INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on July 22, 2016 by staff from the Department of Drug and Alcohol Programs, Program Licensure Division. Based on the findings of the on-site inspection, BioCare Recovery Centers 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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704.12(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 (SRFSR) form completed by the facility on June 6, 2016, the facility documented that employee #3 was scheduled for 4 hours per week which is dedicated to drug and alcohol clients and has a case load of 6 active drug and alcohol clients. At the time of the Staffing Form review employee #3 exceeded the required 35:1 ratio and had a ratio of 53:1.
This information was reviewed with facility staff.
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Plan of Correction
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.
POC: Employee #3 works four hours most weeks. He sees a maximum of four clients each week. The staffing form should have read 4 clients and 4 hours and met the 35:1 ratio.
Anticipated Completion Date: August 1, 2016. Program Director will coordinate with Clinical Director to ensure ratios do not exceed 35:1.
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705.28 (a) (1) (ii) LICENSURE Fire safety.
705.28. Fire safety.
(a) Exits.
(1) The nonresidential facility shall:
(ii) Maintain a minimum of two exits on every floor, including the basement, that are separated by a minimum distance of 15 feet.
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Observations
Based on a physical plant inspection conducted on July 22, 2016 and a conversation with facility staff, the facility failed to maintain a minimum of two exits on every floor.
There was only one exit leading from the second floor of the facility. The facility had a chain-link ladder stored in a box under a window on the second floor that was considered an exit by the facility, however this ladder does not comply with 4 Pa. Code 705.28 (a) (2) which states "Portable ladders and rope escapes are not considered exits, but may be used in addition to standard exits."
This information was reviewed with the facility staff
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Plan of Correction
IAW 705.28. Fire safety. (a) Exits. (1) The nonresidential facility shall: (ii) Maintain a minimum of two exits on every floor, including the basement, that are separated by a minimum distance of 15 feet.
POC: The second floor has a staircase and an emergency ladder. Effective July 22, 2016, no clients are permitted on the second floor. There is a door between the first floor and stairwell. A sign is posted restricting access. We have cancelled all group meetings. Additionally, we have requested an exception to 705.28 through DDAP on August 26, 2016.
Anticipated Completion Date: July 22, 2016. The Program Director notified all staff and posted a sign restricting access to prevent clients from accessing the area. |
709.11-709.18 LICENSURE Subchapter B. Licensing Procedures
Subchapter B. Licensing Procedures
709.11. Application for license.
(a) Persons, partnerships, corporations, or other legal entities intending to provide drug and alcohol treatment services shall apply for a license from the Department. Application shall be made using forms and procedures prescribed by the Department.
(b) The license shall expire 1 year from the date of issuance. Prior to the expiration of the current license, the Department will notify the facility of the date for an annual on-site inspection for renewal of license.
(c) The Department will notify the appropriate SCA of applications for and issuance of a license to any facility or individual within the SCA's area of responsibility.
709.12. Full licensure.
(a) A license to operate the facility will be issued when, after an on-site inspection by an authorized representative of the Department, it has been determined that requirements for licensure under this chapter, have been met.
(b) A license will be issued to the owner of a facility and will indicate the name of the facility, the address, the date of issuance, and the types of activities the facility is authorized to provide.
(c) The current license shall be displayed in a public and conspicuous place in the facility.
709.13. Provisional licensure.
(a) The Department will issue a provisional license, valid for a specific time period of no more than 6 months when the Department finds that a facility:
(1) Has substantially, but not completely, complied with applicable requirements for licensure.
(2) Is complying with a course of correction approved by the Department.
(3) Has existing deficiencies that will not adversely alter the health, welfare or safety of the facility's clients.
(b) Within 15 working days of receipt of the deficiency report, facility staff shall submit a plan to correct deficiencies noted during the site visits.
(c) A provisional license may be renewed no more than three times.
(d) A regular license will be issued upon compliance with this part.
709.14. Restriction on license.
(a) A license applies to the person, the named facility, the premises designated therein and the activities noted, and is not transferable.
(b) The licensee, using Department forms, shall notify the Department within 90 days of the occurrence of any of the following conditions:
(1) Change in ownership.
