INITIAL COMMENTS
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This report is a result of an on-site licensure renewal and methadone monitoring inspection conducted on October 26, 2023, through October 27, 2023, by staff from the Department of Drug and Alcohol Programs, Bureau of 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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704.9(c) LICENSURE Supervised Period
704.9. Supervision of counselor assistant.
(c) Supervised period.
(1) A counselor assistant with a Master's Degree as set forth in 704.8 (a)(1) (relating to qualifications for the position of counselor assistant) may counsel clients only under the close supervision of a trained counselor or clinical supervisor for at least the first 3 months of employment.
(2) A counselor assistant with a Bachelor's Degree as set forth in 704.8 (a)(2) may counsel clients only under the close supervision of a trained counselor or clinical supervisor for at least the first 6 months of employment.
(3) A registered nurse as set forth in 704.8 (a)(3) may counsel clients only under the close supervision of a trained counselor or clinical supervisor for at least the first 6 months of employment.
(4) A counselor assistant with an Associate Degree as set forth in 704.8 (a)(4) may counsel clients only under the close supervision of a trained counselor or clinical supervisor for at least the first 9 months of employment.
(5) A counselor assistant with a high school diploma or GED equivalent as set forth in 704.8 (a)(5) may counsel clients only under the direct observation of a trained counselor or clinical supervisor for the first 3 months of employment. For the next 9 months, the counselor assistant may counsel clients only under the close supervision of a lead counselor or a clinical supervisor.
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Observations
Based on a review of personnel records, the facility failed to maintain documentation that counselor assistants received direct observation as part of their close supervision, in two of two applicable records.
Employee # 9 was promoted to the position of counselor assistant on October 30, 2022 and was current in that position at the time of the inspection. The supervision notes provided at the time of the inspection did not indicate that direct observation of the provision of counseling services was a part of the close supervision.
Employee # 10 was hired a counselor assistant on February 14, 2023 and was current in that position at the time of the inspection. The supervision notes provided at the time of the inspection did not indicate that direct observation of the provision of counseling services was a part of the close supervision.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Facility Director reviewed the citation and PA Regulation 704.9(c) pertaining to supervising a counselor assistant. To ensure that direct supervision is occurring and documented in supervision notes, the Facility Director will review regulation 704.9 and re-train the clinical supervisor(s) by 12/1/2023. To maintain compliance the Facility Director will review supervision notes monthly in I-Auditor for compliance and address any issues in supervision. |
705.26 (2) LICENSURE Heating and cooling.
705.26. Heating and cooling.
The nonresidential facility:
(2) May not permit in the facility heaters that are not permanently mounted or installed.
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Observations
Based on a physical plant inspection on October 26, 2023, the facility failed to ensure that heaters were permanently mounted as a space heater was found in a storage closet in the rear hallway of the facility.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Facility Director reviewed the citation. To safeguard against any safety issues or concerns, heating will be provided by a permanent mounted unit. The Facility Director will ensure compliance by maintaining a functional internal heating unit and checking the interior of the building for space heaters on a monthly basis. |
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
Based on a review of eight client records, the facility failed to obtain an informed and voluntary consent to release information form from the client for the disclosure of information contained in three records reviewed.
Client # 4 was admitted on January 12, 2021 and was discharged on April 17, 2023. The record did not contain an informed and voluntary consent form to the funding source; however, there was evidence of billing.
Client # 5 was admitted on April 28, 2023 and was active at the time of the inspection. The record contained documentation that a disclosure of the client ' s presence in treatment and medication information was made to a treatment provider on May 24, 2023; however, the record contained no client signed consent to release information form to the provider.
Client # 6 was admitted on January 17, 2023 and was active at the time of the inspection. The record did not contain an informed and voluntary consent form to the funding source; however, there was evidence of billing.
These findings were discussed with facility staff during the licensing process.
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Plan of Correction
The Facility Director reviewed the citation and PA regulation 709.28 (c) pertaining to patient confidentiality.
To safeguard against patient confidentiality being breached, the Clinical Supervisor(s) will retrain clinicians by 12/5/23 on how to complete a consent to release thoroughly and completely. The Clinical Supervisor will conduct chart audits monthly for compliance and will address any issues during supervision. The Clinical Supervisors will refer to PTC policies and procedures for clarity. Client #6 signed an ROI for his funding source on 12/5/2023
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709.28 (c) (1) 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:
(1) Name of the person, agency or organization to whom disclosure is made.
