INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on December 3-6th 2019 by staff from the Department of Drug and Alcohol Programs, Bureau of Quality Assurance for Prevention and Treatment, 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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704.6(c) LICENSURE Core Curriculum - Supervisor Training
704.6. Qualifications for the position of clinical supervisor.
(c) Clinical supervisors and lead counselors who have not functioned for 2 years as supervisors in the provision of clinical services shall complete a core curriculum in clinical supervision. Training not provided by the Department shall receive prior approval from the Department.
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Observations
Based on a review of personnel records, staff #3 hired as the clinical supervisor on June 17, 2019 had not functioned for 2 years as a supervisor in the provision of clinical services, failed to complete a core curriculum in clincial supervision.
These findings were discussed with the facility during the inspection process.
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Plan of Correction
The Facility Director reviewed the citation and reviewed PA regulation 704.6 Qualifications for the position of clinical supervisor with the Clinical Supervisor.
The Clinical Supervisor will attend the next 30 hour core curriculum in clinical supervision. Completed certificate will be placed in personnel file. |
704.11(c)(1) LICENSURE Mandatory Communicable Disease Training
704.11. Staff development program.
(c) General training requirements.
(1) Staff persons and volunteers shall receive a minimum of 6 hours of HIV/AIDS and at least 4 hours of tuberculosis, sexually transmitted diseases and other health related topics training using a Department approved curriculum. Counselors and counselor assistants shall complete the training within the first year of employment. All other staff shall complete the training within the first 2 years of employment.
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Observations
Based on a supervisory review of the written report of the onsite licensure inspection conducted on December 3-6, 2019, the facility failed to ensure that staff persons received a minimum of 6 hours of HIV/AIDS and at least 4 hours of tuberculosis, sexually transmitted diseases and other health related topics training using a Department approved curriculum within the regulatory time frames.
A supervisory review of the Staffing Requirements Facility Summary Report submitted by the facility, showed that the facility had two support staff who had not completed the required trainng within two years of employment.
Employee #8 was hired on May 30, 2017 and was still employed as a Case manager at the time of the inspection. The facility lacked documentation that he employee completed the required trainings.
Employee #9 was hired on October 12, 2017 and was still employed as a CRS/Case manager at the time of the inspection. The facility lacked documentation that he employee completed the required trainings.
The facility was informed and confirmed the findings via email.
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Plan of Correction
The Facility Director reviewed the citation. To safeguard against any further employees completion of required minimal training hours in HIV/AIDS and TB/STD in required time frames, the Facility Director will review all personnel files quarterly for compliance.
Employee #8 and #9 will check for the next available trainings and attend. The completed certification will be put in employees personnel file. |
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 December 3-6th, 2019, it was observed that the sidewalk to the left of the building leading to the main enterance of the building was covered with snow and ice each day of the inspection process.
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 on 1/27/2020 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.
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705.23 (3) LICENSURE Counseling or activity areas and office space
705.23. Counseling or activity areas and office space.
The nonresidential facility shall:
(3) Ensure privacy so that counseling sessions cannot be seen or heard outside the counseling room. Counseling room walls shall extend from the floor to the ceiling.
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Observations
Based on a phsyical plant inspection on December 6th, 2019, it was observed that the counselor's office at the end of the hallway on the left did not have window coverings. These windows overlooked the parking lot and counseling sessions could be observed from the parking lot.
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 ensure patient confidentiality and privacy, on 1/17/2020 window covering was installed in the counselors office at the end of the hall.
To ensure continued compliance with licensing standards, the Facility Director will check the physical plant on a weekly basis. |
705.26 (2) LICENSURE Heating and cooling.
705.26. Heating and cooling.
The nonresidential facility:
(2) May not permit in the facility heaters that are not permanently mounted or installed.
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Observations
Based on a physical plant inspection, it was obeserved that the facility had portable heaters in counseling offices and dosing room.
