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 September 16, 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, PA Treatment & Healing 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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709.28 (b) LICENSURE Confidentiality
§ 709.28. Confidentiality.
(b) The project shall secure hard copy client records within locked storage containers. Electronic records must be stored on secure, password protected data bases.
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Observations
Based on a physical site inspection conducted on September 16, 2020, the facility failed to ensure that all hard copy client records were kept in locked storage containers and that there was no ability of unauthorized persons to gain access to such records. Counselor #6's filing cabinet, which contained client records was unlocked and unattended. The door to the office was also unlocked.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
During the physical site inspection it was found that the facility had failed to ensure that all hard copy client records were kept in locked storage containers and that there was no ability of unauthorized persons to gain access to such records with Counselor #6's filing cabinet, containing client records was unlocked and unattended with the office door also unlocked.
The Clinical Supervisor will review the policies and procedures with all staff regarding maintaining standards for confidentiality and maintenance of client records to ensure compliance and will continue to monitor that all office doors remained locked any time a staff member is not present in the room.
The agency will be in compliance with this standard as of 10/23/2020 |
709.28 (d) LICENSURE Confidentiality
§ 709.28. Confidentiality.
(d) A copy of a client consent shall be offered to the client and a copy maintained in the client record.
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Observations
Based on the review of client records on September 16, 2020, the facility failed to document a completed informed and voluntary consent to release information form. In one record, three consent forms were missing documentation that the client was offered a copy of the form.
Client #7 was admitted on January 8, 2019 and discharged on August 26, 2020. Two consent forms dated July 15, 2019, to a government agency and another treatment facility was missing the documentation. In addition, another form, dated January 22, 2019 to a government agency was also missing the documentation.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The facility failed to document a completed informed and voluntary consent to release information form. In one record, three consent forms were missing documentation that the client was offered a copy of the form.
The Clinical Supervisor will review proper completion of all consent forms with all counselors
The Clinical supervisor and/or program director will ensure compliance with this regulation through ongoing supervision and quality review of client files.
The agency will be in compliance with this standard as of 10/23/2020 |
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 client records on September 16, 2020, the facility failed to provide client's #3 and 7 with 2.5 hours of psychotherapy per month during the client's first two years of treatment.
Client #3 was admitted on March 17, 2020 and was still active at the time of the inspection. In June, July and August 2020, the client had one hour of individual therapy during each of those months. There was no documentation of client no shows or cancellation during those time periods.
Client #7 was admitted on January 8, 2019 and discharged on August 26, 2020. In May 2020, the client had one hour of individual therapy and one no show. In June and July 2020, the client received one hour of individual therapy during each of those months, with no documentation of no shows or cancellations.
These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
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.
Based on the review of client records the facility failed to provide 2.5 hours of psychotherapy per month during the first two years of treatment for Client's #3 and 7.
The Clinical supervisor will retrain all staff regarding the required provision of service for all clients admitted into the MAT program and will monitor compliance through supervision and quality review of client files.
The agency will be in compliance with this standard as of 10/23/2020 |
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 client records on September 16, 2020, the facility failed to properly document frequency on the individual treatment plans. For clients #1, 4 and 5, the individual treatment plans provided a range of "1-2X weekly" for individual therapy.
Client #1 was admitted on March 9, 2020 and was still active at the time of the inspection. The individual treatment plan was dated March 13, 2020.
Client #4 was admitted on July 25, 2019 and discharged on December 16, 2019. The individual treatment plan was dated September 26, 2019.
Client #5 was admitted on September 27, 2019 and discharged on November 26, 2019. The individual treatment plan was dated October 11, 2019.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Based on a review of client records on September 16, 2020, the facility failed to properly document frequency on the individual treatment plans. For clients #1, 4 and 5, the individual treatment plans provided a range of "1-2X weekly" for individual therapy.
The agency failed to document the exact frequency of services to be provided to each client instead giving a range of frequency for individual therapy.
The program Director will update the treatment plans to remove the range of frequency and provide the counselor the ability to indicate an exact frequency of provision of services for each client.
The clinical supervisor/Program Director will ensure compliance with this regulation through ongoing supervision and quality review of client files.
The agency will be in compliance with this standard as of 10/23/2020 |