INITIAL COMMENTS
|
This report is a result of an on-site licensure renewal and methadone and buprenorphine monitoring inspection conducted on September 13, 2023 by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, ARS of Lancaster, LP 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:
|
Plan of Correction
|
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.
|
Observations
Based on the review of the Staffing Requirements Facility Summary Report, the facility failed to keep client/staff ratios at or below the regulation limit of 35/1. The counselor Full Time Equivalent (FTE) is determined by dividing the total number of hours the counselor devotes to their clients by facility's work week. Then, in order to obtain the counselor's ratio, the total number of clients on the counselor's caseload is divided by the FTE.Employee #3 was hired as the clincial supervsior on February 7, 2022 and was still acting in that position. Employee #2 was reported to have 20 hours per week devoted to their 20 clients on their caseload.The FTE counselor's caseload calculation is as follows: 20/40 = .50(FTE); 20/.50=40, which equals to a client counselor ratio of 40:1.Employee #5 was hired as a counselor on October 31, 2022 and was still acting in that position. Employee #5 was reported to have 40 hours per week devoted to their 54 clients on their caseload.The FTE counselor's caseload calculation is as follows: 40/40 = 1 (FTE); 54/1 = 54, which equals to a client counselor ratio of 54:1. Employee #8 was hired as a counselor on August 16, 2021 and was still acting in that position. Employee #8 was reported to have 40 hours per week devoted to their 57 clients on their caseload.The FTE counselor's caseload calculation is as follows: 40/40 = 1 (FTE); 57/1 = 57, which equals to a client counselor ratio of 57:1. These findings were reviewed with facility staff during the licensing inspection.
|
Plan of Correction
The Clinical Supervisor will review counselor caseloads during weekly supervision to determine counselor to patient ratios. The Clinical Supervisor will identify the number of patients who are exempt status versus non-exempt status, this will allow for continued compliance with the 1:35 ratio. Caseloads will be adjusted as needed based on new admissions and patient promotions to exempt status. Executive Director will ensure implementation by 10/27/23. |
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:
|
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.These findings were discussed with facility staff during the inspection process.
|
Plan of Correction
The Director of Nursing will re-educate all nursing staff on the proper procedure for the disposal of empty take-home bottles, to secure confidentiality. Nurses will remind patients to cross off patient identifying information on empty bottles prior to disposal. Will be completed effective 10/5/23. |
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
|
Observations
Based on the review of physician timesheets, the facility failed to provide at least one hour of physician time a week, onsite for every ten patients. During the week of May 1-6,2023, the patient census was 651. The facility was required to provide at least 65.1 physician hours. There were 46 physician hours documented. This finding was reviewed with facility staff during the licensing inspection.
|
Plan of Correction
The Executive Director and the Medical Director will meet on 10/9/23. A review will be completed of the required physician hours for the month. The Executive Director will review the physician hours monthly to ensure that the required coverage is in place. The Executive Director and the Medical Director will identify back-up coverage if an emergency arises or for vacation coverage. |
715.14(b) LICENSURE Urine testing
(b) A narcotic treatment program shall develop and implement policies and procedures to ensure that urine collected from patients is unadulterated. These policies and procedures shall include random observation which shall be conducted professionally, ethically and in a manner which respects patient privacy.
|
Observations
Based on observation conducted of the urinalysis process during the onsite inspection, the facility failed to ensure that the urine collection was unaltered as staff did not watch the monitors during the process for two patients. These findings were reviewed with facility staff during the licensing inspection.
|
Plan of Correction
The Director of Nursing will provide training to all nurses on the policy and procedure for urine drug screen collections. This training will include the importance of ensuring that urine specimens are observed to prevent adulteration. Training will be completed on 10/5/23. |
715.15(a) LICENSURE Medication Dosage
(a) The narcotic treatment physician shall review the dosage levels at least twice a year, with each review occurring at least 2 months apart, to determine a patient 's therapeutic dosage.
|
Observations
Based on a review of patient records, the facility failed to document a review of the dosage levels at least twice a year in one of eight patient records. Patient #1 was admitted on May 27, 2008 and was still active at the time of the inspection. No dose reviews were documented in the patient record. These findings were reviewed with facility staff during the licensing inspection.
|
Plan of Correction
The Medical Director/physician/PA will complete Biannual dose review appointments with patients, twice per year. The Director of Nursing will flag patients when appointments need scheduled for Biannual dose review. The nurse will then schedule these appointments with the provider for completion. Once the appointment is completed by the provider, the provider will then ensure that a new flag is placed for the next time the appointment will need scheduled. The Director of Nursing will then review monthly the appropriate flags are in place and appointments are scheduled and completed |
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.
|
Observations
Based on a review of patient records, the facility failed to provide patients with 2.5 hours of psychotherapy per month during the patient's first two years of treatment, one hour of which shall be individual psychotherapy, in three out of four applicable records reviewed.Patient #2 was admitted on March 27, 2023 and was still active at the time of the inspection. The patient only received psychotherapy for one hour and thirty minutes in May 2023 and one hour in both July and August. Patient #3 was admitted on October 28, 2022 and was still active at the time of the inspection. The patient only received psychotherapy one hour in May 2023, 30 minutes in June 2023 and one hour in both July and August 2023. Patient #6 was admitted on May 5, 2022 and was discharged on August 11, 2023. The patient received psychotherapy for zero hours in May 2023, and one hour for both June and July 2023. This finding was reviewed with facility staff during the licensing inspection.
|
Plan of Correction
The Clinical Supervisor will provide training to clinical staff regarding the 2.5 hours of required counseling per month. Primary counselors will review caseloads weekly to identify patients that have not completed their 2.5 hours of counseling/group requirements. Counselors will immediately schedule their patients who are not compliant with session requirements to become complaint. The clinical supervisor will review with counselor during weekly supervision, to ensure compliance. |
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.