(2) Change in name of the facility.
(3) Change in location of the facility.
(4) Change in activity/discontinuance of an activity.
(5) Change in authorized maximum capacity.
(6) Closing of facility.
(c) Failure to notify the Department under subsection (b) will result in automatic expiration of the license.
709.15. Right to enter and inspect.
(a) An authorized representative of the Department has the right to enter, visit, and inspect a facility licensed or applying for a license under this chapter.
(b) The authorized Department representative shall have full and free access to the records of the facility and its clients.
(c) The authorized Department representative has the right to interview clients as part of the visitation and inspection process.
709.16. Notification of deficiencies.
(a) The authorized Department representative will leave appropriate Department forms with the facility director to address areas of noncompliance with the standards.
(b) These forms shall be completed and submitted to the Division of Licensing within 15 working days after the site visit.
(c) A license may not be issued until a plan of action has been approved by the Department.
709.17. Refusal or revocation of license.
(a) The Department may revoke or refuse to issue a license for any of the following reasons:
(1) Failure to comply with a directive issued by the Department.
(2) Violation of, or noncompliance with, this chapter.
(3) Failure to comply with a plan of correction approved by the Department, unless the Department approves an extension or modification of the plan of correction.
(4) Gross incompetence, negligence or misconduct in the operation of the facility.
(5) Fraud, deceit, misrepresentation or bribery in obtaining or attempting to obtain a license.
(6) Lending, borrowing or using the license of another facility.
(7) Knowingly aiding or abetting the improper granting of a license.
(8) Mistreating or abusing individuals cared for or treated by the facility.
(9) Continued noncompliance in disregard of this part.
(10) Operating a facility that, by nature of its physical condition, endangers the health and safety of the public.
(b) If the Department proposes to revoke or refuse to issue a license, it will give written notice to the facility by certified mail, stating the following:
(1) The reasons for the proposed action.
(2) The specific time period for the facility to correct deficiencies.
(c) If the facility does not correct the deficiencies within the specified time, the Department will officially notify the licensee that it shall show cause why its license should not be revoked under 1 Pa. Code Subsection 35.14 (relating to orders to show cause), and that it has a right to a hearing authorized by the Department on this question. A request to the Department for a hearing shall be filed, in writing, within 30 days of receipt of the show cause order.
(d) Subsection (c) supplements 1 Pa. Code Subsection 35.14.
709.18. Hearings.
(a) The Department will convene and conduct a show cause hearing for a facility under 1 Pa. Code Subsection 35.37 (relating to answers to orders to show cause) and this chapter.
(b) An administrative hearing held under this section shall be conducted under 1 Pa. Code Part II (relating to general rules of administrative practice and procedure).
(c) The Department may institute appropriate legal proceedings to enforce compliance with this chapter.
(d) This section supplements 1 Pa. Code Part II.
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Observations
Based on a review of client records it was discovered that the facility failed to notify the Department within 90 days of the occurrence of a change in activity/discontinuance of an activity.
A Consent for Suboxone Treatment, dated August 28, 2015, was discovered in client record #2. The form states "We use Suboxone for the purpose of opiate detoxification.", and details the use of, and potential harmful side-effects of ingesting Suboxone. The line of text directly above the client signature states: "I have read and understand these details about Suboxone treatment. I wish to be treated with Suboxone." Client #2 signed the form and dated it August 28, 2015.
The facility is not approved by the Department to provide Suboxone treatment.
This information was reviewed with the facility staff.
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Plan of Correction
IAW 709.11-709.18 LICENSURE Subchapter B. Licensing Procedures 709.11.
POC: Buprenorphine information has been removed from all BioCare registration documents and will not be considered for detox.
Anticipated Completion Date: August 24, 2016. The Program Director reviewed registration paperwork and removed buprenorphine information from BioCare packets.
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709.28 (c) 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.
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Observations
Based on a review of client records, and a conversation with the facility staff, the facility failed to document a valid consent form in six of seven records.
