INITIAL COMMENTS
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This report is a result of an on-site licensure renewal and methadone and buprenorphine monitoring inspection conducted on September 12, 2023 by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, ARS of Epharta LLC 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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704.11(c)(1) LICENSURE Mandatory Communicable Disease Training
704.11. Staff development program.
(c) General training requirements.
(1) Staff persons and volunteers shall receive a minimum of 6 hours of HIV/AIDS and at least 4 hours of tuberculosis, sexually transmitted diseases and other health related topics training using a Department approved curriculum. Counselors and counselor assistants shall complete the training within the first year of employment. All other staff shall complete the training within the first 2 years of employment.
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Observations
Based on a review of personnel records and the facility's Staffing Requirement Facility Summary Report (SRFSR) form, the facility failed to ensure that employee #3 received the minimum of 6 hours of HIV/AIDS training and at least 4 hours of TB/STD and other health related topics within the regulatory timeframe.
Employee #3 was hired as a counselor on April 11,2022 and was due to have the communicable disease trainings no later than April 11, 2023. There was no documentation in the personnel file of the completion of the HIV/AIDS training and the TB/STD training as of the date of the inspection.
The findings were discussed with facility staff during the licensing process.
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Plan of Correction
Employee #3 completed the HIV training on 8/31/2023. She will schedule and complete the 4 hours of TB, STD and other health related topics training by 12/31/2023. This length of time was given due to the difficulty in finding open courses available to schedule locally or virtually that work with all schedules.
A spreadsheet has been created to track trainings for all staff to ensure completion. New staff will be added as they are hired to ensure completion within required timeframes. The lead counselor/clinical supervisor will be responsible for maintaining the spreadsheet and ensuring that all staff are up to date with their trainings.
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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.
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.
Employee #2 was hired as the facility director on July 8, 2020 and was still acting in that position. Employee #2 was reported to have 10 hours per week devoted to their 12 clients on their caseload.
The FTE counselor's caseload calculation is as follows: 10/40 = .25 (FTE); 12/1 = 48, which equals to a client counselor ratio of 48:1.
Employee #5 was hired as a counselor on February 28, 2023 and was still acting in that position. Employee #5 was reported to have 40 hours per week devoted to their 44 clients on their caseload.
The FTE counselor's caseload calculation is as follows: 40/40 = 1 (FTE); 44/1 = 44, which equals to a client counselor ratio of 44:1.
These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
Clinical supervisor will review all counselor's caseloads in weekly supervisions to determine counselor to patient ratios which will begin in supervisions the week of 10/16/2023. Clinical supervisor will identify the number of patients with exempt status versus non-exempt status in order to ensure that counselor to patient ratio is remaining within the 1:35 ratio that is required. Caseloads will be adjusted as needed based on incoming admissions and patients moving to exempt status. In times when there are vacant counselor positions, all attempts to keep caseloads within ratio will be made and will be kept as close to the ratio as possible until the position(s) are filled. |
705.10 (d) (4) LICENSURE Fire safety.
705.10. Fire safety.
(d) Fire drills. The residential facility shall:
(4) Maintain a written fire drill record including the date, time, the amount of time it took for evacuation, the exit route used, the number of persons in the facility at the time of the drill, problems encountered and whether the fire alarm or smoke detector was operative.
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Observations
Based on a review of the September 2022 through August 2023 fire drill logs during the inspection, the facility failed to document the exit route used for drills completed October 2022, November 2022, December 2022 and January 2023.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
Health and Safety officer was retrained on need to identify the exit that was used during the drills. All staff were retrained on this requirement in the DDAP audit review in the September monthly all staff meeting on 9/19/2023. Executive Director will ensure that the exit is identified on each drill report monthly when signing off on completion of report. |
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 October May 7- 13, 2023 the patient census was 190. The facility was required to provide at least 19 physician hours. There were 14 physician hours documented.
During the week of June 18-24, 2023, the patient census was 194. The facility was required to provide at least 19.4 physician hours. There were 14 physician hours documented.
During the week of July 9-15, 2023, the patient census was 203. The facility was required to provide at least 20.3 physician hours. There were 14 physician hours documented.