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Observations
Based on a review of eight client records, the facility failed to document the name of the person, agency, or organization to whom disclosure is made on consent to release information forms in two client records reviewed.
Client # 1 was admitted on August 16, 2023 and was active at the time of the inspection. The release of information form to a doctor was signed and dated by the client on August 16, 2023; however, the form did not include the name of the person, agency, or organization to whom the disclosure would be made.
Client # 3 was admitted on August 24, 2015 and was discharged May 29, 2023. The release of information form to an emergency contact was signed and dated by the client on March 15, 2023; however, the form did not include the name of the person, agency, or organization to whom the disclosure would be made.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Facility Director reviewed the citation pertaining to patient confidentiality.
To safeguard against patient confidentiality being breached, the Clinical Supervisor(s) will retrain clinicians by 12/1/23 on how to complete a consent to release thoroughly and completely. The Clinical Supervisor will conduct chart audits monthly for compliance and will address any issues during supervision. The Clinical Supervisors will refer to PTC policies and procedures for clarity.
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709.32 (b) LICENSURE Medication control
§ 709.32. Medication control.
(b) Verbal orders for medication can be given only by a physician or other medical professional authorized by State and Federal law to prescribe medication and verbal orders may be received only by another physician or medical professional authorized by State and Federal law to receive verbal orders. When a verbal or telephone order is given, it has to be authenticated in writing by a physician or other medical professional authorized by State and Federal law to prescribe medication. In detoxification levels of care, written authentication shall occur no later than 24 hours from the time the order was given. Otherwise, written authentication shall occur within 3 business days from the time the order was given.
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Observations
Based on a review of patient records, the facility failed to ensure that verbal medication orders were authenticated in writing by a physician or other medical professional within three business days in five of eight records reviewed.
Client # 2 was admitted on October 21, 2021 and was discharged on April 27, 2023. A verbal order was given on February 20, 2023, and was not authenticated in writing until February 24, 2023. A verbal order was given on March 9, 2023, and was not authenticated in writing until April 19, 2023. A verbal order was given on March 16, 2023, and was not authenticated in writing until April 19, 2023.
Client # 4 was admitted on January 12, 2021 and was discharged on April 17, 2023. A verbal order was given on January 4, 2023, and was not authenticated in writing until January 18, 2023. A verbal order was given on February 21, 2023, and was not authenticated in writing until April 25, 2023.
Client # 6 was admitted on January 17, 2023 and was active at the time of the inspection. A verbal order was given on January 30, 2023, and was not authenticated in writing until February 3, 2023.
Client # 7 was admitted on October 4, 2022 and was active at the time of the inspection. A verbal order was given on January 10, 2023, and was not authenticated in writing until January 18, 2023.
Client # 8 was admitted on March 27, 2022 and was discharged August 10, 2023. A verbal order was given on March 27, 2023, and was not authenticated in writing until April 19, 2023. A verbal order was given on March 29, 2023, and was not authenticated in writing until April 19, 2023.
These findings were reviewed with project staff during the licensing process.
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Plan of Correction
The Facility Director reviewed citation pertaining to medication control.
The Facility Director will review PA regulation 709.32(b) with the physician by 12/1/2023 to ensure there is a clear understanding of the standard. The Facility Director will ensure the physician prescribing the medication and giving the verbal order completes written authentication within 3 business days from the time the order was given, by conducting monthly chart audits for compliance.
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709.34 (c) (4) 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:
(4) Event at the facility requiring the presence of police, fire or ambulance personnel.
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Observations
Based on the review of the unusual incident records, the facility failed to file a written unusual incident report with the Department within three business days following an unusual incident involving the presence of police, fire, or ambulance personnel onsite.
There was documentation of ambulance personnel at the facility on January 4, 2023, January 19, 2023, and October 5, 2023; however, there was no documentation that written unusual incident reports were filed with the Department.
These findings were reviewed with project staff during the licensing process.
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Plan of Correction
The Facility Director reviewed citation pertaining to reporting unusual incidents.
