INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection and methadone monitoring conducted on November 1, 2021 through November 2, 2021 by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, John F. Kennedy Behavioral Health Center 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 (c) (4) 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:
(4) Dated signature of client or guardian as provided for under 42 CFR 2.14(a) and (b) and 2.15 (relating to minor patients; and incompetent and deceased patients).
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Observations
Based on a review of client records, the facility failed to ensure that all informed and voluntary consent to release information forms were signed and dated by the client in seven of twelve records reviewed.
Client #1 was admitted into the outpatient maintenance level of care on December 1, 2018 and was active at the time of inspection. Release of information forms to a funding source, a transportation agency, a primary care physician, and an emergency contact were present in the record; however, all the consent forms did not have the dated signatures of the client.
Client #2 was admitted into the outpatient maintenance level of care on April 1, 2019 and was active at the time of inspection. Release of information forms to a funding source, a transportation agency, a primary care physician, and an emergency contact were present in the record; however, all the consent forms did not have the dated signatures of the client.
Client #3 was admitted into the outpatient maintenance level of care on February 4, 2019 and was active at the time of inspection. Release of information forms to a funding source, a transportation agency, a primary care physician, and an emergency contact were present in the record; however, all the consent forms did not have the dated signatures of the client.
Client #4 was admitted into the outpatient maintenance level of care on December 23, 2020 and was active at the time of inspection. Release of information forms to a funding source, a transportation agency, a primary care physician, and an emergency contact were present in the record; however, all the consent forms did not have the dated signatures of the client.
Client #5 was admitted into the outpatient maintenance level of care on April 17, 2018 and was active at the time of inspection. Release of information forms to a funding source, a transportation agency, a primary care physician, and an emergency contact were present in the record; however, all the consent forms did not have the dated signatures of the client.
Client #6 was admitted into the outpatient maintenance level of care on July 1, 2020 and was active at the time of inspection. Release of information forms to a funding source, a transportation agency, a primary care physician, and an emergency contact were present in the record; however, all the consent forms did not have the dated signatures of the client.
Client #11 was admitted into the outpatient maintenance level of care on February 24, 2020 and was discharged August 31, 2021. Release of information forms to a funding source, a transportation agency, a primary care physician, and an emergency contact were present in the record; however, all the consent forms did not have the dated signatures of the client.
The findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
By 12/30/21, every active client in treatment will meet in-person with their counselor to complete a new set of consent forms. Every consent form, including but not limited to funding source; transportation agency; primary care physician; and emergency contact, will contain a dated signature of the client. The clinical supervisor will review client records on a weekly basis to ensure that all informed and voluntary release of information forms are signed and dated by the client. The clinical supervisor is also responsible for ensuring on going compliance with this regulatory requirement. |
709.33 (a) LICENSURE Notification of termination.
§ 709.33. Notification of termination.
(a) Project staff shall notify the client, in writing, of a decision to involuntarily terminate the client ' s treatment at the project. The notice shall include the reason for termination.
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Observations
Based on a review of client records, the facility failed to notify clients, in writing, of a decision to involuntarily terminate the client's treatment at the facility in one of one applicable client records reviewed.
Client #7 was admitted into the outpatient maintenance level of care on December 1, 2018 and was involuntarily discharged on August 18, 2021.
These findings were discussed with facility staff during the licensing process.
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Plan of Correction
Effective 11/05/2021, any client, who is subject to involuntary termination, will be notified, in writing, of a decision to terminate treatment services. A client will be notified of a decision to terminate treatment by their counselor. The clinical supervisor is responsible to ensure compliance with client this regulatory requirement. |
709.33 (b) LICENSURE Notification of termination.
§ 709.33. Notification of termination.
(b) The client shall have an opportunity to request reconsideration of a decision terminating treatment.
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Observations
Based on a review of client records, the facility failed to give the client an opportunity to request reconsideration of a decision to terminate treatment in one of one applicable client records reviewed.
Client #7 was admitted into the outpatient maintenance level of care on December 1, 2018 and was involuntarily discharged on August 18, 2021.
These findings were discussed with facility staff during the licensing process.