|
Observations
Based on a review of patient records, the facility failed to document transfer of patient files to the patient's new treatment facility in one out of one applicable record. Patient #6 was admitted on January 5, 2022 and was transferred to another facility on August 11, 2023. This finding was reviewed with facility staff during the licensing inspection.
|
Plan of Correction
Prior to discharging a patient the counselor and clinical supervisor will meet to review discharge transfer documentation is accurate and complete, ensure appropriate documents are transferred to new facility. The Clinical Supervisor will provide training to all clinical staff on the documentation requirements for discharge transfers. The Clinical Supervisor will complete monthly discharge audits to ensure there are no further deficits in this area. Clinical supervisor is responsible for implementation. |
715.20(4) LICENSURE Patient transfers
A narcotic treatment program shall develop written transfer policies and procedures which shall require that the narcotic treatment program transfer a patient to another narcotic treatment program for continued maintenance, detoxification or another treatment activity within 7 days of the request of the patient.
(4) The receiving narcotic treatment program shall document in writing that it notified the transferring narcotic treatment program of the admission of the patient and the date of the initial dose given to the patient by the receiving narcotic treatment program.
|
Observations
Based on a review of patient records, the facility failed to document the notification of the previous narcotic treatment program of the admission and initial dose of the patient in one out of one applicable record.Patient #5 was admitted on July 7, 2023 and was still active at the time of the inspection. This finding was reviewed with facility staff during the licensing inspection.
|
Plan of Correction
The Clinical Supervisor will train the clinical staff on completing the "transfer acknowledgement" form. The Clinical Supervisor will educate the clinical staff on where the form is in the electronic record, when to complete it and how. Clinical Supervisor will meet with counselor prior to discharging a patient to review that appropriate transfer acknowledgement form has been completed and sent. Clinical supervisor will meet with counselor when a transfer admission is received in order to ensure that transfer acknowledgement form is completed and faxed back to referring clinic. Clinical Supervisor will complete clinical training by 10/24/23. |
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.
|
Observations
Based on a review of patient records, the facility failed to document an annual physical examination within the regulatory timeframe in one out of four applicable records.Patient #4 was admitted on August 24, 2022 and was still active at the time of the inspection. The annual physical examination was due August 24, 2023; however, no annual physical was documented in the patient record at the time of the inspection. This finding was reviewed with facility staff during the licensing inspection.
|
Plan of Correction
The Director of Nursing and Physician Assistant will ensure that all new admissions and completed annual physicals are flagged to appointments scheduled. The nurses will schedule these appointments in a timely manner and place a flag for the day of the scheduled appointment. The Medical provider will document when patient is a no show for their scheduled appointments and place a priority flag to have these annual physicals completed prior to due date. |
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.
|
Observations
Based on a review of patient records, the facility failed to document an annual clinical evaluation within the regulatory timeframe in three out of four applicable records. Patient #1 was admitted on May 27, 2008 and was still active at the time of the inspection. The annual clinical evaluation was due on May 27, 2023; however, no review was documented in the patient record at the time of the inspection. Patient #4 was admitted on August 24, 2022 and was still active at the time of the inspection. The annual clinical evaluation was due on August 24, 2023; however, no review was documented in the patient record at the time of the inspection. Patient #7 was admitted on January 23, 2013 and was discharged on June 27, 2023. The annual clinical evaluation was due on January 23, 2023; however, no review was documented in the patient record at the time of the inspection.These findings were reviewed with facility staff during the licensing inspection.
|
Plan of Correction
The Clinical Supervisor will complete training with clinical staff by 10/27/23, on annual evaluations. The clinical staff will be trained in creating a spread sheet to track the due dates for annual evaluations, to ensure timely completion. The Clinical Supervisor will review with counselors spread sheets during supervision. The clinical supervisor is responsible for implementation by 10/28/23. |
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.
|
Observations
Based on a review of client record, the facility failed to complete treatment plans within the regulatory timeframe in three of eight client records reviewed.Client #3 was admitted on October 28, 2022 and was still active at the time of the inspection. A treatment plan update was completed January 24, 2023, and an update was due no later than March 24, 2023; however, a treatment plan update was not documented in the record until April19, 2023.Client #6 was admitted on January 5 2022 and was discharged August 11, 2023. A treatment plan update was completed on March 1, 2023, and an update was due no later than May 1, 2023; however, a treatment plan update was not documented in the record until June 14, 2023. Client #7 was admitted on January 23, 2013 and was discharged on June 27, 2023. A treatment plan update was completed on November 15, 2022, and an update was due no later than March 15, 2023; however, no treatment plan update was documented in the client record. These findings were reviewed with facility staff during the licensing inspection.
|
Plan of Correction
The clinical supervisor will complete a treatment plan training on 10/27/23. The training will be information on the requirement of treatment plan update reviews timeframes, and signatures. Primary counselor will identify "next review dates" on the problem list and will ensure treatment plans are reviewed and updated by the next review date. The Clinical Supervisor will track the next review dates weekly. |
709.93(a)(9) 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:
(9) Aftercare plan, if applicable.
|
Observations
Based on a review of client records, the facility failed to provide a complete client record, which is to include aftercare information in one out of one applicable discharged records reviewed.Client #7 was admitted on January 23, 2013 and was discharged on June 27, 2023. This finding was reviewed with facility staff during the licensing process.
|
Plan of Correction
The Director of Clinical Services will complete clinical training on 10/27/23. This training will include a review of aftercare planning. Counselors will ensure all patients with planned discharge receive an aftercare plan prior to discharge. The Clinical Supervisor will audit all discharge charts to ensure this does not re-occur. |