INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on January 21-22, 2021 by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure Division. Based on the findings of the on-site inspection, Pennsylvania Associates, LLC dba Mount Pocono Medical 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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704.7(b) LICENSURE Counselor Qualifications
704.7. Qualifications for the position of counselor.
(a) Drug and alcohol treatment projects shall be staffed by counselors proportionate to the staff/client and counselor/client ratios listed in 704.12 (relating to full-time equivalent (FTE) maximum client/staff and client/counselor ratios).
(b) Each counselor shall meet at least one of the following groups of qualifications:
(1) Current licensure in this Commonwealth as a physician.
(2) A Master's Degree or above from an accredited college with a major in chemical dependency, psychology, social work, counseling, nursing (with a clinical specialty in the human services) or other related field which includes a practicum in a health or human service agency, preferably in a drug and alcohol setting. If the practicum did not take place in a drug and alcohol setting, the individual's written training plan shall specifically address a plan to achieve counseling competency in chemical dependency issues.
(3) A Bachelor's Degree from an accredited college with a major in chemical dependency, psychology, social work, counseling, nursing (with a clinical specialty in the human services) or other related field and 1 year of clinical experience (a minimum of 1,820 hours) in a health or human service agency, preferably in a drug and alcohol setting. If a person's experience did not take place in a drug and alcohol setting, the individual's written training plan shall specifically address a plan to achieve counseling competency in chemical dependency issues.
(4) An Associate Degree from an accredited college with a major in chemical dependency, psychology, social work, counseling, nursing (with a clinical specialty in the human services) or other related field and 2 years of clinical experience (a minimum of 3,640 hours) in a health or human service agency, preferably in a drug and alcohol setting. If a person's experience was not in a drug and alcohol setting, the individual's written training plan shall specifically address a plan to achieve counseling competency in chemical dependency issues.
(5) Current licensure in this Commonwealth as a registered nurse and a degree from an accredited school of nursing and 1 year of counseling experience (a minimum of 1,820 hours) in a health or human service agency, preferably in a drug and alcohol setting. If a person's experience was not in a drug and alcohol setting, the individual's written training plan shall specifically address a plan to achieve counseling competency in chemical dependency issues.
(6) Full certification as an addictions counselor by a statewide certification body which is a member of a National certification body or certification by another state government's substance abuse counseling certification board.
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Observations
Based on a review of eight personnel records, it was determined that employee #5 hired on June 22, 2020 as a counselor did not meet the educational requirements to be a counselor. At the time of hire, the employee had a bachelor ' s degree in Health Education, which is a non- qualifying degree for the position of counselor.
These findings were discussed with facility staff during the inspection process.
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Plan of Correction
The Facility Director reviewed the citation and PA regulation 704.7 pertaining to Counselor Qualifications.
To safeguard against any further employees not meeting counselor qualifications, the Facility Director will confirm with the candidate their credentials and follow-up on the on-boarding back ground check. The Facility Director will obtain the background check in a timely manner from the corporate office. |
704.9(c) LICENSURE Supervised Period
704.9. Supervision of counselor assistant.
(c) Supervised period.
(1) A counselor assistant with a Master's Degree as set forth in 704.8 (a)(1) (relating to qualifications for the position of counselor assistant) may counsel clients only under the close supervision of a trained counselor or clinical supervisor for at least the first 3 months of employment.
(2) A counselor assistant with a Bachelor's Degree as set forth in 704.8 (a)(2) may counsel clients only under the close supervision of a trained counselor or clinical supervisor for at least the first 6 months of employment.
(3) A registered nurse as set forth in 704.8 (a)(3) may counsel clients only under the close supervision of a trained counselor or clinical supervisor for at least the first 6 months of employment.
(4) A counselor assistant with an Associate Degree as set forth in 704.8 (a)(4) may counsel clients only under the close supervision of a trained counselor or clinical supervisor for at least the first 9 months of employment.
(5) A counselor assistant with a high school diploma or GED equivalent as set forth in 704.8 (a)(5) may counsel clients only under the direct observation of a trained counselor or clinical supervisor for the first 3 months of employment. For the next 9 months, the counselor assistant may counsel clients only under the close supervision of a lead counselor or a clinical supervisor.
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Observations
Based on a review of the staffing facility summary report and eight personnel records it was determined that employee #8 hired as a counselor assistant on November 23, 2020 only has a high school diploma and did not receive direct observation for the first three months.
These findings were discussed with facility staff during the inspection process.
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Plan of Correction
The Facility Director reviewed the citation and PA regulation 704.7 pertaining to Counselor Qualifications.