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 and to be in-compliance with PA regulation 705.26, portable space heaters will not be used within the facility. Only heaters that are permanently mounted or installed will be utilized. Space heaters were removed from counseling and dosing rooms.
The Facility Director will ensure compliance by observing the interior of the building on a daily basis. |
705.28 (c) (4) LICENSURE Fire safety.
705.28. Fire safety.
(c) Fire extinguishers. The nonresidential facility shall:
(4) Instruct staff in the use of the fire extinguisher upon staff employment. This instruction shall be documented by the facility.
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Observations
Based on a review of personnel files, employee #2 was not trained in fire extinguisher use upon hire. Employee #2 was hired on November 1, 2019 and was still employed at the time of the inspection. There was no documentation that the employee received the training until the date of inspection December 4th, 2019.
These findings were discussed with facility staff during the time of inspection.
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Plan of Correction
The Facility Director reviewed the citation. To ensure compliance with PA regulation 705.28 (c) all employees will be training in fire safety and the use of a fire extinguisher upon hire. Documentation will be placed in employee personnel file.
Employee #2 was trained on the fire safety and the use of a fire extinguisher immediately following survey.
The Facility Director will ensure compliance by reviewing personnel files on a monthly basis.
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705.28 (d) (3) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(3) Ensure that all personnel on all shifts are trained to perform assigned tasks during emergencies.
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Observations
Based upon a review of personnel files, the facility failed to ensure that all personnel on all shifts were trained to perform assigned tasks during emergencies. Employee #2 was hired on November 1, 2019 and was still employed at the time of the inspection. There was no documentation in employee #2 ' s personnel file indicating that the employee had been trained on what to do during emergencies until the date of inspection December 4th 2019.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Facility Director reviewed the citation. To ensure compliance with PA regulation 705.28 (d) all employees will be trained on emergency drill assigned tasks. Documentation will be placed in employee personnel file.
Employee #2 was trained on the fire safety and the use of a fire extinguisher immediately following the survey.
The Facility Director will ensure compliance by reviewing personnel files on a monthly basis.
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705.28 (d) (6) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(6) Conduct fire drills on different days of the week, at different times of the day and on different staffing shifts.
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Observations
Based on a review of the facility fire drills on December 3rd, 2019, the facility failed to ensure that fire drills are conducted at different times of the day and different days of the week. The fire drill log from March 28, 2019 until November 27, 2019 were conducted within the last three days of the month and between 11am-12pm.
These findings were discussed with facility staff during inspection process.
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Plan of Correction
The Facility Director reviewed the citation. To ensure compliance with PA regulation 705.28 (d)(6) the Facility Director will ensure the Health and Safety officer conducts fire drills on different days of the week, at different times of the day and
on different staffing shifts.
The Facility Director will ensure compliance by reviewing the health and Safety binder on a monthly basis.
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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 nine client records, the facility failed to keep disclosures of client identifying information within the limits established by 4 Pa. Code 255.5 (b) for releases of information in client record #'s 3.
Client#1 was admitted on January 15, 2019 and was an active client as of the date of the inspection. Consent to release forms were signed and dated on January 30, 2019 to parole, to a Probation officer dated April 2, 2019 and to CYS dated July 5, 2019, that allowed for the release of dose hsitory/dosage, labortory test, admission summary, treatment plan, physical exam, progress notes, D&A notes, psychological evaluation and discharge summary.
The findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
The Facility Director reviewed the citation. To safeguard against a breech of patient confidentiality, The clinical director facilitated a confidentiality training for all staff to ensure that only specific information is disclosed and releases are completed within standard guidelines. The Clinical Supervisor will review patient charts with clinician/case managers during individual supervision.
The facility revoked/voided out the releases referenced. The facility was unable to complete new consent due to patient discharge.
Further, the clinical supervisor and facility director will conduct monthly chart audits to maintain compliance with confidentiality standards . |
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 a review of nine client records, client #5 was admitted June 14, 2019 and was still active at the time of inspection record was viewed without a photograph of the patient.