During the week of August 6- 12, 2023, the patient census was 203. The facility was required to provide at least 20.3 physician hours. There were 14 physician hours documented.
This finding was reviewed with facility staff during the licensing inspection.
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Plan of Correction
Executive Director has filled the Physician Assistant position, the Physician assistant having started on 9/5/2023. The PA will provide a minimum of 20 hours per week and the doctor will provide a minimum of 6 hours per week at this time. This will allow the clinic room to grow past its current census and remain in compliance with this regulation. This will also keep the clinic in compliance with the approved exception of the 80/20 split of PA to Dr hours covered at our clinic. |
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 patient records, the facility failed to provide patients with 2.5 hours of psychotherapy per month during the patient's first two years of treatment, one hour of which shall be individual psychotherapy, in five out of six applicable records reviewed.
Patient #2 was admitted on February 10, 2023 and was still active at the time of the inspection. The patient only received psychotherapy for one hour in May 2023, zero hours in June 2023, and 30 minutes in both July and August 2023.
Patient #3 was admitted on June 13, 2023 and was still active at the time of the inspection. The patient only received psychotherapy for one hour in July 2023 and 54 minutes in August 2023.
Patient #4 was admitted on June 23, 2023 and was still active at the time of the inspection. The patient only received psychotherapy for 30 minutes in May 2023, zero hours in both June 2023 and July 2023 and 30 minutes in August 2023.
Patient #7 was admitted on May 11, 2021 and was discharged on June 15, 2023. The patient only received psychotherapy for thirty minutes in both February 2023 and March 2023 and zero hours in both April 2023 and May 2023.
Patient #8 was admitted on January 27, 2023 and was discharged on April 12, 2023. The patient only received psychotherapy for thirty minutes in February 2023 and zero hours in March 2023.
This finding was reviewed with facility staff during the licensing inspection.
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Plan of Correction
Clinical Supervisor will retrain clinical staff regarding the required 2.5 hours of counseling per month for individuals in treatment 0-2 years, 1 hours of counseling per month for individuals in treatment 2-4 years, and 1 hour of counseling every other month for individuals in treatment more than 4 years. Primary Counselors will monitor their Kipu BI Census dashboard weekly to determine individuals that have yet to be seen each month. Primary Counselor and Clinical Supervisor will discuss any engagement concerns in supervision and improvement plans will be created on at least a quarterly basis addressing areas to improve engagement that identify each counselors' individual strengths that will help improve patient engagement. |
715.19(2) LICENSURE Psychotherapy services
A narcotic treatment program shall provide individualized psychotherapy services and shall meet the following requirements:
(2) A narcotic treatment program shall provide each patient at least 1 hour per month of group or individual psychotherapy during the third and fourth year of treatment. 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 patients with one hour per month of therapy during the third and fourth year of treatment in one out of one applicable record.
Patient #6 was admitted on October 22, 2020 and was still active at the time of the inspection. The patient only received psychotherapy for thirty minutes in June 2023, zero hours in July 2023, and 30 minutes in August 2023.
This finding was reviewed with facility staff during the licensing inspection.
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Plan of Correction
Clinical Supervisor will retrain clinical staff regarding the required 2.5 hours of counseling per month for individuals in treatment 0-2 years, 1 hours of counseling per month for individuals in treatment 2-4 years, and 1 hour of counseling every other month for individuals in treatment more than 4 years. Primary Counselors will monitor their Kipu BI Census dashboard weekly to determine individuals that have yet to be seen each month. Primary Counselor and Clinical Supervisor will discuss any engagement concerns in supervision and improvement plans will be created on at least a quarterly basis addressing areas to improve engagement that identify each counselors' individual strengths that will help improve patient engagement. |
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 a review of patient records, the facility failed to document that it notified a patient's previous facility of the patient's admission including the date of initial dose in one out of two applicable records.
Patient #2 was admitted on February 10, 2023 and was still active at the time of the inspection.
This finding was reviewed with facility staff during the licensing inspection.
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Plan of Correction
Clinical Supervisor/Executive Director will review with all staff in the all staff meeting on 10/18/2023 the paperwork required to be sent to an individual's previous treatment facility when they are transferred into our clinic as a new admission. Primary Counselor and DON will ensure all patients admitted as a transfer from another clinic complete a ROI for their previous treatment provider. Clinical Supervisor or Lead Counselor will audit all admission charts within 5 business days of admission to ensure deficiency does not reoccur. |
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 three applicable records.