To safeguard against any further employees not receiving the correct type and amount of supervision required, the Facility Director will confirm the candidates credentials and follow-up on the on-boarding back ground check. The Facility Director will obtain the background check in a timely manner from the corporate office.
The Facility Director will consult with supervisor of Pinnacle Improvement Department if there are any questions pertaining to employee credentials and supervision.
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705.22 (2) LICENSURE Building exterior and grounds.
705.22. Building exterior and grounds.
The nonresidential facility shall:
(2) Keep the grounds of the facility clean, safe, sanitary and in good repair at all times for the safety and well being of clients, employees and visitors. The exterior of the building and the building grounds or yard shall be free of hazards.
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Observations
Based on a physical plant inspection on January 21, 2021 the facility failed to keep the grounds of the facility clean, safe, sanitary and in good repair at all times for the safety and well being of clients, employees and visitors. The exterior of the building and the building grounds or yard shall be free of hazards.
The emergency exit to the left of the building by the clinical supervisor office was not cleared of snow creating a potential safety hazard.
These findings were discussed with facility staff during the inspection process.
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Plan of Correction
The Facility Director reviewed the citation. To safeguard against any safety issues presented by inclement weather, all staff will be retrained by 3/31/2021 on how to maintain a safe exterior environment for all patients, employees and visitors.
The Facility Director will ensure compliance by observing the exterior of the building on a daily basis. |
705.28 (a) (1) (i) LICENSURE Fire safety.
705.28. Fire safety.
(a) Exits.
(1) The nonresidential facility shall:
(i) Ensure that stairways, hallways and exits from rooms and from the nonresidential facility are unobstructed.
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Observations
Based on a physical plant inspection on January 21, 2021 it was observed that the emergency exit to the left of the building by the clinical supervisor office had a chair and debris from the ceiling obstructing the exit.
These findings were discussed with facility staff during the inspection process.
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Plan of Correction
The Facility Director reviewed the citation. To safeguard against any safety issues stairways, hallways, and exits will remain clear of any/all obstructions and debris.
All staff will be retrained by 3/31/2021 on how to maintain a safe exterior environment for all patients, employees and visitors.
The Facility Director will ensure compliance by observing the interior/exterior of the building on a daily basis. |
709.28 (a) LICENSURE Confidentiality
§ 709.28. Confidentiality.
(a) A written procedure shall be developed by the project director which shall comply with 4 Pa. Code § 255.5 (relating to projects and coordinating bodies: disclosure of client-oriented information). The procedure must include, but not be limited to:
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Observations
Based on an observation of medication administration the facility failed to maintain confidentiality of all patients. Patients were observed throwing away take home bottles without blacking out each name and dose into a trash can which was later emptied into the dumpster.
These findings were discussed with facility staff during the inspection process.
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Plan of Correction
The Facility Director reviewed the citation and PA regulation 709.28 pertaining to patient confidentiality.
To safeguard against patient confidentiality being breached, the Facility Director will retrain nursing staff by 3/31/2021 on PTC procedures pertaining to the disposal of take home bottles.
The Facility Director will consult with supervisor of Pinnacle Improvement Department if there are any questions pertaining to PTC policies and procedures. |
709.28 (c) (1) 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:
(1) Name of the person, agency or organization to whom disclosure is made.
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Observations
Based on a review of eight client records, the facility failed to ensure that all consent to release forms contained the name of the person, agency, or organization to whom the disclosure is made in one client record.
Client #2 was admitted on September 10, 2020 and was still active at the time of the inspection. A consent to release form was signed and dated on September 23, 2020 that failed to include the name of the person, agency or organizations whom the disclosure is for.
These findings were discussed with facility staff during the inspection process.
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Plan of Correction
The Facility Director reviewed the citation and PA regulation 709.28 pertaining to patient confidentiality.
To safeguard against patient confidentiality being breached, the Clinical Supervisors will retrain clinicians by 3/31/2021 on how to complete a consent to release thoroughly and completely. The Clinical Supervisors will conduct chart audits monthly for compliance and address any issues during supervision.
The Clinical Supervisors will consult with supervisor of Pinnacle Improvement Department if there are any questions pertaining to PTC policies and procedures. |
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 a review of eight client records the facility failed ensure that one record stayed within the limits of 255.5.
Client #8 was admitted on June 26, 2019 and was discharged on November 9, 2020. A fax was sent to the funding source on October 9, 2020 that released progress notes, case management, treatment team notes, urine drug screen and treatment plan.
These findings were discussed with facility staff during the inspection process.
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Plan of Correction
The Facility Director reviewed the citation and PA regulation 709.28 pertaining to patient confidentiality.