The Facility Director will review licensing procedures on reporting unusual incidents and PTC policies and procedures. To ensure the proper procedures are followed, for compliance PTC QI department completes quarterly audits of reportable events. Unusual incident reports will be reported within 3 business days. The unusual incident reports were submitted on 12/12/23
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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
Based on the review of physician timesheets, the facility failed to provide at least one hour of physician services a week on site for every ten patients in three of the fifteen weeks reviewed.
During the week of June 19, 2023 through June 25, 2023, the patient census was 334. The facility was required to provide at least 33.4 physician hours. There were only 32.15 hours documented.
During the week of July 3, 2023 through July 9, 2023, the patient census was 338. The facility was required to provide at least 33.8 physician hours. There were only 30.86 hours documented.
During the week of September 4, 2023 through September 10, 2023, the patient census was 332. The facility was required to provide at least 33.2 physician hours. There were only 23.11 hours documented.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Facility Director reviewed citation pertaining to physician staffing. The Facility Director will ensure there is a medical provider available on site to cover weekly required hours and holidays to provide medical care as needed. If there is no medical provider available, an exception will be completed. Compliance will be monitored by the Facility Director by reviewing upcoming holiday's and schedule a physician to cover the shift or complete an exception a month in advance. |
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 patient records, the facility failed to ensure that emergency contact information was obtained during the intake process in one of four records reviewed.
Patient # 5 was admitted on April 28, 2023 and was active at the time of the inspection. Emergency contact information was not obtained until May 24, 2023, and the record contained no documentation showing that the patient declined to provide it during the intake process or that there was a lapse in attendance preventing the information from being gathered.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Facility Director reviewed the citation pertaining to documenting an emergency contact in a patient's chart on admission.
To safeguard against the patient's emergency contact not being identified and documented on admission the Clinical Supervisors will retrain clinicians on 12/1/23 on what forms need to be completed on admission in the EHR. The emergency contact will be listed in the patient profile section of their chart and an ROI will be completed and signed.
The Clinical Supervisor(s) will conduct a chart audit on all admissions in I-Auditor to maintain compliance and address any issues during individual and/or group supervision.
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715.17(c)(1)(i-vi)) LICENSURE Medication control
(c) A narcotic treatment program shall develop and implement written policies and procedures regarding the medications used by patients which shall include, at a minimum:
(1) Administration of medication.
(i) A narcotic treatment physician shall determine the patient 's initial and subsequent dose and schedule. The physician shall communicate the initial and subsequent dose and schedule to the person responsible for the administration of medication. Each medication order and dosage change shall be written and signed by the narcotic treatment physician.
(ii) An agent shall be administered or dispensed only by a practitioner licensed under the appropriate Federal and State laws to dispense agents to patients.
(iii) Only authorized staff and patients who are receiving medication shall be permitted in the dispensing area.
(iv) There shall be only one patient permitted at a dispensing station at any given time.
(v) Each patient shall be observed when ingesting the agent.
(vi) Administering and dispensing shall be conducted in a manner that protects the patient from disruption or annoyance from other individuals.
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Observations
During an observation of medication administration on October 27, 2023, one nurse was observed preparing for subsequent medication doses, and on one occasion talking, instead of observing patients when ingesting the agent.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Facility Director reviewed the citation pertaining to medication control. The Regional Nursing Supervisor will re-train medical staff on PTC policies and procedures pertaining to medication administration, and complete training in Relias on medication control by 12/1/2023. The Facility Director and the Regional Nursing Supervisor will monitor compliance monthly by observing staff medicating patients and reviewed completed trainings in Relias. |
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 patient records the facility 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 in four of six applicable records.
Patient # 1 was admitted on August 16, 2023 and was active at the time of the inspection. The patient only received 2.08 hours of psychotherapy for the month of September 2023.
Patient # 2 was admitted on October 21, 2021 and was discharged on April 27, 2023. The patient ' s treatment and rehabilitation plan designated one hour of psychotherapy a month and one and half hours of group psychotherapy a month to fulfill the 2.5 required hours of psychotherapy monthly. The patient did not receive any individual psychotherapy during the months of February and January 2023, and only 0.33 hours in the month of December 2022. Additionally, the record did not document any group psychotherapy was offered the months of December 2022 and January and February 2023.
