INITIAL COMMENTS
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This report is a result of an on-site licensure renewal and methadone monitoring inspection conducted on August 29, 2022 through August 30, 2022, by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, Lebanon Treatment 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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704.12(a)(6) LICENSURE OutPatient Caseload
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.
(6) Outpatients. FTE counselor caseload for counseling in outpatient programs may not exceed 35 active clients.
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Observations
Based on the review of the Staffing Requirements Facility Summary Report, the facility failed to keep client/staff ratios at or below the regulation limit of 35/1.
Employee #5 was hired as the clinical supervisor on July 25, 2022 and was still acting in that position at the time of the inspection. Employee #5 was reported to have 25 hours per week devoted to their 35 clients on their caseload.
The counselor Full Time Equivalent (FTE) is determined by dividing the total number of hours the counselor devotes to their clients by facility ' s work week. Then, in order to obtain the counselor ' s ratio, the total number of clients on the counselor ' s caseload is divided by the FTE.
The FTE counselor ' s caseload calculation is as follows: 25/40 = 0.62(FTE); 35/0.62 = 56, which equals to a client/counselor ratio of 56:1.
The overall facility FTE follows the above equation. The facility was reported to have 196 hours per week devoted to their 184 clients.
The facility FTE caseload calculation is as follows: 196/40=4.9 (FTE); 184/4.9= 37.5, which equals to a client/counselor ration of 38:1.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
LTC is currently in the process of hiring new counselors, which will assist with counselor/client ratios. A new counselor began on 9/26/2022 and LTC has a position posted for another counselor. LTC is working towards full compliance with case loads by 10/31/2022.
CS is responsible for hiring and training new counselors. CD will monitor CS progress with compliance with this POC which will be reviewed in weekly management meetings. |
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 seven client records, the facility failed to ensure that verbal orders were authenticated in writing by a physician or other medical professional within 72 hours.
Client # 3 was admitted on July 1, 2022 and was active at the time of the inspection. A verbal order was given on July 1, 2022 but was not authenticated in writing until July 5, 2022.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
CD is working with IT to correct log on ability of the Physician to ensure Physician access to the EHR when Physician is not on site. Additionally, nursing staff/PA have will begin communicating with the Physician that verbal orders are ready for signing at the end of each business day to ensure compliance to this regulation is met. Physician will receive education from Supervisory staff to this end as well.
Clinic Director will monitor on-going compliance via random chart audits and monthly medical team meetings
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709.33 (a) LICENSURE Notification of termination.
§ 709.33. Notification of termination.
(a) Project staff shall notify the client, in writing, of a decision to involuntarily terminate the client ' s treatment at the project. The notice shall include the reason for termination.
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Observations
Based on a review of seven client records, the facility failed to document that the patient was notified, in writing, of the facility's decision to involuntarily terminate the patient's treatment at the project in one of one applicable record reviewed.
Client #2 was admitted on August 13, 2020 and was involuntarily discharged on March 30, 2022. There was no documentation that the patient was notified, in writing, of the facility's decision to involuntarily terminate.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Clinical Supervisor will review the discharge follow up policy with the clinical team. Counselors will inform patients in writing of pending termination and or involuntary termination of treatment. A copy of this will be maintained in the patient record. Discharge quality record reviews completed by CD weekly will monitor adherence with this policy. |
715.6(e) LICENSURE Physician Staffing
(e) A physician assistant or certified registered nurse practitioner may perform functions of a narcotic treatment physician in a narcotic treatment program if authorized by Federal, State and local laws and regulations, and if these functions are delegated to the physician assistant or certified registered nurse practitioner by the medical director, and records are properly countersigned by the medical director or a narcotic treatment physician. One-third of all required narcotic treatment physician time shall be provided by a narcotic treatment physician. Time provided by a physician assistant or certified registered nurse practitioner may not exceed two-thirds of the required narcotic treatment physician time.
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Observations
Based on a review of seven patient records, the facility failed to ensure that documentation of duties performed by a physician assistant or certified registered nurse practitioner were properly countersigned in two records reviewed.
Patient #3 was admitted on July 1, 2022 and was active at the time of the inspection. The record contained documentation of an order by the physician ' s assistant on August 19, 2022, which was not countersigned by the narcotic treatment physician within three days.
Patient #6 was admitted on November 23, 2020 and was discharged on June 18, 2022. The record contained documentation of dose reviews on November 19, 2021 and April 25, 2022 completed by the certified registered nurse practitioner and the physician ' s assistant, respectively, which were not countersigned by the narcotic treatment physician within three days.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Physician assistant and/or CRNP will have records appropriately counter-signed by NTP physician within 3 days. CD is working with IT to correct log on ability of the Physician to ensure Physician access to the EHR when Physician is not on site. Additionally, nursing staff/PA/CRNP will communicate with the Physician that verbal orders are ready for signature at the end of each business day to ensure compliance to this regulation is met. Physician will receive education from Supervisory staff to this end as well.