To safeguard against patient confidentiality being breached, the Clinical Supervisors will retrain clinicians by 3/31/2021 on remaining within the limits of 255.5. The Clinical Supervisors will conduct chart audits monthly for compliance and address any issues during supervision.
The Clinical Supervisors will consult with supervisor of Pinnacle Improvement Department if there are any questions pertaining to PTC policies and procedures. |
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 a review of eight client records the facility failed to ensure that three records documented whether the client was offered a copy of the consent.
Client #2 was admitted on September 10, 2020 and was still active at the time of the inspection. Consent to release forms for an outside agency and emergency contact signed and dated on September 23, 2020 failed to include if the client was offered a copy.
Client #3 was admitted on November 24, 2020 and was still active at the time of the inspection. All consent to release forms signed and dated on November 24, 2020 failed to include if the client was offered a copy.
Client #4 was admitted on October 27, 2020 and was still active at the time of inspection. Consent to release forms for the funding source and outside agency signed and dated October 27, 2020 failed to include if the client was offered a copy.
These findings were discussed with facility staff during the inspection process.
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Plan of Correction
The Facility Director reviewed the citation and PA regulation 709.28 pertaining to patient confidentiality.
To safeguard against patient confidentiality being breached, the Clinical Supervisors will retrain clinicians by 3/31/2021 on how to complete a consent to release thoroughly and completely. The Clinical Supervisors will conduct chart audits monthly for compliance and address any issues during supervision.
The Clinical Supervisors will consult with supervisor of Pinnacle Improvement Department if there are any questions pertaining to PTC policies and procedures. |
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 a review of medical hours for the weeks of September 28, 2020 and December 14, 2020, the facility did not provide narcotic treatment physician services at least one hour per week for every ten patients.
For the week of September 28, 2020 with a census of 387 the facility needed to provide 38.7 physician hours. The facility provided 10.91 physician hours and 22.95 CRNP hours for a total of 33.86 medical hours.
For the week of December 14, 2020 with a census of 409 the facility needed to provide 40.9 medical hours. The facility provided 15.25 physician hours and 21.29 CRNP hours for a total of 36.54 medical hours.
These findings were discussed with facility staff during the inspection process.
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Plan of Correction
The Facility Director reviewed the citation and PA regulation 715.6 (d) pertaining to physician staffing.
To ensure physician staffing maintains adequate service hours, the Facility Director will retrain the MD/CRNP/PA on the physician services requirements as being at least one hour per week for every ten patients by 3/15/2021.
The Facility Director will review time sheet and patient census weekly to maintain compliance.
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715.6(e) LICENSURE Physician Staffing
(e) A physician assistant or certified registered nurse practitioner may perform functions of a narcotic treatment physician in a narcotic treatment program if authorized by Federal, State and local laws and regulations, and if these functions are delegated to the physician assistant or certified registered nurse practitioner by the medical director, and records are properly countersigned by the medical director or a narcotic treatment physician. One-third of all required narcotic treatment physician time shall be provided by a narcotic treatment physician. Time provided by a physician assistant or certified registered nurse practitioner may not exceed two-thirds of the required narcotic treatment physician time.
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Observations
Based on a review of medical hours, the narcotic treatment physician did not provide at least one-third of the medical hours for the week of December 14, 2020. The narcotic treatment physician was required to provide at least 12.9 medical hours and only provided 10.91 medical hours.
These findings were discussed with facility staff during the inspection process.
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Plan of Correction
The Facility Director reviewed the citation and PA regulation 715.6 (d) pertaining to physician staffing.
To ensure physician staffing maintains adequate service hours, the Facility Director will retrain the MD/CRNP/PA on the physician services requirements as being at least one hour per week for every ten patients by 3/15/2021.
The Facility Director will review time sheet and patient census weekly to maintain compliance.
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715.13(a) LICENSURE Patient identification
(a) A narcotic treatment program shall use a system for patient identification for the purpose of verifying the correct identity of a patient prior to administration of an agent.
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Observations
Based on an observation of medication administration, the facility failed to use a system for patient identification. Patients approaching the dosing window did not have to identify themselves before they were dosed.
These findings were discussed with facility staff during the inspection process.
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Plan of Correction
The Facility Director reviewed the citation and PA regulation 715.13(a)pertaining to patient identification.
To safeguard against any possibility of incorrect patient identification, a patients photos and ID number are uploaded in the EHR during the admission process.
The clinical supervisors will retrain all staff on PTC policies and procedures pertaining to verifying correct patient identity by 3/31/2021
To maintain compliance with licensing standards, the clinical supervisors will conduct monthly record reviews for compliance.