Patient # 6 was admitted on January 17, 2023 and was active at the time of the inspection. The patient ' s treatment and rehabilitation plan designated one hour of psychotherapy a month and one and half hours of group psychotherapy a month to fulfill the 2.5 required hours of psychotherapy monthly. The patient did not receive any individual therapy during the month of September 2023. Additionally, the record did not document that any group sessions were offered during any month between June and September 2023.
Patient # 7 was admitted on October 4, 2022 and was active at the time of the inspection. The patient only received one hour per month in August and September 2023.This is a repeat citation from the November 14, 2022 annual licensing renewal inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Facility Director reviewed the citation pertaining to individualized psychotherapy services. To ensure patients are completing required monthly counseling units, the Clinical Supervisor(s) will conduct a training on 12/1/23 on how to utilize the Methasoft HER to assist patients in meeting monthly counseling units.
The Facility Director will re-train clinicians on how to use Methasoft HER reports "Scheduled Events", the Scheduler, Daily Activities, and dose delay (dose delay is an alert in the EHR that stops the patient when checking in indicating the patient is required to see a counselor before medicating), to assist patients with meeting monthly required units. Utilize phone, video, and/or group counseling as needed to help patient's complete units.
The Facility Director will monitor compliance by conducting monthly chart audits and reviewing completed scheduled events, and monthly requirement reports. Non-compliance will be addressed in supervision.
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715.19(2) LICENSURE Psychotherapy services
A narcotic treatment program shall provide individualized psychotherapy services and shall meet the following requirements:
(2) A narcotic treatment program shall provide each patient at least 1 hour per month of group or individual psychotherapy during the third and fourth year of treatment. Additional psychotherapy shall be provided as dictated by ongoing assessment of the patient.
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Observations
Based on a review of patient records, the facility failed to provide each patient at least 1 hour per month of group or individual psychotherapy during the third and fourth year of treatment in one of one applicable records reviewed.
Patient # 4 was admitted on January 12, 2021 and was discharged on April 17, 2023. The patient only received 0.75 hours of psychotherapy in March and February 2023 and 0.33 hours in December 2022 and January 2023.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Facility Director reviewed the citation pertaining to individualized psychotherapy services. To ensure patients are completing required monthly counseling units, the Clinical Supervisor(s) will conduct a training on 12/1/23 on how to utilize the Methasoft EHR to assist patients in meeting monthly counseling units.
The Clinical Supervisor(s) will re-train clinicians 11/30/23 on how to use Methasoft HER reports "Scheduled Events", the Scheduler, Daily Activities, and "flag" that alerts the patient when checking in that a counselor wants to see them to assist patients with meeting monthly required units. Utilize phone, video, and/or group counseling as needed to help patient's complete units.
The Clinical Supervisor(s) will monitor compliance by conducting monthly chart audits and reviewing completed scheduled events and monthly requirement reports. Non-compliance will be addressed in supervision.
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715.23(c)(1-7) LICENSURE Patient records
(c) An annual evaluation of each patient 's status shall be completed by the patient 's counselor and shall be reviewed, dated and signed by the medical director. The annual evaluation period shall start on the date of the patient 's admission to a narcotic treatment program and shall address the following areas:
(1) Employment, education and training.
(2) Legal standing.
(3) Substance abuse.
(4) Financial management abilities.
(5) Physical and emotional health.
(6) Fulfillment of treatment objectives.
(7) Family and community supports.
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Observations
Based on a review of patient records, the facility failed to ensure an annual evaluation of each patient's status was completed by the patient's counselor and reviewed, dated and signed by the medical director in one of two applicable records reviewed.
Patient # 4 was admitted on January 12, 2021 and was discharged on April 17, 2023. An annual evaluation was due to be completed by January 12, 2023, however, the annual evaluation was not completed until March 24, 2023.
This is a repeat citation from the November 14, 2022 and January 3, 2022 annual licensing renewal inspections.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Facility Director reviewed the citation pertaining to annual evaluation.
The Facility Director will re-train clinicians on 12/1/23 on how to use Methasoft EHR reports "Scheduled Events", the Scheduler, Daily Activities, and "flag" that alerts the patient when checking in that a counselor wants to see them to complete evaluation in person and/or use the scheduler as a reminder to complete the document during a counseling phone call. After completing the evaluation, signatures will be completed within 24 hours.
