INITIAL COMMENTS
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This report is a result of an on-site licensure renewal and methadone monitoring inspection conducted on November 28-30, 2022 by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, Tadiso, Inc. 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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704.2(b) LICENSURE Staffing Plan
704.2. Compliance plan.
(b) The plan documenting the qualifications and training of staff shall be presented to Department licensing representatives at the time of the project's site visit.
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Observations
Based on a review of the staffing requirements facility summary report, the facility failed to document accurate information related to staff qualifications and training. The staffing requirements facility summary report required multiple revisions due to the discovery of inaccurate information throughout the inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Director of Human Resources and the Policy Specialist will meet quarterly to review the facility summary report to keep an exact staff roster. The review will include adding new employees, removing terminated or resigned employees, adding training hours that employees attended for licensing requirements, and for accuracy.
The HR Director, Policy Specialist, and Director of Social Service will choose a day prior to audit pre-submission to complete the facility summary report. The following items will be reviewed; census numbers, verification that all current full-time and part-time employees are rostered, identifying eligible staff support employees who can support a caseload, and ensure proper calculations are completed for staffing regulation of 35:1 ratio. |
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 a review of the Staffing Requirements Facility Summary Report, the facility failed to maintain counselor caseloads at or below 35:1 in two of thirty-one caseloads.
Counselor #12 works 10 hours per week with D/A clients. 10 hours / 37.5 workweek = .27 FTE. Counselor #12 is assigned 12 clients. 12/.27 FTE = 44.4. Counselor #12 has a 44:1 caseload.
Counselor #15 works 10 hours per week with D/A clients. 10 hours / 37.5 workweek = .27 FTE. Counselor #15 is assigned 13 clients. 12/.27 FTE = 48.14. Counselor #12 has a 48:1 caseload.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Director of Social Service and Supervisors will monitor Full-time equivalent (FTE) client/counselor ratios. FTE staff will have no more than thirty-five active clients. Part-time staff weekly hours will be checked by the Director of Social Services and the ratio calculated before they are given added patients. Clinical supervisor will monitor caseload numbers.
For record on Plan of Correction
Counselor #15 should not have been on the staffing requirement form, as he was no longer employed the day the staffing form was completed.
Counselor #12 was no longer employed the day after the staffing form was completed. |
715.9(a)(1) 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:
(1) Verify that the individual has reached 18 years of age.
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Observations
Based on a review of patient records, the facility failed to document verification the patient was at least 18 years of age in one of eight patient records.
Patient #1 was admitted on March 21, 2022 and is a current and active patient. There was no documentation of age verification in patient record #1.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
DDAP (Department of Drug and Alcohol Programs) Licensing brought to our attention on 11/30/2022 that a patient file was missing the verification of age and identity (I.D.). After further review by the Director of Social Services, it was not able to be located. The current process is as follows, there is a form in the electronic health record that allows a counselor, or supervisor to confirm an ID has been verified at intake. Once the ID is obtained, a note would be documented in the electronic health record by Social Service or Fiscal employee. The Director of Social Services and the Fiscal Department will oversee ensuring that all ID's are verified as received for all admissions.
Please see our policy attached to 715.9(a)(2)
Reviewed with Fiscal and Intake 1/5/2023 |
715.9(a)(2) 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:
(2) Verify the individual 's identity, including name, address, date of birth, emergency contact and other identifying data.
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Observations
Based on a review of patient records, the facility failed to document verification of identity, including name, address and date of birth in one of eight patient records.
Patient #1 was admitted on March 21, 2022 and is a current and active patient. There was no documentation of identity verification in patient record #1.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
DDAP Licensing brought to our attention on 11/30/2022 that a patient file was missing the process of verifying the individual 's identity, including name, address, date of birth, emergency contact and other identifying data. After further review, identity documents were not able to be located. The current process is as follows, there is a form in the electronic health record that allows a counselor, or supervisor to confirm an ID has been verified at intake. Once the ID is obtained, a note would be documented in the electronic health record by Social Service or Fiscal employee. The Director of Social Service and Fiscal Department will oversee ensuring that all ID's are verified as received for all admissions that includes verifying the individual's identity, including name, address, date of birth, emergency contact and other identifying information.