These findings were discussed with facility staff during inspection process.
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Plan of Correction
The Facility Director reviewed the citation. To safeguard against any possibility of incorrect patient identification, a patients photo will be taken by the facility and uploaded into his/her EHR during the admission process.
To maintain compliance with licensing standard, the facility and clinical directors will conduct weekly record reviews using Pinnacle Treatment Centers 2 tier auditing process. |
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 nine patient records, the facility failed to ensure that each patient recieved 2.5 hours of psychotherpay per month during the first 2 years in seven patient records.
Patient # 1 was admitted on April 20, 2018 andwas still ative at the time of inspection. The patient had not recieved an individual session since July 24, 2019. There was no documentation of client no shows or cancellations during those time periods.
Patient #4 was admitted on November 18, 2018 and was discharged on September 17, 2019. In July, the patient did not recieve an individual session. In August, the patient had a 30 minute individual session and no group session. There was no documentation of client no shows or cancellations during those time periods.
Patient #5 was admitted on June 14, 2019 and was discharged on December 3, 2019. In July, the patient did not recieve an individual or group counseling session. There was no documentation of client no shows or cancellations during those time periods.
Patient #6 was admitted on February 5, 2018 and was still active at the time of inspection. In January, the patient recieved 1 hour individual and 0 hours group. In February, the patient recieved 0 hours individual 1.5 hours group. In July, the patient recieve 0 hours of individual and 1.5 hours group. In September, the patient recieved 1 hour individual and 0 hours group. In Novemeber, the patient recieved 0 hours individual and 1.5 hours group. There was no documentation of client no shows or cancellations during those time periods.
Patient #8 was admitted on January 10, 2018 and was still active at the time of inspection. The patient record was missing documentation of individual session and group session for the months of April, May, June, July, August, and September. There was no documentation of client no shows or cancellations during those time periods.
Patient #9 was admitted on December 3, 2018 and was discharged on September 25, 2019. In May, the patient recieved 1 hour of individual and 0 hours of group. In July, the patient recieved 30 minutes of indivdiual and 1.5 hours of group. In August, the patient recieved 0 hours of individual and 1.5 hours of group. There was no documentation of client no shows or cancellations during those time periods.
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 ensure patients are attending 2.5 hours of psychotherapy per month, the Clinical Supervisor will conduct a training by 2/1/2020 on how to utilize the EHR to assist patients in meeting monthly counseling requirements.
The Clinical Supervisor will train clinicians/case managers to use dose holds (a dose hold is an alert in the EHR that stops the patient when checking in indicating the patient is required to see a counselor), Services Due Report and Services Provided Report in the EHR (SMART) to reach required monthly counseling. Non-compliance will be addressed during supervision.
The Clinical Supervisor and Facility Director will also complete weekly chart audits using Pinnacle Treatment Centers 2 tier auditing process to maintain compliance. |
715.23(d)(2) LICENSURE Patient records
(d) A narcotic treatment program shall prepare a treatment plan that outlines realistic short and long-term treatment goals which are mutually acceptable to the patient and the narcotic treatment program.
(2) The narcotic treatment physician or the patient 's counselor shall review, reevaluate, modify and update each patient 's treatment plan as required by Chapters 157, 709 and 711 (relating to drug and alcohol services general provisions; standards for licensure of freestanding treatment activities; and standards for certification of treatment activities which are a part of a health care facility).
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Observations
Based on a review of nine patient records, the facility failed to document treatment plan updates within the regulatory timeframe in five patient records reviewed.
Patient #1 was admitted on April 20, 2018 and was still active at the time of the inspection. A treatment plan update was completed on August 21, 2019 and the next update was due no later than November 21, 2019 ; however, there was no update documented in the record at the time of the inspection.