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Plan of Correction
Effective 11/05/2021, any client, who is subject to involuntary termination, will be afforded an opportunity to request reconsideration of a decision to terminate treatment. This language or similar language will be included in the written notification of a decision to terminate treatment services written by the counselor. The clinical supervisor will review and consider a client's request for reconsideration and provide a written response to the client within 5 calendar days. The clinical supervisor is responsible for ensuring compliance with this regulatory requirement. |
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 patient records, the facility failed complete and document a random urinalysis, for each patient, at least monthly in ten of twelve patient records reviewed.
Patient #1 was admitted on December 1, 2018 and was active at the time of inspection. There was no documentation in the record that a random urinalysis was conducted for the months of September 2021 and October 2021.
Patient #2 was admitted on April 1, 2019 and was active at the time of inspection. There was no documentation in the record that a random urinalysis was conducted for the months of July 2021 and August 2021.
Patient #3 was admitted on February 4, 2019 and was active at the time of inspection. There was no documentation in the record that a random urinalysis was conducted for the month of October 2021.
Patient #4 was admitted on December 23, 2020 and was active at the time of inspection. There was no documentation in the record that a random urinalysis was conducted for the months of September 2021 and October 2021.
Patient #5 was admitted on April 17, 2018 and was active at the time of inspection. There was no documentation in the record that a random urinalysis was conducted for the month of October 2021.
Patient #7 was admitted on December 1, 2018 and was discharged August 18, 2021. There was no documentation in the record that a random urinalysis was conducted for the months of April 2021, May 2021, and June 2021.
Patient #8 was admitted on February 6, 2019 and was discharged July 14, 2021. There was no documentation in the record that a random urinalysis was conducted for the months of March 2021 and June 2021.
Patient #9 was admitted January 9, 2019 and was discharged August 19, 2021. There was no documentation in the record that a random urinalysis was conducted for the months of April 2021 and July 2021.
Patient #10 was admitted on June 8, 2015 and was discharged May 12, 2021. There was no documentation in the record that a random urinalysis was conducted for the month of January 2021.
Patient #12 was admitted on April 10, 2019 and was discharged January 31, 2020. There was no documentation in the record that a random urinalysis was conducted for the months of November 2020 and December 2020.
The findings were discussed with facility staff during the licensing process.
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Plan of Correction
715.14 (a)
Effective 12/01/2021, our nursing staff will utilize a checklist to track all clients who have been randomly selected for monthly urinalysis testing by our electronic dosing system. The nurse will closely monitor the client's placement of the urine sample in the secured urine drug sample container. Medication reminders will be used to obtain a urine sample from those who miss their initial urine sample date. Prior to the end of each month, the nurse will review the checklist to ensure that every client has submitted a urine sample for the month. The administrative assistance is responsible for prompt placement of an original copy urine results (received from the lab) into Carelogic for easy access and review. The clinical supervisor is responsible for ensuring consistent compliance with this regulatory requirement.
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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 that each patient received 2.5 hours of psychotherapy group or individual sessions per month during the patient's first two years in treatment in three of twelve records reviewed.
Patient #7 was admitted into the outpatient maintenance level of care on December 1, 2018 and was discharged August 18, 2021. The record documented the following psychotherapy hours: 0 hours for April 2021, 0 hours for May 2021, 0 hours for June 2021, and 2 hours for July 2021.
Patient #8 was admitted into the outpatient maintenance level of care on February 6, 2019 and was discharged July 14, 2021. The record documented the following psychotherapy hours: 0 hours for March 2021, 0 hours for April 2021, 0 hours for May 2021, and 0 hours for June 2021.
Patient #12 was admitted into the outpatient maintenance level of care on April 10, 2019 and was discharged January 31, 2020. The record documented the following psychotherapy hours: 0 hours for November 2020 and 0 hours for December 2020.
The findings were discussed with facility staff during the licensing process.
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Plan of Correction
Effective 12/01/21, all clients will receive an average of 2.5 hours of psychotherapy per month during the client's first 2 years and 1 hour of which will be individual psychotherapy. Additional hours of psychotherapy will be provided based on the client's ongoing treatment needs. The clinical supervisor will generate a report in Carelogic to track the number of hours provided to all active clients prior to the end of each month. The clinical supervisor is also responsible for ensuring compliance with the regulatory requirement.
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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 that each patient received at least 1 hour of psychotherapy group or individual sessions per month during the patient's third and fourth years in treatment in one of one applicable records reviewed.