Our policy created on 3/2019
Reviewed with Fiscal and Intake 1/5/2023
MANAGEMENT OF VERIFICATION OF PATIENT IDENTIFICATION
PURPOSE: To aid the patient in verifying identification and to aid in accommodating the start of Medicated Assisted Treatment for the prospective patient.
POLICY: Tadiso will help the patient to verify identification and to make accommodations to start treatment as soon as possible.
PATIENT WITH NO ID
The prospective patient will meet with the intake coordinator.
The intake coordinator will notify the Director of Social Service if the patient does not have photo ID.
The Director of Social Service will give the scheduled intake counselor instructions for retrieving an ID
The following steps will take place to obtain an ID.
The prospective patient will be interviewed and potential treatment facilities and hospitals that the patient last attended will be named.
A fiscal staff member from the fiscal office will be contacted and EVS will be run to verify potential past or present medical aid.
If a new ID is needed an RSS will be contacted to help coordinate the delivery of service and help this prospective patient secure an ID.
Accommodation will be made to get the patient into treatment.
A fiscal staff member will stay in touch with administration about the status of the ID.
Fiscal will scan any presented form of ID (hospital ID bracelet, jail identification, passport, et cetera) along with an attestation form into the electronic health record until patient can obtain a government issued identification card. A hard copy is filed in the patient's fiscal department file.
PATIENT WITH ID
The prospective patient will produce a photo identification to intake coordinator for verification purposes of identity.
The Fiscal Department will complete a Verification of Patient Identification Attestation form and scan the provided ID and form into the patient's electronic health record. A hard copy of the form is filed in the patient's fiscal department record. |
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 document at least 2.5 hours of psychotherapy per month in six of nine patient records.
Patient #2 was admitted on April 22, 2022 and is currently an active patient. According to patient #2 ' s treatment plan, 2.5 hours of counseling are required each month. The patient had 2.25 hours of psychotherapy documented for August 2022, 1.5 hours for September 2022 and 2 hours for October 2022.
Patient #3 was admitted on September 8, 2022 and is currently an active patient. According to patient #3 ' s treatment plan, 2.5 hours of counseling are required each month. The patient had 0 hours of counseling for October 2022.
Patient #4 was admitted on March 8, 2022 and is currently an active patient. According to patient #4 ' s treatment plan, 2.5 hours of counseling are required each month. The patient had 2.5 hours in September and October 2022; however, only 1.5 hours of counseling were documented for August 2022.
Patient #5 was admitted on October 1, 2020 and is currently an active patient. According to patient #5 ' s treatment plan, 2.5 hours of counseling are required each month. The patient had 2 hours of counseling for August 2022, 1 hour for September 2022.
Patient #6 admitted to September 25, 2019 and is currently an active patient. According to Patient #6 ' s treatment plan, 2.5 hours of counseling is required each month. The patient had 1.5 hours for August 2022.
Patient #9 was admitted on November 10, 2020 and discharged on August 11, 2022. According to patient #9 ' s treatment plan, 2.5 hours of counseling are required each month. The patient had .5 hour of counseling in May 2022, 2.5 hours in June 2022 and .5 hour for July 2022.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
All standard level of care patients must attend 2.5 hours of counseling.
The patient's primary counselor will schedule the patient for all required counseling hours. If the patient misses a scheduled counseling appointment, the counselor will place a note in the patient's file saying that they did not cancel or show for the appointment. The counselor will also document any time the patient reschedules their counseling appointment in the case history.
The patient may have to attend a group at the end of the day if they miss their individual counseling appointment, this is up to the discretion of the primary counselor.
If a patient does not receive the required 2.5 hours of counseling for the month, they will speak with their primary counselor on counseling requirements for the program. If the 2nd month the patient does not receive their required counseling hours, they will then speak with the clinical supervisor on counseling requirements. If the patient does not receive the 2.5 hours of required counseling for a 3rd month, they will then go to case conference, where they will meet with the doctor, clinical supervisor, and their counselor to discuss what the barriers are to engaging in treatment at the required level.