The Facility Director will monitor compliance by conducting monthly chart audits and completed schedule events. Non-compliance will be addressed in supervision.
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709.91(b)(7) LICENSURE Intake and admission
709.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(7) Preliminary treatment and rehabilitation plan.
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Observations
Based on a review of client records and the facility's policies and procedures, the facility failed to document a preliminary treatment plan within seven days of admission, per policy, in three of four applicable records reviewed.
Client # 1 was admitted on August 16, 2023 and was active at the time of the inspection. The preliminary treatment plan was not completed until September 12, 2023.
Client # 5 was admitted on April 28, 2023 and was active at the time of the inspection. The preliminary treatment plan was not completed until May 15, 2023.
Client # 8 was admitted on March 27, 2023 and was discharged on August 10, 2023. The preliminary treatment plan was not completed until April 21, 2023.
These finding were discussed with facility staff during the licensing process.
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Plan of Correction
The Facility Director reviewed the citation pertaining to completing initial treatment plans on admission.
To safeguard against treatment plans not being completed on admission the Clinical Supervisors will retrain clinicians on 12/1/23 on how to utilize the EHR when completing an admission and the documents that are required to be reviewed with the patient and signed.
The clinical supervisor will conduct a chart audit on all admissions in I-Auditor to maintain compliance and address any issues during individual and group supervision.
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709.92(b) LICENSURE Treatment and rehabilitation services
709.92. Treatment and rehabilitation services.
(b) Treatment and rehabilitation plans shall be reviewed and updated at least every 60 days.
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Observations
Based on a review of eight client records, the facility failed to document treatment plan updates within the regulatory timeframe in five of seven applicable records reviewed.
Client # 2 was admitted on October 21, 2021 and was discharged on April 27, 2023. A treatment plan update was completed on October 6, 2022, and the next update was due no later than December 6, 2022; however, the next treatment plan update was not completed until January 4, 2023.
Client # 4 was admitted on January 12, 2021 and was discharged on April 17, 2023. A treatment plan update was completed on December 7, 2022, and the next update was due no later than February 7, 2023; however, the update was not completed until April 3, 2023.
Client # 6 was admitted on January 17, 2023 and was active at the time of the inspection. A treatment plan update was completed on June 27, 2023, and the next update was due no later than August 27, 2023; however, the update was not completed until September 30, 2023.
Client # 7 was admitted on October 4, 2022 and was active at the time of the inspection. The individual treatment and rehabilitation plan was completed on November 18, 2022, and the treatment plan update was due no later than January 18, 2023; however, the update was not completed until February 13, 2023. Additionally, a treatment plan update was completed on March 7, 2023, and the next update was due no later than May 7, 2023; however, the update was not completed until June 28, 2023.
Client # 8 was admitted on March 27, 2023 and was discharged on August 10, 2023. The individual treatment and rehabilitation plan was completed on April 6, 2023, and the treatment plan update was due no later than June 6, 2023; however, the update was not completed until June 22, 2023.
These findings were discussed with facility staff during the inspection process.
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Plan of Correction
The Facility Director reviewed the citation. To safeguard against treatment plans not being completed in a timely manner the clinical supervisors will retrain clinicians 12/1/23 on how to utilize the EHR "Scheduled Events Report" to identify when treatment plans are due, review and develop the plan with the patient in either counseling or telehealth counseling sessions, and on the process of stopping the patient while checking in at the kiosk to obtain a signature if needed prior to the plans end date.
The Clinical Supervisor(s) will have a face-to-face training with all clinicians on DDAP regulation pertaining to updating treatment plans every 60 days, she/he will offer time management suggestions and give instructions on how to review reports in Methasoft what will allow them to work ahead of schedule to ensure treatment plans are completed in a timely manner. She/He will show the clinicians what reports to use in EHR to show the dates treatment plans are due. She/He will give the clinicians samples of completed plans and will review reports daily for compliance. The clinicians will learn how to use the daily activities option and scheduled events report in the EHR to determine when treatment plans are due allowing them to be completed in a timely manner.
The clinical supervisors will conduct monthly audit charts for compliance and address any issues in supervision.
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709.93(a)(8) LICENSURE Client records
709.93. 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:
(8) Case consultation notes.