Patient #9 was admitted on January 9, 2019 and was discharged August 19, 2021. The record documented the following psychotherapy hours: 0 hours for April 2021, 0 hours for May 2021, 0 hours for June 2021, and 2 hours for July 2021.
The findings were discussed with facility staff during the licensing process.
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Plan of Correction
Effective 12/01/21, all clients in treatment during their 3rd and 4th years will receive an average of 1 hour of group or individual psychotherapy per month. Additional hours of psychotherapy will be provided based on the client's ongoing treatment needs. The clinical supervisor will generate a report in Carelogic to track the number of hours provided to these clients prior to the end of each month. The clinical supervisor is also responsible for ensuring compliance with the regulatory requirement. |
715.20(1) 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.
(1) The transferring narcotic treatment program shall transfer patient files which include admission date, medical and psychosocial summaries, dosage level, urinalysis reports or summary, exception requests, and current status of the patient, and shall contain the written consent of the patient.
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Observations
Based on a review of patient records, the facility failed to document that they transferred patient files, which is to include the clients admission date, medical and psychosocial summaries, urinalysis reports or summary and current status of the patient, upon transfer in one of one applicable patient record reviewed.
Patient #10 was admitted on June 8, 2015 and was transferred to another narcotic treatment program on May 12, 2021.
The findings were discussed with facility staff during the licensing process.
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Plan of Correction
Effective 11/26/21, JFK's Medication Assisted Treatment Program will document transfer files that include the client's admission date, medical and psychosocial summaries, urinalysis reports or summaries, and the current status of the client. The counselor of record is responsible collecting these documents. The clinical supervisor will review and approve the documents prior to forwarding the information to the receiving agency. The clinical supervisor is responsible for ensuring compliance with this regulatory requirement. |
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 ensure that the results of all annual physical examinations given by the narcotic treatment program are documented in the patient record in eight of twelve patient records reviewed.
Patient #1 was admitted on December 1, 2018 and was active at the time of inspection. There was no annual physical examination documented during 2020.
Patient #2 was admitted into the outpatient maintenance level of care on April 1, 2019 and was active at the time of inspection. There was no annual physical examination documented during 2020, as the last physical examination was completed in April 2019.
Patient #3 was admitted on February 4, 2019 and was active at the time of inspection. The facility failed to conduct an annual physical examination for the year 2020.
Patient #7 was admitted on December 1, 2018 and was discharged August 18, 2021. There was no annual physical examination documented during 2020, as the last physical examination was completed in December 2018.
Patient #8 was admitted on February 6, 2019 and was discharged July 14, 2021. There was no annual physical examination documented during 2021, as the last physical examination was completed in February 2020.
Patient #9 was admitted on January 9, 2019 and was discharged August 19, 2021. There was no annual physical examination documented during 2021, as the last physical examination was completed in January 2020.
Patient #10 was admitted on June 8, 2015 and was discharged May 12, 2021. There was no annual physical examination documented during 2020, as the last physical examination was completed in June 2019.
Patient #11 was admitted on February 24, 2020 and was discharged August 31, 2021. There was no annual physical examination documented during 2021, as the last physical examination was completed in February 2020.
The findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
By May 1 2022, our nurses and clinic physician will complete annual physical examinations for clients who missed their examination over the past year. Our nursing staff have a list of clients and will continue scheduling these individuals, on a weekly basis, for their annual physical until such time all names on the list are complete. Our nursing and physician staff will continue to coordinate this process. The clinical supervisor is responsible for ensuring compliance with this regulatory requirement.
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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 of each patient's status by the patient ' s counselor and reviewed and signed by the medical director, in four of twelve patient records reviewed.
Patient #5 was admitted on April 17, 2018 and was active at the time of inspection. There was an annual clinical evaluation completed in April of 2019 and April of 2021; however, there was no annual evaluation completed for 2020.
Patient #8 was admitted on February 6, 2019 and was discharged July 14, 2021. There was an annual clinical evaluation completed in June of 2020; however, there was no annual evaluation completed after the admit anniversary due date of February 2020.
Patient #9 was admitted on January 9, 2019 and was discharged August 19, 2021. There was no documentation of an annual clinical evaluation for the entire period the patient was in treatment as of the date of the inspection.