Each month the primary counselor and their clinical supervisor will review their direct service hours and create a plan of action for any patient who did not receive their required counseling requirements.
Effective 11/30/2022 |
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 document at least one hour of counseling services per month for patients in their third and fourth year of treatment in three of four patient records.
Patient #5 was admitted on October 1, 2020 and is currently an active patient. Patient #5 started the third year of treatment on October 1, 2022 and would required at least 1 hour of counseling services per month. The patient had 0 hours of counseling for October 2022.
Patient #8 was admitted on July 7, 2020 and discharged on November 16, 2022. Patient #8 entered the third year of treatment on July 7, 2022 and at least 1 hour of counseling services was required each month. The patient had 1 hour of counseling in August 2022, .5 hours in September 2022 and 1 hour for October 2022.
Patient #10 was admitted on June 5, 2018 and discharged on August 24, 2022. Patient #10 entered the third year of treatment on June 5, 2020 and at least 1 hour of counseling services was required each month. The patient had 1 hour of counseling in May 2022, 1 hours in June 2022 and 0 hours for July 2022.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Effective 11/30/2022
The assigned counselor will document in the patient's electronic health record why a patient may have missed or cancelled an appointment for all 3rd and 4th year patients.
All patients who have received a 2-year justification status will have to receive 1 hour of individual counseling per month.
All patients who have received a 4-year justification status will have to receive 1 hour of individual counseling every other month, or 30 minutes of counseling per month.
For a 2-year justification status patient misses 1 month of individual counseling, patient will be taken to case conference. In case conference, they will meet with the doctor, clinical supervisor, and their counselor to discuss the barriers to treatment at the required level.
For a 4-year justification status if the patient misses required individual counseling, the patient will be taken to case conference. In case conference, they will meet with the doctor, clinical supervisor, and their counselor to discuss barriers to treatment at the required level. |
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 the transferring facility, in writing, of the admission of the patient and the date of the initial dose given to the patient by the receiving narcotic treatment program in one of two patient records.
Patient #4 was transferred into the facility and was admitted on March 8, 2022. There was no documentation that written notification was sent to the transferring facility including the patient's admission and initial dose.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Current process of Tadiso;
When a patient transfers into Tadiso and completes the intake process. The Assistant Director of Admissions notifies the transferring facility via fax that the patient has completed the intake process and received medication. The Social Service Administrative Assistant scans the transferring paperwork, and fax confirmation into the patient's chart. A hard copy of the paperwork is kept in the "transfer in" binder that is kept in the Assistant Director of Admissions office.
Reviewed 1/3/2023 with Assistant Director of Admissions and effective at once. |
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 evaluation of each patient 's status that was reviewed, dated and signed by the medical director in five of seven patient records.
Patient #5 was admitted on October 1, 2020 and is currently an active patient. An annual evaluation was completed on November 9, 2022; however, it was not dated and signed by the medical director.
Patient #6 was admitted on September 25, 2019 and is currently an active patient. An annual evaluation was completed on October 14, 2022; however, it was not dated and signed by the medical director.
Patient #7 was admitted on March 3, 2021 and discharged on July 5, 2022. An annual evaluation was completed on May 7, 2022; however, it was not dated and signed by the medical director.
Patient #8 was admitted on July 7, 2020 and discharged on November 16, 2022. An annual evaluation was completed on July 12, 2022; however, it was not dated and signed by the medical director.
Patient #10 was admitted on June 5, 2018 and discharged on August 24, 2022. An annual evaluation was completed on May 17, 2022; however, it was not dated and signed by the medical director.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
DDAP (Department of Drug and Alcohol Programs) Licensing on 11/30/2022 found that five out of seven patient records were lacking a signature with date from the medical director on the patient's annual evaluation. The Director of Medical Services confirmed that annual evaluations will be reviewed, signed, and dated during a designated time by the doctor. Director of Social Service and Quality Assurance Coordinators will do quality checks to confirm that doctor has signed and dated annual evaluations during patient chart reviews.