Client record #1 contained a health insurance claim form dated November 16, 2015 to the insurance provider for client #1, however no consent to release information form for this entity was found in record #1.
Client record #2 contained a facsimile transmission verification sheet, dated September 1, 2015, to a pharmacy; the facsimile contained client-identifying information however no consent to release information form for this entity was found in record #2. Additionally, record #2 contained two health insurance claim form dated September 27 and November 27, 2015 to the insurance provider for client #2, however no consent to release information form for this entity was found in record #2.
Client record #3 contained a facsimile transmission verification sheet, dated April 8, 2016, to the insurance provider for client #3; the facsimile contained client-identifying information however no consent to release information form for this entity was found in record #3.
Client record #4 contained a facsimile transmission verification sheet, dated January 14, 2016, to a pharmacy; the facsimile contained client-identifying information however no consent to release information form for this entity was found in record #4.
Client #5 was admitted on February 29, 2016 and was an active client as of the date of the inspection. Client record #5 contained letter, dated April 8, 2016, from the insurance provider for client #5 authorizing coverage, however no consent to release information form for this entity was found in record #5.
Client #7 was admitted on March 11, 2016 and was discharged on July 1, 2016. Client record #7 contained letter, dated June 21, 2016, from the insurance provider for client #7 authorizing coverage, however no consent to release information form for this entity was found in record #7.
This information was reviewed with facility staff during the licensing inspection.
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Plan of Correction
IAW 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.
POC: BioCare Recovery began accepting insurance in 2016. We added the following statement to our Consent for Treatment: "Required Consents: Coordination with pharmacies and insurance companies to facilitate services/billing may be necessary. You give BioCare Recovery staff permission to provide the minimum information permitted under Pennsylvania Code 255.5 to your insurance company, specialty pharmacy and, if needed, local pharmacy." Starting on July 22, any new BioCare patients must also sign individual releases for their insurance companies and pharmacies. As current clients are seen, they are asked to update their releases and include individual releases for pharmacies and insurance companies. No information will be released until a valid consent form is completed and entered in the current client's records.
Anticipated Completion Date: September 30, 2016. The Program Director, Clinical Director and Executive Director will print and witness releases of existing clients. |
709.92(a) LICENSURE Treatment and rehabilitation services
709.92. Treatment and rehabilitation services.
(a) An individual treatment and rehabilitation plan shall be developed with a client. This plan shall include, but not be limited to, written documentation of:
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Observations
Based on a client record review, and a conversation with the facility staff, the facility failed to develop individual treatment and rehabilitation plans with the client in two of seven client records.
Client #4 was admitted on January 13, 2016 and was an active client at the time of the inspection and client #6 was admitted on September 15, 2015 and was discharged on November 30, 2015. Client records #4 and #6 did not contain documentation that an individual treatment and rehabilitation plans was developed with the client.
This information was reviewed with the facility staff.
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Plan of Correction
IAW 709.92. Treatment and rehabilitation services. (a) An individual treatment and rehabilitation plan shall be developed with a client. This plan shall include, but not be limited to, written documentation of:
POC: Clients are given the treatment plan acknowledgement to sign. Clerical errors occurred in these two cases. Each counselor will be given additional instruction on the requirement to have a signature on the acknowledgement at time of service. Additionally, updates to the EMR will include electronic signatures in the fourth quarter 2016, so clients can sign electronically and avoid clerical errors.
Anticipated Completion Date: September 1, 2016. Clinical Director will review requirement with counselors.
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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 provide documentation that treatment and rehabilitation plans were reviewed and updated at least every 60 days in three of seven records.
Client record #3 had a comprehensive treatment plan dated March 28, 2016. A treatment plan update was due by May 28, 2016 however there was no documentation of an update as of the date of the inspection. There was a treatment plan update form dated July 6, 2016 in record #3 however it was blank as of the date of the inspection.
Client record #4 had a comprehensive treatment plan dated May 17, 2016. A treatment plan update was due by July 17, 2016 however there was no documentation of an update as of the date of the inspection. There was a treatment plan update form dated June 30, 2016 in record #4 however it was blank as of the date of the inspection.