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Observations
Based on a review of client records and the facility's policy and procedure manual, the facility failed to ensure a complete client record included information relative to the client's involvement with the project, to include case consultation information quarterly for the first year and annually thereafter, in two of six records reviewed.
Client # 6 was admitted on January 17, 2023 and was active at the time of the inspection. A case consultation was documented on July 17, 2023, and the next consultation was due to be completed by October 17, 2023; however, no additional case consultations were completed prior to the inspection.
Client # 7 was admitted on October 4, 2022 and was active at the time of the inspection. The first case consultation was due to be completed by January 4, 2023, however, it was not completed until April 18, 2023.
This is a repeat citation from the November 14, 2022 annual licensing inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Facility Director reviewed the citation pertaining to case consultations.
The Facility Director will re-train clinicians on 12/1/23 on how to use Methasoft EHR reports "Scheduled Events", the Scheduler, and "flags" that alerts the patient when checking in that a counselor wants to see them to complete a case consultation either quarterly or annually, based on their time in treatment, in person and/or during a counseling phone call. After completing the case consultation, signatures will be completed within 24 hours.
The Facility Director will monitor compliance by conducting monthly chart audits. Non-compliance will be addressed in supervision.
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709.93(a)(11) LICENSURE Client records
709.93. 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 client records and the facility's policy and procedure manual, the facility failed to ensure a complete client record included information relative to the client's involvement with the project, to include follow-up notes within 30 and 120 days of discharge, in three of four applicable records reviewed.
Client # 2 was admitted on October 21, 2021 and was discharged on April 27, 2023. The record did not contain documentation of follow-up notes.
Client # 4 was admitted on January 12, 2021 and was discharged on April 17, 2023. The record did not contain documentation of follow-up notes.
Client # 8 was admitted on March 27, 2023 and was discharged on August 10, 2023. The record did not contain documentation of follow-up notes.
This is a repeat citation from the November 14, 2022 annual licensing inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Facility Director reviewed the citation pertaining to following up with patients after discharge.
The Facility Director will re-train clinicians on 12/1/23 on how to use Methasoft EHR reports "Scheduled Events" report to identify when the first and second discharge follow up is due and where to locate and complete the forms. The Clinical Supervisor(s) will review how to complete the form and give examples to assist with the process.
The Facility Director will monitor compliance by conducting monthly chart audits. Non-compliance will be addressed in supervision.
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709.17(a)(3) LICENSURE Subchapter B.Licensing Procedures.Refusal/rev
709.17. Refusal or revocation of license.
(a) The Department may revoke or refuse to issue a license for any of the following reasons:
(3) Failure to comply with a plan of correction approved by the Department, unless the Department approves an extension or modification of the plan of correction.
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Observations
Based on a review of client records, the facility failed to comply with plans of correction that were approved by the Department.
A plan of correction for completing annual evaluations was submitted and approved by the Department for November 14, 2022 and January 3, 2022 annual licensing inspections. Completing annual evaluations was again found to be a deficiency in the October 26, 2023 through October 27, 2023 licensing inspection.
A plan of correction for including follow-up information in the client record was submitted and approved by the Department for the November 14, 2022 annual licensing inspection. Completing follow-up information was again found to be a deficiency in the October 26, 2023 through October 27, 2023 licensing inspection.
A plan of correction for ensuring that required clients received 2.5 hours of psychotherapy per month was submitted and approved by the Department for the November 14, 2022 annual licensing inspection. Psychotherapy hours were again found to be a deficiency in the October 26, 2023 through October 27, 2023 licensing inspection.
A plan of correction for completing case consultation notes according to policy was submitted and approved by the Department for November 14, 2022 annual licensing inspection. Case consultation notes were again found to be a deficiency in the October 26, 2023 through October 27, 2023 licensing inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Facility Director will ensure the plans of correction is implemented by the corrective action date and clinical supervisor will assist in the monitoring process. Clinical Supervisor(s) will monitor progress of the plan and quarterly reviews of plans of correction implantation will occur during staff/supervision meetings. Additional monitoring will occur monthly through chart audits completed by the PTC compliance team and if deficiencies are noted they will be reviewed within the month. If the plan of correction appears to be not working as written, a supervisory meeting will occur to adjust the current plan. The Facility Director will report to the Project Director the findings each quarter during PTCs regional operations meeting. |