INITIAL COMMENTS
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This report is a result of an on-site licensure renewal and methadone monitoring inspection conducted on April 20-21, 2023 by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, Williamsport Family Medical Center 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 patient records, the facility failed to provide patients with 2.5 hours of psychotherapy per month during the patient's first two years of treatment, one hour of which shall be individual psychotherapy, in one out of six applicable records reviewed.Patient #1 was admitted on July 19, 2022 and discharged on February 20, 2023. In September 2022, the patient received .75 minutes of individual psychotherapy and no group sessions. In October 2022, the patient received 1 hour of individual psychotherapy and no group sessions. In November 2022, the patient was a no show for two sessions and did not receive any other individual psychotherapy or group sessions. In December, the patient received a half hour of individual psychotherapy and no group sessions. This finding was reviewed with facility staff during the licensing inspection. This is a repeat citation from the May 5, 2022 licensing inspectionn.
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Plan of Correction
n 5/4/23 Executive Director and Regional CS provided re-training on managing caseloads to ensure that patients are receiving their required psychotherapy services as well as continuously documenting when patients do not attend group or individual sessions and attempts to re-engage into treatment.
Quality Department will conduct monthly chart audits and review psychotherapy time to ensure that patients are receiving the required time in treatment.
Executive Director will monitor the Monthly Requirements report from the EMR weekly to ensure that counselors are able to successfully manage their caseloads and ensure that the corrective action is implemented and patients are receiving their required psychotherapy time and/or there is copious documentation related to missed sessions and attempts to re-engage. |
709.91(b)(6) LICENSURE Intake and admission
709.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(6) Psychosocial evaluation.
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Observations
Based on the review of patient records, the facility failed to document a complete psychosocial evaluation within the guidelines established by the facility's policy and procedure manual in two out of five applicable records. The facility's policy and procedures manual states the psychosocial evaluation must be completed within 7 days following admission.Patient #1 was admitted on July 19, 2022 and was discharged on February 20, 2023. The psychosocial evaluation was completed on September 26, 2022.Patient #8 was admitted on July 16, 2022 and was discharged on October 24, 2022. The psychosocial evaluation was completed on September 15, 2022.These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
All individuals being admitted into the program will complete all regulatory documentation, specifically documentation of Psychosocial Evaluation. Facility Director and Clinical Supervisor provided re-education to all clinicians on 5/4/23. All intakes will be reviewed by either Facility Director or Clinical Supervisor within first 7 days of treatment to ensure the completion of required documentation. |
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 patient records, the facility failed to provide a complete patient record, which is to include follow-up information within the guidelines established by the facility's policy and procedure manual in four out of four discharged records reviewed. The facility's policy and procedure manual states the follow-up must be completed within 30 days and 60 days following discharge.Patient #1 was admitted on July 19, 2022 and was discharged on February 20, 2023. A follow-up was due no later than March 22, 2023; however, it was not completed until March 24, 2023.Patient #4 was admitted on September 6, 2022 and was discharged on November 2, 2022. There was no follow-up completed.Patient #8 was admitted on July 16, 2022 and was discharged on October 24, 2022. A follow-up was due no later than November 23, 2022; however, it was not completed until December 5, 2022.Patient #9 was admitted on February 6, 2020 and was discharged on June 2, 2022. There was no follow-up completed.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Training on discharge follow up policy was completed by Facility Director with all staff on 5/4/23. Executive Director will monitor and verify the completion of discharge follow through a monitoring report in EMR, that was corrected to match policy on 4/22/23. Upcoming discharge follow ups will be reviewed during group clinical supervision on a weekly basis with counselors responsible for the completion. Clinical Supervisor will provide individual reports in weekly supervision and report will be reviewed by Facility Director each week to verify and ensure timely follow ups. |