Patient #10 was admitted into the outpatient maintenance level of care on June 8, 2015 and was discharged May 12, 2021. There was an annual clinical evaluation completed in January 2019; however, there was no annual evaluation completed for 2020 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
Effective 12/01/21, an annual evaluation will be documented by the counselor of record in a timely manner. The clinical supervisor will provide a training on timely completion of annual evaluations. Counselors will use their case management logs to track the date that an annual evaluation is due. The clinical supervisor will simultaneously track these dates along with the counselors. Once completed, the counselor, clinical supervisor, and medical director will sign the document. The clinical supervisor is responsible for ensuring compliance with this regulatory requirement. |
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 that treatment plans were reviewed and updated at least every 60 days in ten of twelve client records reviewed.
Client #1 was admitted on December 1, 2018 and was active at the time of inspection. A treatment plan update was completed on November 20, 2020 and the next update was due no later than January 20, 2021. However, the update was not completed until February 1, 2021.
Client #3 was admitted on February 4, 2019 and was active at the time of inspection. A treatment plan update was completed on March 9, 2021 and the next update was due no later than May 9, 2021. However, the update was not completed until September 9, 2021.
Client #4 was admitted on December 23, 2020 and was active at the time of inspection. The comprehensive treatment plan was completed on December 23, 2020 and a treatment plan update was due no later than February 23, 2021. However, the update was not completed until April 1, 2021. Additionally, a treatment plan update was completed on July 22, 2021 and the next update was due no later than September 22, 2021. However, the update was not completed until October 18, 2021.
Client #5 was admitted on April 17, 2018 and was active at the time of inspection. A treatment plan update was completed on November 17, 2020 and the next update was due no later than January 17, 2021. However, the update was not completed until February 8, 2021. Also, a treatment plan update was completed on April 19, 2021 and the next update was due no later than June 9, 2021. However, the update was not completed until July 9, 2021. Additionally, a treatment plan update was completed on July 9, 2021 and the next update was due no later than September 9, 2021. However, the update was not completed until October 19, 2021.
Client #6 was admitted on July 1, 2020 and was active at the time of inspection. The comprehensive treatment plan was completed July 1, 2020 and a treatment plan update was due no later than September 1, 2020. However, the update was not completed until January 1, 2021.
Client #7 was admitted on December 1, 2018 and was discharged August 18, 2021. A treatment plan update was completed on March 8, 2021 and the next update was due no later than May 8, 2021. However, the update was not completed until June 8, 2021.
Patient #8 was admitted on February 6, 2019 and was discharged July 14, 2021. A treatment plan update was completed on February 22, 2021 and the next update was due no later than April 22, 2021. However, the update was not completed at the time of inspection.
Patient #9 was admitted on January 9, 2019 and was discharged August 19, 2021. A treatment plan update was completed on November 30, 2020 and the next update was due no later than January 30, 2021. However, the update was not completed until May 14, 2021. Additionally, a treatment plan update was completed on May 14, 2021 and the next update was due no later than June 14, 2021. However, the update was not completed at the time of inspection.
Patient #10 was admitted on June 8, 2015 and was discharged May 12, 2021. A treatment plan update was completed on February 18, 2020 and the next update was due no later than April 18, 2020. However, the update was not completed until October 13, 2020. Additionally, a treatment plan update was completed on October 13, 2020 and the next update was due no later than December 13, 2020. However, the update was not completed until February 21, 2021.
Client #11 was admitted on February 24, 2020 and was discharged August 31, 2021. A treatment plan update was completed on July 6, 2020 and the next update was due no later than September 6, 2020. However, the update was not completed until November 13, 2020. Additionally, a treatment plan update was completed on November 13, 2020 and the next update was due no later than January 13, 2021. However, the update was not completed until February 3, 2021.
The findings were reviewed with facility staff during the licensing inspection
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Plan of Correction
Effective 12/01/2021, counselors will document a treatment plan update at least every 60 days. The clinical supervisor will provide a training on timely documentation of treatment plan updates. Counselors will use their case management logs to track due dates for treatment plan updates. The clinical supervisor will simultaneously track these dates along with the counselors. The clinical supervisor is also responsible for ensuring compliance with this regulatory requirement.
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