Nursing supervisor will review all orders to ensure that the physician countersigned and dated.
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715.9(a)(4) 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:
(4) Have a narcotic treatment physician make a face-to-face determination of whether an individual is currently physiologically dependent upon a narcotic drug and has been physiologically dependent for at least 1 year prior to admission for maintenance treatment. The narcotic treatment physician shall document in the patient 's record the basis for the determination of current dependency and evidence of a 1 year history of addiction.
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Observations
Based on a review of seven patient records, the facility failed to have a narcotic treatment physician make a face-to-face determination of whether an individual is currently physiologically dependent upon a narcotic drug and has been for at least one year in one record reviewed.
Patient #3 was admitted on July 1, 2022 and was active at the time of the inspection. The initial face-to-face determination of physiological dependency was made by a physician ' s assistant on July 1, 2022.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Any and all individuals seeking Treatment and Recovery via the OTP will be seen by the Narcotic Treatment Physician for a face-to-face determination of need as denoted in 715.9(a)(4).
The Clinic Director, Medical Director and Charge Nurse will ensure compliance to this regulation. Charge nurse will ensure documentation is completed and signed timely.
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715.12(1-5) LICENSURE Informed patient consent
A narcotic treatment program shall obtain an informed, voluntary, written consent before an agent may be administered to the patient for either maintenance or detoxification treatment. The following shall appear on the patient consent form:
(1) That methadone and LAAM are narcotic drugs which can be harmful if taken without medical supervision.
(2) That methadone and LAAM are addictive medications and may, like other drugs used in medical practices, produce adverse results.
(3) That alternative methods of treatment exist.
(4) That the possible risks and complications of treatment have been explained to the patient.
(5) That methadone is transmitted to the unborn child and will cause physical dependence.
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Observations
Based on a review of seven patient records, the facility failed to obtain an informed, voluntary, written consent before an agent was administered in one record reviewed.
Patient # 7 was admitted on September 9, 2021 and was active at the time of the inspection. The patient was initially administered an agent on September 9, 2021; however, the informed, voluntary, written consent was not signed until September 13, 2021.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Each patient must complete a consent treatment for regardless of type of MAT Prior to getting first dose or prescription, patients will complete this with provider. Dosing nurses will verify that this was completed prior to providing first dose and/or prescription.
Nursing supervisor will monitor through weekly admission audits. Nursing Supervisor will review compliance to this process during weekly management meetings. |
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, the facility failed to provide each patient with the required number of individual and group psychotherapy hours in two records reviewed.
Patient #1 was admitted on September 8, 2021 and was active at the time of the inspection. The patient was required to have at least two and a half hours of individual and group psychotherapy per month. During the 2022 month of July, the patient only received two hours of individual therapy.
Patient #7 was admitted on September 9, 2021 and was discharged on January 29, 2022. The patient was required to have at least one hour of individual psychotherapy per month. During the 2021 month of December and October, the patient did not receive any individual therapy per month.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
All patients will complete 2.5 hours of counseling a month. Counselors will document no shows and efforts to assist patients gain compliance. CS will monitor patients' attendance and compliance and discuss efforts with CD. |
715.19(3) LICENSURE Psychotherapy services
A narcotic treatment program shall provide individualized psychotherapy services and shall meet the following requirements:
(3) After 4 years of treatment, a narcotic treatment program shall provide each patient with at least 1 hour of group or individual psychotherapy every 2 months. 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 with the required number of individual or group psychotherapy hours in one record reviewed.
Patient #5 was admitted on March 25, 2015 and was discharged on May 17, 2022. The patient was required to have at least one hour of individual psychotherapy every two months. During the 2022 months of January and February, the patient only received a total of 30 minutes of psychotherapy.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
All patients will be scheduled to complete hour/30 minutes therapy a month. Counselors will document no shows and efforts to assist patients gain compliance. CS will monitor patients' attendance and compliance and discuss efforts with CD. |
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 seven records, the facility failed to ensure an annual physical reevaluation in one of three applicable records reviewed.
Patient #2 was admitted on August 13, 2020 and was discharged on March 30, 2022. The most recent annual physical evaluation was due no later than August 13, 2021; however, it was not documented in the patient record until September 22, 2021.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
All annual physicals will be monitored via our EMR report and scheduled one month in advance to ensure timely completion. The patient will have a hold placed by the scheduler on their EMR Account for the day of the annual appointment and reminders will be given prior to the appointment day.
