INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection and methadone monitoring inspection conducted on December 1 & 2, 2022 by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, Center for Behavioral Health-HA, Inc. 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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715.6(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 time a week, onsite for every ten patients.
During the week of June 26-July 2, 2022, the patient census was 395. The facility was required to provide at least 39.5 physician hours. There were 13.5 physician hours documented.
During the week of August 21-27, 2022, the patient census was 395. The facility was required to provide at least 39.5 physician hours. There were 36.75 physician hours documented.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Per Regional Director, Clinic Director is to complete an exception request to DDAP when facility is not able to meet required physician hours (such as when physician extender is out sick, on vacation, etc). In the event that the exception request is not approved, Clinic Director will work with Regional Director to identify another PA-C in the Acadia network who would be able to take on the hours that are needed for this facility so that the minimum required medical hours are met. |
715.23(b)(5) LICENSURE Patient records
(b) Each patient file shall include the following information:
(5) The results of all annual physical examinations given by the narcotic treatment program which includes an annual reevaluation by the narcotic treatment physician.
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Observations
Based on a review of patient records, the facility failed to document an annual physical examination within the regulatory timeframe in one out of six applicable records.
Patient #10 was admitted on November 4, 2019 and was still active at the time of the inspection. The annual physical examination was due no later than November 4, 2022; however, it was not documented until November 8, 2022.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
Clinic Director reviewed this citation with physicians and physician extender. Medical staff are aware that all annual physical examinations are to be completed and signed off on by the due date. Physician extender and Clinic Director will monitor to ensure that they are completed by due date. |
709.92(a) LICENSURE Treatment and rehabilitation services
709.92. Treatment and rehabilitation services.
(a) An individual treatment and rehabilitation plan shall be developed with a client. This plan shall include, but not be limited to, written documentation of:
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Observations
Based on a review of client records, the facility failed to develop a comprehensive treatment and rehabilitation plan with the client within their policy ' s set time frame of 8-30 days of admission in two out of four applicable records.
Client #2 was admitted on August 25, 2022 and discharged on November 12, 2022. A comprehensive treatment plan was due no later than September 25, 2022; however, it was not documented until September 29, 2022.
Client #3 was admitted on May 26, 2022 and discharged on July 12, 2022. A comprehensive treatment plan was due no later than June 26, 2022; however, it was not documented until June 28, 2022.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Clinical Supervisor met with all clinicians on 12/15/22 to discuss citation and the requirement that all comprehensive treatment plans be completed and signed off on by the due date. Clinicians were instructed to have all comprehensive treatment plans completed at least one week prior to due date to provide Clinical Supervisor enough time to review and send back for corrections if necessary so that they will be completed correctly and signed no later than due date. Clinical Supervisor will monitor this area on weekly basis to ensure comprehensive treatment plans are being completed on time. |