reported by the facility on the SRFSR, was 122 hours. The facility also reported on the SRFSR that the total number of drug and alcohol clients was 43.The facility's calculation is as follows: 122/35 = 3.4857 Facility FTE; 43/3.4857 = 12.3361, which equals a client to counselor ratio of 13:1.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The program will hire a 5th counselor and will make caseload adjustment to ensure 10:1. Our Admission Coordinator will also be used to help manage caseloads until the 5th counselor is hired. The program will also use temporary clinician services if there is a vacancy in the future until the position is filled. The program has an agreement with Delta-T. |
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 a review of 7 client records, the facility failed to document the specific information to be released, the person, agency, or organization to whom the disclosure would be made to, and the witness's dated signature on consent to release information forms in client records #'s 2 and 7.Client #2 was admitted on 3/1/17 and was discharged 5/15/17. A consent to release form was signed and dated on 5/1/17 to another treatment provider. However, the consent form did not contain any specific information to be released and was not signed/dated by a witness.Client #7 was admitted on 3/8/17 and was discharged 6/2/17. A consent to release form, with the stated purpose of billing was signed and dated on 3/8/17. However, the consent form did not contain the name of the person, agency, or organization to whom the disclosure would be made to and did not contain any specific information to be released.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Program and Clinical Director will retrain all staff on the release of information process and consent form by 8/15/17. Program and Clinical Director along with TQM department will monitor adherence to release of information policy through routine chart reviews, and will provide remediation training and follow-up if staff are not within compliance. |
709.83(a)(11) LICENSURE Client records
709.83. Client records.
(a) There shall be a complete client record on an individual which includes information relative to the client's involvement with the project. This shall include, but not be limited to the following:
(11) Follow-up information.
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Observations
Based on a review of 7 client records, the facility failed to provide a complete client record in client records #'s 2, 3, 6 and 7.Client #2 was admitted on 3/1/17 and was discharged on 5/15/17. The record did not contain any documentation of follow-up information as of the date of the inspection. Client #3 was admitted on 3/25/17 and was discharged on 5/11/17. The record did not contain any documentation of follow-up information as of the date of the inspection. Client #6 was admitted on 4/19/17 and was discharged on 6/23/17. The record did not contain any documentation of follow-up information as of the date of the inspection. Client #7 was admitted on 3/8/17 and was discharged on 6/2/17. The record did not contain any documentation of follow-up information as of the date of the inspection.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Program and Clinical Director will review follow-up procedure with staff in a training scheduled for 8/23/17. The assigned therapist will be required to make a note in the chart 5 days post discharge reflecting confirmation if the participant attended the next level of care appointment. The therapist will also check-in with the peer specialist who will make outreach attempts to the participant and document outcome. The Clinical Director will review all discharges to ensure that this has occurred. |
709.84(c) LICENSURE Project management services
709.84. Project management services.
(c) A telephone number shall be displayed conspicuously to the general public for emergency purposes.
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Observations
Based on a physical plant inspection conducted on 7/24/17, at approximately 2:30 pm, it was observed that the facility failed to have a phone number displayed conspicuously to the general public.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Correction made- a sign was posted with program phone number and emergency number. This will be stenciled on the glass window outside of the program by October 15, 2017. |
715.9(a)(2) 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:
(2) Verify the individual 's identity, including name, address, date of birth, emergency contact and other identifying data.
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Observations
Based on a review of 7 client records, the facility failed to obtain verification of the client's identity, which is to include their name, address, date of birth, emergency contact and other identifying data, during the intake process and prior to the administration of a narcotic agent in client record #'s 1 and 2.Client #1 was admitted on 5/23/17 and was still active at the time of the inspection.Client #2 was admitted on 3/1/17 and was discharged on 5/15/17.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Identity verification has been incorporated in the admission process. Individuals without a photo ID will have their identify confirmed by the admission coordinator and receptionist. If the participant does not have a photo ID, case management services will provide assistance in obtaining a State Issued ID. If the participant has verification of Date of Birth and/or Social Security Number and data can be verified in EVS, a program photo ID may be made until a State issued ID can be secured for anyone prescribed narcotic medications. |
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
Based on a review of 7 client records, the facility failed to maintain on-site photographs, which is to include the client's name and birthday, of client #'s 1 and 2.Client #1 was admitted on 5/23/17 and was still active at the time of the inspection.Client #2 was admitted on 3/1/17 and was discharged on 5/15/17.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The program will maintain a copy of participant Photo ID in the clinical Record and separate copies will be kept with the nurse. Program will purchase camera equipment and begin to keep photos of participants that receive medications in the MAR by September 15, 2017. |