INITIAL COMMENTS
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This report is a result of an on-site licensure renewal and methadone AND/OR buprenorphine monitoring inspection conducted on November 14, 2022 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 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 four applicable patient records, the facility failed to provide patient # 7 with 2.5 hours of psychotherapy per month during the patient's first 2 years of treatment.
Patient # 7 was admitted on August 21, 2020 and was discharged on February 18, 2022. In January 2022, the patient had 1.45 hours of individual therapy and 0 hours of group therapy. There was no documentation of patient no shows or cancellations during those time periods.
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 ensure patients are completing required monthly counseling units, the Clinical Supervisor(s) re-trained the staff on 12/2/2022 on how to utilize the Methasoft EHR to assist patients in meeting monthly counseling units.
The Clinical Supervisor(s) trained clinicians to use EHR Methasoft reports "Scheduled Events", the Scheduler, Daily Activities, and utilizing dose holds (a dose hold is an alert in the EHR that stops the patient when checking in indicating the patient is required to see a counselor), to assist patients with meeting required monthly counseling units. Utilize phone, video, and/or group counseling as needed to help patients complete monthly units. Non-compliance will be addressed during supervision.
The Clinical Supervisor will audit the minimum of one chart per month for each counselor/CA. Pinnacle Treatment Centers utilizes a 2-tier auditing process to maintain compliance. PTC QI Department completes the second-tier auditing and when needed a PoC is completed indicating compliance and training as needed.
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715.20(4) LICENSURE Patient transfers
A narcotic treatment program shall develop written transfer policies and procedures which shall require that the narcotic treatment program transfer a patient to another narcotic treatment program for continued maintenance, detoxification or another treatment activity within 7 days of the request of the patient.
(4) The receiving narcotic treatment program shall document in writing that it notified the transferring narcotic treatment program of the admission of the patient and the date of the initial dose given to the patient by the receiving narcotic treatment program.
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Observations
Based on one applicable patient records reviewed, the facility failed to provide, in writing, documentation that it notified the transferring narcotic treatment program of the admission of the patient and the date of the initial dose given to the patient by the receiving narcotic treatment program.
Patient # 3 was admitted on May 6, 2022 and was still active at the time of the inspection. There was no documentation in the patient record of the admission of the patient or initial dose given to the patient by the receiving treatment program.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Facility Director reviewed the citation. The facility failed to ensure that all required information was sent to the receiving narcotic treatment program for patients that transferred to/from another treatment program. The Clinical Supervisor(s) re-trained the staff on 12/2/2022 on reviewing patient transfer regulations and policies and procedures. The training was focused on ensuring the clinical team members submit all required information to receiving treatment programs utilizing Methasoft EHR Transfer Acknowledgment letter and scan into the chart after faxed with confirmation. Clinical Supervisor(s) will audit discharge charts monthly to monitor compliance. Compliance concerns will be address in supervision. |
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 seven patient records, the facility failed to document an annual clinical evaluation of the patient in one of three applicable patient records.
Patient #1 was admitted on January 21, 2021 and was still active at the time of the inspection. The most recent annual evaluation was due no later than January 21, 2022; however, it was not documented in the patient record until April 29, 2022 and was not signed by any clinical staff.
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 not being completed as scheduled. The facility failed to ensure annual evaluations were complete as scheduled.
The Clinical Supervisor(s) re-trained on 12/2/2022 on how to utilize Methasoft EHR report "Scheduled Events", the Scheduler, Daily Activities, and utilizing dose holds (a dose hold is an alert in the EHR that stops the patient when checking in indicating the patient is required to see a counselor), to complete the evaluation in person and/or use the scheduler as a reminder during counseling phone calls. After completing the evaluation, signatures will be obtained by all required employees. Clinical Supervisor(s) will monitor compliance via monthly chart audits. Non-compliance will be addressed during 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 two of six applicable client records reviewed, the facility failed to provide case consultations in accordance with the facility policy and procedure manual. The facility policy and procedure manual indicate a case consultation to occur quarterly for the first year of services and then annually thereafter.
Client # 3 was admitted on May 5, 2022 and was still active at the time of the inspection. A case consultation was due to occur no later than September 5, 2022. There was no case consultation documented in the patient record.
Client # 5 was admitted on June 17, 2019 and was discharged on October 18, 2022. A case consultation was due to occur no later than June 17, 2022. There was no case consultation documented in the patient record.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Facility Director reviewed the citation. The facility failed to ensure case consultations were complete as scheduled.
The Clinical Supervisor(s) re-trained staff on 12/6/2022 on how to utilize Methasoft EHR report "Scheduled Events", to identify when a consultation is due for each patient on their caseload. Counselor will review patient with clinical supervisor during supervisor and complete the form. Signatures will be completed withing 24 hours.
Clinical Supervisor(s) will monitor compliance via monthly chart audits. Non-compliance will be addressed during 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 seven client records, the facility failed to document and compete and follow up information in one of three applicable client records.
Client #7 was admitted on August 21, 2020 and was discharged on February 18, 2022. There was no documentation of follow up information being completed in the client record.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Facility Director reviewed the citation. The facility failed to document, complete, and follow-up with a patient after discharge.
The Clinical Supervisor(s) re-trained staff on 12/6/2022 on how to utilize Methasoft EHR report "Scheduled Events" to determine when the 1st and 2nd discharge follow ups are due. Counselors will contact the discharge patient at the phone number provided in the EHR and document the results of the call. Signatures will be completed within 24 hours.
Clinical Supervisor(s) will monitor compliance via monthly chart audits. Non-compliance will be addressed during supervision.
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