Effective 1/5/2023 and reviewed with medical department. |
709.92(c) LICENSURE Treatment and rehabilitation services
709.92. Treatment and rehabilitation services.
(c) The project shall assure that counseling services are provided according to the individual treatment and rehabilitation plan.
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Observations
Based on a review of client records, the facility failed to document counseling services as per the treatment plan in eight of ten client records.
Client #2 was admitted on April 18, 2022 and is currently an active client. The treatment plan documented for client #2 stated the client was to receive 2.5 hours of counseling per month. Client #2 had documentation of 2 hours in October 2022, 1.5 hours in September 2022 and 2.25 in August 2022.
Client #3 was admitted on September 8, 2022 and is currently an active client. The treatment plan documented for client #3 stated the client was to receive 2.5 hours of counseling per month. Client #3 had documentation of 0 hours in October 2022.
Client #4 was admitted on March 8, 2022 and is currently an active client. The treatment plan documented for client #4 stated the client was to receive 2.5 hours of counseling per month. Client #4 had documentation of 2.5 hours in October and September 2022; however, only 1.5 hours documented for August 2022.
Client #5 was admitted on October 1, 2020 and is currently an active client. The treatment plan documented for client #5 stated the client was to receive 2.5 hours of counseling per month. Client #5 had documentation of 0 hours in October 2022, 1 hours in September 2022 and 2 hours in August 2022.
Client #6 was admitted on September 25, 2019 and is currently an active client. The treatment plan documented for client #6 stated the client was to receive 2.5 hours of counseling per month. Client #6 had documentation of 1 hour in October 2022, 1 hour in September 2022 and 1.5 hours in August 2022.
Client #8 was admitted on July 7, 2020 and discharged on November 16, 2022. The treatment plan documented for client #8 stated the client was to receive 2.5 hours of counseling per month. Client #8 had documentation of 1 hour in October 2022, .5 hours in September 2022 and 1 hour in August 2022.
Client #9 was admitted on November 10, 2020 and discharged on August 11, 2022. The treatment plan documented for client #9 stated the client was to receive 2.5 hours of counseling per month. Client #9 had documentation of .5 hours in July 2022, 2.5 hours in June 2022 and .5 in May 2022.
Client #10 was admitted on June 5, 2018 and discharged on August 24, 2022. The treatment plan documented for client #10 stated the client was to receive 2.5 hours of counseling per month. Client #10 had documentation of 0 hours in July 2022, 1 hour in June 2022 and 1 hour in May 2022.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Effective 11/30/2022
The assigned counselor will follow the required counseling service hours according to the individual treatment and rehabilitation of the patient.
All standard patients must receive 2.5 hours of counseling a month, with 1 hour that can be group counseling.
All patients who receive a 2-year justification status must receive 1 hour of individual counseling per month.
All patients who receive a 4-year justification status must receive 1 hour of individual counseling every other month, or 30 minutes of counseling per month.
If the patient misses a scheduled counseling appointment, the counselor will place a note in the patient's file saying that they did not cancel or show for the appointment. The counselor will also document any time the patient reschedules their counseling appointment in the case history.
The patient may have to attend a group at the end of the day if they miss their individual counseling appointment, this is up to the discretion of the primary counselor.
If a standard patient does not receive the required 2.5 hours of counseling for the month, they will speak with their primary counselor on counseling requirements for the program. If the 2nd month the patient does not receive their required counseling hours, they will then speak with the clinical supervisor on counseling requirements. If the patient does not receive the 2.5 hours of required counseling for a 3rd month, they will then go to case conference, where they will meet with the doctor, clinical supervisor, and their counselor to discuss what the barriers are to engaging in treatment at the required level.
For 2-year justification status patient misses 1 month of individual counseling, patient will go to case conference, where they will meet with the doctor, clinical supervisor, and their counselor to discuss what the barriers are to engaging in treatment at the required level.
For 4-year justification status patient misses one set of their two consecutive months of individual counseling, patient will go to case conference, where they will meet with the doctor, clinical supervisor, and their counselor to discuss what the barriers are to engaging in treatment at the required level.
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