Patient #4 was admitted on June 23, 2022 and was still active at the time of the inspection. The annual physical examination was due June 23, 2023. No annual physical was documented in the patient record at the time of the inspection.
This finding was reviewed with facility staff during the licensing inspection.
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Plan of Correction
The Director of Nursing will conduct an audit of all active patients to identify those individuals who are past due for annual physical examinations by 10/31/2023. These individuals will be flagged to be scheduled for the evaluations within the month of October with one of the three medical providers on site now five days per week.
Moving forward, H&P/Annual flags will be placed on all individual charts at admission for every 6 months to conduct the annual and biannual physical evaluations with the medical providers. DON will be responsible for ensuring that individuals are maintaining compliance with annual and biannual physical evaluations.
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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 patient records, the facility failed to document an annual clinical evaluation within the regulatory timeframe in one out of two applicable records.
Patient #4 was admitted on June 23, 2022 and was still active at the time of the inspection. The annual clinical evaluation was due on July 23, 2023. No annual clinical evaluation was documented in the patient record at the time of the inspection.
These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
The Clinical Supervisor will conduct an audit of all active patients to identify those individuals who are past due for annual clinical evaluations by 10/31/2023. Primary Counselors will be given a two week period to complete any past due evaluations.
Moving forward, Primary Counselors will be responsible for completing their annual clinical reviews within 30 days of the individuals admission anniversary. This will be monitored via quarterly peer review audits as well as chart reviews done in individual supervisions.
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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 client records, the facility failed to document treatment plan updates within the regulatory timeframe in five out of eight records reviewed.
Client #1 was admitted on November 8, 2022 and was still active at the time of the inspection. A treatment plan update was completed on April 17, 2023 and the next update was due no later than June 17, 2023; however, the next update was completed on July 12, 2023.
Client #2 was admitted on February 10, 2023 and was still active at the time of the inspection. A treatment plan update was completed on April 13, 2023 and the next update was due no later than June 13, 2023; however, it was completed on July 23, 2023.
Client #4 was admitted on June 23, 2022 and was still active at the time of the inspection. A treatment plan update was completed on April 17, 2023 and the next update was due no later than June 17, 2023; however, it was completed on July 20, 2023.
Client #5 was admitted on November 18, 2022 and was still active at the time of the inspection. A treatment plan update was completed on December 19, 2022 and the next update was due no later than February 19, 2023; however, it was not completed until May 24, 2023.
Client # 8 was admitted on January 27, 2023 and was discharged on April 12, 2023. A comprehensive treatment plan was completed on January 31, 2023. A treatment plan updated was due March 31, 2023. No update was documented in the record at the time of the inspection.
These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
The Clinical Supervisor will review with all counselors the need to obtain signatures for treatment plans within 3 days of completing the treatment plan and completing the treatment plan review in the treatment plan review tab on Kipu. This review occurred with counselors in group clinical supervision on 9/27/2023.
Counselors treatment plans will be monitored weekly via the overdue treatment plan report. Accuracy of treatment plans will be monitored through quarterly peer review audits and monthly DQRAT audits where treatment plans are assessed for completion and content.
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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 client records and the facility policy and procedure manual, the facility failed to provide a complete client record, which is to include follow-up information within 30 days of discharge in two out of two discharged records reviewed.
Client #7 was admitted on May 11, 2021 and was discharged on June 15, 2023.
Client #8 was admitted on January 27, 2023 and was discharged on April 12, 2023.
These findings were reviewed with facility staff during the licensing process
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Plan of Correction
The Clinical Supervisor will review with all staff the need for follow up calls to be made to individuals who have been discharged from the program within 30 days of their discharge in the all staff meeting on 9/19/2023.
The staff member completing the monthly discharge report will make the follow up calls when completing the discharge report at the end of each month. Currently the discharge report is being completed by the office manager however this will transition to the lead counselor by 10/31/2023. This will be audited in the monthly discharge audit as well as in quarterly peer review chart audits.
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