Client record #6 had a comprehensive treatment plan dated September 15, 2015. A treatment plan update was due by November 15, 2015 however there was no documentation of an update as of the date of the inspection.
This information was reviewed with the facility staff.
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Plan of Correction
IAW 709.92. Treatment and rehabilitation services. (b) Treatment and rehabilitation plans shall be reviewed and updated at least every 60 days.
POC Client 3 discontinued counseling, but continued MAT after 5/10/16. Client 4 discontinued counseling, but continued MAT after 6/30/16. Client 6 was hospitalized on 11/3/16 and did not return to counseling ? she was discharged after we confirmed she would not be returning. Clients choosing to stop counseling will be discharged from BioCare Recovery. Clients hospitalized or seeking a HLOC will be discharged and readmitted when they return for services. The Clinical Director will meet with the Program Director the last Friday of every month to review all clients for required updates.
Anticipated Completion Date: August 1, 2016 Program Director and Clinical Director will discharge patients immediately upon change in level of care and August 26, 2016 the Clinical Director and Program Director will begin their monthly chart reviews to ensure updates are completed or scheduled as appropriate. |
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 assure that counseling services are provided according to the individual treatment and rehabilitation plan.
Client record #1 contained a treatment plan dated December 16, 2015 that stipulated individual treatment "1-2 x per week" however the progress notes and record of service indicate the attempted provision of treatment by the facility only on the following dates for the past four months:
May 15, 2016
April 5, 2016 (session cancelled)
March 28, 2016
Client record #3 contained a treatment plan dated March 28, 2016 that stipulated individual treatment "1x per week" however the progress notes and record of service indicate the attempted provision of treatment by the facility only on the following dates for the past four months:
May 10, 2016
April 19, 2016
April 12, 2016
March 28, 2016
March 22, 2016
Client record #5 contained a treatment plan dated March 4, 2016 that stipulated individual treatment "2x per week" however the progress notes and record of service indicate the attempted provision of treatment by the facility only on the following dates for the past three months:
July 20, 2016
June 20, 2016
June 9, 2016
June 2, 2016
May 19, 2016
May 10, 2016
This information was reviewed with the facility staff
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Plan of Correction
IAW 709.92. Treatment and rehabilitation services. (c) The project shall assure that counseling services are provided according to the individual treatment and rehabilitation plan.
POC Treatment plans are completed within the first two weeks and updated at approximately 60 days. Clients 1, 3 and 5 adjusted their frequency of counseling sessions, but their treatment plan failed to reflect the change. Treatment plans will be updated at time of service to capture the increase/decrease in weekly counseling session.
Anticipated Completion Date: September 1, 2016. Clinical Director will review requirement with counselors and review treatment plans monthly to ensure changes are captured.
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709.92(d) LICENSURE Treatment and rehabilitation services
709.92. Treatment and rehabilitation services.
(d) Counseling shall be provided to a client on a regular and scheduled basis.
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Observations
Based on a review of client records, the facility failed to provide counseling on a regular and scheduled basis.
Client #4 was admitted to the facility on January 13, 2016 and signed applicable consent to treatment forms for drug and alcohol services and to be treated with Vivitrol. At this time other applicable intake-oriented procedures, such as client histories, a psychosocial evaluation, a preliminary treatment plan, were not documented by the facility as stipulated by Department regulations. Client #4 received Vivitrol injections on January 15, February 2, March 9, April 6 and May 4, 2016, however, no counseling was documented as having been offered by the facility until May 17, 2016.
This information was reviewed with the facility staff.
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Plan of Correction
IAW 709.92. Treatment and rehabilitation services. (d) Counseling shall be provided to a client on a regular and scheduled basis.
POC: Client #4 completed inpatient detox in 2015 and requested only medicated assisted treatment at BioCare Recovery. Clients requesting only MAT will not be admitted to BioCare Recovery. Additionally, Program Director and Clinical Director will meet the last Friday of each month to review all charts and ensure compliance.
Anticipated Completion Date: August 26, 2016 ? Program Director and Clinical Director will review all clients to ensure compliance with 709.92 and discharge any patient refusing counseling. |