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715.13(b) LICENSURE Patient identification
(b) A narcotic treatment program shall maintain onsite a photograph of each patient which includes the patient 's name and birth date. The narcotic treatment program shall update the photograph every 3 years.
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Observations
Based on an observation of medication administration, the facility failed to maintain onsite photographs of each patient in ten patient records observed.
These findings were discussed with facility staff during the inspection process.
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Plan of Correction
The Facility Director reviewed the citation and PA regulation 715.13(b)pertaining to patient photo identification.
To safeguard against any possibility of incorrect patient identification, patients photos are uploaded in the EHR during the admission process.
The clinical supervisors will retrain all staff on PTC policies and procedures pertaining to verifying correct patient identity by 3/31/2021
To maintain compliance with licensing standards, the clinical supervisors will conduct monthly record reviews for compliance.
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715.14(a) LICENSURE Urine testing
(a) A narcotic treatment program shall complete an initial drug-screening urinalysis for each prospective patient and a random urinalysis at least monthly thereafter.
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Observations
Based on a review of eight patient records, the facility failed to ensure that patients receive a urine drug screen at least monthly in two patient records.
Patient #2 was admitted on September 10, 2020 and was still active at the time of the inspection. A urine drug screen for the month of November 2020 was missing.
Patient #5 was admitted on May 16, 2018 and was still active at the time of the inspection. A urine drug screen was missing for the month of September 2020.
These findings were discussed with facility staff during the inspection process.
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Plan of Correction
The Facility Director reviewed the citation and PA regulation 715.14(a)pertaining to patient urine testing.
To safeguard against patient urine testing, the clinical supervisors will retrain all staff on PTC policies and procedures for urine testing by 3/31/2021.
Pennsylvania Associates is making every effort to follow CDC guidelines during the COVID pandemic. When a patient reports a positive COVID test result, they are dosed in their car and unable to enter the facility in efforts to stop the spread of the virus. When a patient is unable to submit a urine test due to being positive for the virus, he/she will submit one as soon as they are able to re-enter the facility without the possibility of infecting other patients or staff.
To maintain compliance with licensing standards, the clinical supervisors will conduct monthly record reviews for compliance.
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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 eight client records, the facility failed to ensure that treatment plan updates were completed every 60 days in three client records.
Client #2 was admitted on September 10, 2020 and was still active at the time of the inspection. A treatment plan update was completed October 3, 2020 and the next update was due by December 3, 2020; however, it was not completed until January 20, 2021.
Client #5 was admitted on May 16, 2020 and was still active at the time of the inspection. A treatment plan update was completed on September 16, 2020 and an update was to be completed no later than November 16, 2020; however, there was no update completed until November 30, 2020.
Client #8 was admitted on June 26, 2019 and was discharged on November 9, 2020. A treatment plan update was completed on October 18, 2019 and an update was to be completed no later than December 18, 2020; however, no update was completed until February 5, 2020.
These findings were discussed with facility staff during the inspection process.
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Plan of Correction
The Facility Director reviewed citation pertaining to 709.92(b), treatment and rehabilitation plans shall be reviewed every 60 days.
To safeguard against treatment plans not being completed in a timely manner the clinical supervisors will retrain clinicians on how to utilize the EHR to identify when treatment plans are due and on the process of stopping the patient while checking in at the kiosk to obtain signatures prior to the plans end date.
The clinical supervisors will retrain the clinicians on using the flag delay at the kiosk that alerts the patient the primary counselor is requesting to talk with them and review the plan and obtain their signature on plan. The clinicians will learn to use the services due reports to determine when treatment plans are due allowing them to be completed in a timely manner.
The clinical supervisor will audits charts on a monthly basis for compliance and address any issues during individual and group supervision. |
709.93(a)(10) 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:
(10) Discharge summary.
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Observations
Based on a review of eight client records, the facility failed to include a complete discharge summary for one client record.
Client #7 wad admitted on October 10, 2018 and discharged on October 6, 2020. The discharge summary was not filled out and completed.
These findings were discussed with facility staff during the inspection process.
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Plan of Correction
The Facility Director reviewed citation pertaining to 709.93(a)(10) completing discharge summaries.
To safeguard against discharge plans not being completed in a timely manner the clinical supervisors will retrain clinicians on how to utilize the EHR to identify when discharge summaries are due via direct service reports by 3/31/2021 to allow for the summaries to be completed in a timely manner.
The clinical supervisor will audit charts on a monthly basis for compliance and address any issues during individual and group supervision. |