INITIAL COMMENTS
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Based on the concerns arising from COVID-19, The Department of Drug and Alcohol Programs, Bureau of Quality Assurance for Prevention and Treatment, has implemented temporary procedures for conducting an annual renewal inspection. The inspection will be divided into two parts. 1, an abbreviated off-site inspection, will be conducted off site, and will require the submission of administrative information via email to a Licensing Specialist. 2, an abbreviated on-site inspection, will be conducted on-site at a later date and will include a review of client/patient records, and a physical plant inspection.This report is a result of Part 2, an abbreviated on-site inspection, conducted on October 14, 2020 by staff from the Department of Drug and Alcohol Programs, Bureau of Quality Assurance for Prevention and Treatment. Not all regulations were reviewed, the remainder of the regulations were reviewed during Part 1.Based on the findings of Part 2, an abbreviated on-site inspection, Polaris Renewal Services 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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705.23 (3) LICENSURE Counseling or activity areas and office space
705.23. Counseling or activity areas and office space.
The nonresidential facility shall:
(3) Ensure privacy so that counseling sessions cannot be seen or heard outside the counseling room. Counseling room walls shall extend from the floor to the ceiling.
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Observations
Based on a physical plant inspection, the facility failed to ensure privacy so that counseling sessions cannot be seen or heard outside the counseling room. A counselor's office in the back hallway had a counseling session occurring that could be heard in the room next to it and in the hallway. These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
PRS Director purchased white noise machines for each counselor. Counselors have been instructed by Director and Supervisor that white noise machines must be on and in use during all counseling sessions to ensure patient privacy.
All counseling staff will be instructed by the director and clinical supervisor to turn on their white noise machines at the start of each day, prior to any patient interaction. The noise machines will be turned off by the clinical staff as they are leaving for the day. The Director and/or Supervisor will do a daily walk through of the facility to ensure that all present staff have their white noise machines turned on. |
709.24 (a) (3) LICENSURE Treatment/rehabilitation management.
§ 709.24. Treatment/rehabilitation management.
(a) The governing body shall adopt a written plan for the coordination of client treatment and rehabilitation services which includes, but is not limited to:
(3) Written procedures for the management of treatment/rehabilitation services for clients.
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Observations
Based on the review of the facility policy and procedure manual and review of client records, the facility failed to follow the policy and procedures for the development of the comprehensive treatment plan and case consultations.The policy and procedure manual indicate comprehensive treatment plans to be developed with the client within thirty days of admission. Comprehensive treatment plans were not developed with client within thirty days in client records # 1, 2, 3, 4, 5, and 8.The policy and procedure manual indicate case consultations are to be collaborative with the clinical supervisor and physician. Case consultations were not collaborative within client records # 3, 4, 6, 7, and 8.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Director changed the policies and procedures to reflect treatment plan practice. The initial treatment plan will be developed with the patient at intake/admission. The comprehensive treatment plan will be developed with the patient within 60 days of admission.
Case consultations will indicate the staff members involved in the case consultation process. Staff have been instructed by the Director and Supervisor to include staff names in the case consultation record. The clinical supervisor, during routine chart reviews, will check each consult to ensure that the staff participating in the consult are listed. |
709.28 (c) (2) 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:
(2) Specific information disclosed.
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Observations
Based on one of eight client records reviewed, the facility failed to keep disclosures of client identifying information within the limits established by 4 Pa. Code 255.5 (b).Client # 4 was admitted on October 17, 2019 and was still active at the time of the inspection. A consent to release form to a funding source dated October 17, 2019 allowed for the release of "admission summary, treatment plans, laboratory tests, physician exam, progress notes, drug & alcohol assessment, dose history/current dose, psychiatric evaluation, and discharge summary. "These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Director will provide trainig to all staff on completing releases of information and what information can be identified and released,and to whom,according to 4.Pa.Code 255.5.
The counselor who incorrectly completed the funding source release for patient #4 was given individualized training by the director and supervisor about proper completion of consents to release information to comply with Pa. Code 255.5 and what can and cannot be released.
There is a funding source ROI template in the SMART EMR that follows 255.5. All staff will be instructed to use this template and not alter this release unless approved by Director.
The clinical supervisor will, as part of her routine chart review, will check all releases to ensure that all releases are completed according to 255.5 and that all disclosures are within the limits established by 4 Pa. Code 255.5.
As part of the peer review process, all releases of information and will be checked to make sure that the are completed in accordance with 255.5. Staff will be instructed to review disclosures or requests for information with clinical supervisor or director prior to the releaseo of any information. |
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 one of eight patient records reviewed, the facility failed to document the required 2.5 hours of psychotherapy per month during the patient 's first 2 years in patient record # 2.Patient # 2 was admitted on May 18, 2020 and was still active at the time of the inspection. In June 2020 the patient had 1 hour of individual therapy. In July 2020 the patient had .5 hours of individual therapy.In September 2020 the patient had 1.5 hours of individual therapy.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
All patients will receive their required 2.5 hours per month of psychotherapy during their first two years of treatment. This will be documented in the patient record and reviewed by the clinical supervisor using chart reviews and administrative services reports. Any patient who does not complete their required monthly therapy hours will be placed on a corrective action plan.
Patient #2's primary counselor did document attempts to schedule patient for session and also patient missing one of her scheduled sessions in June. This patient's primary counselor resigned and as Polaris was actively seeking a new counselor to fill that vacancy, this patient was monitored by the clinical supervisor but did not meet her required 2.5 hours of psychotherapy for the identified months. Polaris will make every effort to recruit and retain qualified counseling staff to ensure that all patients are meeting their monthly required therapy hours.
The clinical supervisor will review service reports with each counselor mid month and at the end of each month to make sure their patients are on track to receive their required counseling. |
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 of eight patient records reviewed, the facility failed to document the notification to the referring facility by the receiving facility of the admission and initial dosage of the patient.Patient # 8 was admitted as a transfer on July 17, 2019 and was still active at the time of the inspection. These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
A written notice of admission and initial dose of all transfers to Polaris will be contained in their record. The office administor will complete and fax the notice of admission and first dose to the referring clinic of each patient within 7 days of patient admission. The notification letter and fax confirmation will be uploaded by the administrator into the patient record. In the event that the office administrator is out of the office the clinical supervisor will complete and send the notice of transfer to the referring facility and upload into the patient record. The supervisor will conduct chart reviews on each discharged chart to verify that the notification was sent and is present in the patient chart. The director reviewed this process with supervisor and office admin. |