Patient #4 was admitted on November 15, 2018 and was discharged on September 17, 2019. A treatment plan update was completed on June 27, 2019 and the next update was due no later than August 27, 2019 ; however, there was no update documented in the record at the time of the inspection.
Patient #6 was admitted on February 5, 2018 and was still active at the time of the inspection. A treatment plan update was completed on November 26, 2018 and the next update was due no later than February 2, 2019 ; however, the update was not completed until February 1, 2019.
Patient #8 was admitted on January 10, 2018 and was still active at the time of the inspection. A treatment plan update was completed on July 24, 2019 and the next update was due no later than September 24, 2019 ; however, there was no update documented in the record until November 15, 2019.
Patient # 9 was admitted on December 3, 2018 and was discharged on September 25, 2019. A treatment plan update was completed on June 6, 2019 and the next update was due no later than August 6, 2019; however, there was no update documented in the record until August 30, 2019.
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 treatment plans not being completed in a timely manner, the Clinical Supervisor will conduct a training by 2/1/2020 on how to utilize the EHR to identify when treatment plans are due and a train the clinicians on a process that will allow for signatures to be obtained prior to the plans end date.
Patient #1 was an active patient during survey, but was discharged before an updated plan could be completed.
Patient #4
The Clinical Supervisor will train clinicians to use dose holds/delays(a dose hold/delay is an alert in the EHR that stops the patient when checking in indicating the patient is required to see their counselor. At that time the service would be provided. ie treatment plan would be signed), the Services Due Report and Services Provided Report in the EHR (SMART) to determine when treatment plans are due and complete them in a timely manner that allows for all signatures to be obtained before plans expiration date. Non-compliance will be addressed during supervision.
The Clinical Supervisor and Facility Director will also complete weekly chart audits using Pinnacle Treatment Centers 2 tier auditing process to maintain compliance. |
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 nine patient records, the facility failed to document treatment plan updates within the regulatory timeframe in five patient records reviewed.
Patient #1 was admitted on April 20, 2018 and was still active at the time of the inspection. A treatment plan update was completed on August 21, 2019 and the next update was due no later than November 21, 2019 ; however, there was no update documented in the record at the time of the inspection.
Patient #4 was admitted on November 15, 2018 and was discharged on September 17, 2019. A treatment plan update was completed on June 27, 2019 and the next update was due no later than August 27, 2019 ; however, there was no update documented in the record at the time of the inspection.
Patient #6 was admitted on February 5, 2018 and was still active at the time of the inspection. A treatment plan update was completed on November 26, 2018 and the next update was due no later than February 2, 2019 ; however, the update was not completed until February 1, 2019.
Patient #8 was admitted on January 10, 2018 and was still active at the time of the inspection. A treatment plan update was completed on July 24, 2019 and the next update was due no later than September 24, 2019 ; however, there was no update documented in the record until November 15, 2019.
Patient # 9 was admitted on December 3, 2018 and was discharged on September 25, 2019. A treatment plan update was completed on June 6, 2019 and the next update was due no later than August 6, 2019; however, there was no update documented in the record until August 30, 2019.
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 treatment plans not being completed in a timely manner, the Clinical Supervisor will conduct a training by 2/1/2020 on how to utilize the EHR to identify when treatment plans are due and a train the clinicians on a process that will allow for signatures to be obtained prior to the plans end date.
Patient #1 was an active patient during the survey, but was discharged before an updated plan could be completed.
The Clinical Supervisor will train clinicians to use dose hold/delay (a dose hold/delay is an alert in the EHR that stops the patient when checking in indicating the patient is required to see their counselor. At that time the service would be provided. ie treatment plan would be signed), the Services Due Report and Services Provided Report in the EHR (SMART) to determine when treatment plans are due and complete them in a timely manner that allows for all signatures to be obtained before plans expiration date. Non-compliance will be addressed during supervision.
The Clinical Supervisor and Facility Director will also complete weekly chart audits using Pinnacle Treatment Centers 2 tier auditing process to maintain compliance. |