Nursing supervisor will be responsible for ensuring annuals are completed timely. Nursing supervisor will report to Clinic Director during 1 on 1 supervision on compliance with this plan of correction. |
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 the review of patient records, the facility failed to document a completed annual evaluation signed by the medical director in three of three applicable records.
Patient #2 was admitted on August 13, 2020 and was discharged on March 30, 2022. The annual clinical evaluation was completed on August 17, 2021.
Patient #5 was admitted on March 25, 2015 and was discharged on May 17, 2022. The annual clinical evaluation was completed on March 29, 2022.
Patient #6 was admitted on November 23, 2020 and was discharged on June 18, 2022. The annual clinical evaluation was completed on November 17, 2021.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
CD and/or NS will meet with the extender to discuss the need to have all pending documents reviewed and signed prior to leaving for the day. CD will monitor timely completion via the direct services report through the EMR. |
709.92(a)(2) 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:
(2) Type and frequency of treatment and rehabilitation services.
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Observations
Based on a review of seven client records, the project failed to develop an individual treatment and rehabilitation plan to include written documentation of type and frequency of treatment and rehabilitation services in one of three applicable records reviewed.
Client #7 was admitted on September 9, 2021 and was active at the time of the inspection. A treatment and rehabilitation plan signed on October 27, 2021 did not include type or frequency of treatment and rehabilitation services.
These findings were reviewed with project staff during the licensing process.
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Plan of Correction
Clinical Supervisor will provide training for all clinicians to ensure that the written person-centered plan includes specific service or treatment objectives that are measurable, achievable, and time specific and that they include a description of the modality to be used as well as the type and frequency of services.
CS will complete qualitative record reviews will ensure conformance to the standard. CS will follow up with clinicians in supervision with any areas of concern.
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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 seven client records, the facility failed to ensure that treatment and rehabilitation plans were reviewed updated according to regulatory standards in two of six applicable records reviewed.
Client #5 was admitted on March 25, 2015 and was discharged on May 17, 2022. A treatment plan update was completed on August 3, 2021 and a treatment plan update was due to be completed by December 3, 2021; however, the next treatment plan update was not completed until January 18, 2022.
Client #7 was admitted on September 9, 2021 and was discharged on January 29, 2022. A treatment plan update was completed on November 11, 2021 and a treatment plan update was due to be completed by January 11, 2022; however, no treatment plan updates were completed prior to discharge.
These findings were reviewed with facility staff during the licensing process.
This is a repeat citation from the August 27, 2021 annual licensing inspection.
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Plan of Correction
CD will work with the CS and clinical team to ensure timely updates are documented to all patient individual treatment plans in accordance to regulations.
CS will monitor /review during weekly supervision meetings with their team to ensure tx plans are updated every 60 days with assistance from reports in the electronic health record.
Progress and updates will be reviewed during the CS weekly supervision meetings with the CD.
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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 the facility's written plan for the coordination of client treatment and rehabilitation services, the facility's written procedures for the management of treatment/rehabilitation services for clients indicated case consultations would occur quarterly in the first year of treatment and annually thereafter. Documentation consistent with these procedures was missing in two of six applicable records reviewed.
Client #1 was admitted on September 8, 2021 and was active at the time of the inspection. The record contained documentation of only one case consultation occurring on December 1, 2021, without the required subsequent case consultation in the first year.
Client #7 was admitted on September 9, 2021 and was discharged on January 29, 2022. The first case consultation was due to be completed by December 9, 2021, however, it was not documented as being completed until December 17, 2021.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
CS will review case consultation dates with clinical staff and will monitor for compliance monthly. CS will follow up with counselors in individual supervisions. |
709.94(e) LICENSURE Project management services
709.94. Project management services.
(e) The project shall develop a written client follow-up policy.
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Observations
Based on a review of client records, the facility failed to follow their written client follow-up policy in two of four applicable records reviewed.
Client #2 was admitted on August 13, 2020 and was discharged on March 30, 2022. The record did not contain documentation of follow up information with the client within 72 hours of discharge in accordance with the facility policy.
Client #6 was admitted on November 23, 2020 and discharged on June 18, 2022. The record did not contain documentation of follow up information with the client within 30 days of discharge in accordance with the facility policy.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Clinical Supervisor will review the Post discharge follow up policy with the clinical team. Clinical Supervisor will review discharges to ensure that counselors are completing discharge summaries within 72 hours; The clinical team will attempt to contact all unplanned discharge patients to offer referrals for any identified services needed. Ongoing clinical supervision and qualitative record review will ensure conformance to regulation. |