INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection and methadone monitoring inspection conducted on September 11 & 12, 2024 by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. 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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709.24 (a) (3) LICENSURE Treatment/rehabilitation management.
§ 709.24. Treatment/rehabilitation management.
(a) The governing body shall adopt a written plan for the coordination of client treatment and rehabilitation services which includes, but is not limited to:
(3) Written procedures for the management of treatment/rehabilitation services for clients.
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Observations
Based on a review of client records, the facility failed to follow their written procedures for case consultations in five out of ten applicable client records reviewed and follow up contacts for clients in one out of two applicable client records reviewed.
The facility ' s policy and procedures manual states that case consultations occur at three, six, nine months, one year and annually thereafter.
Client #1 was admitted on January 5, 2024 and was still active at the time of the inspection. A case consultation was due no later than April 5, 2024; however, it was completed on May 10, 2024.
Client #5 was admitted on November 21, 2023 and was still active at the time of the inspection. A case consultation was due no later than February 21, 2024; however, it was completed on April 2, 2024.
Client #6 was admitted on August 1, 2016 and was still active at the time of the inspection. A case consultation was completed on August 2, 2023 and the next one was due no later than August 2, 2024; however, it was completed on August 23, 2024.
Client #7 was admitted on April 4, 2024 and was still active at the time of the inspection. A case consultation was due no later than July 4,2024; however, it was completed on July 22, 2024.
Client #9 was admitted on November 28, 2023 and was discharged on March 27, 2024. A case consultation was due no later than February 28, 2024; however, there was no documentation that one was completed.
The facility ' s policy and procedures manual states that follow up contacts occur at seven, thirty and sixty business days after discharge.
Client #8 was admitted on May 9, 2022 and discharged on January 24, 2024. A follow up contact was due no later than January 31, 2024; however, was not completed until April 12, 2024.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Facility Director reviewed the citation pertaining to case consultations and follow-up contacts.
The Facility Director will re-train clinicians on 10/21/2024 on how to use Methasoft EHR reports "Scheduled Events", the "Scheduler", and "Flags" to alert patients when they are checking in their counselor wants to see them to complete a case consultation either quarterly or annually, based on their time in treatment. The form will be completed either in person and/or during a counseling phone call. After completing the case consultation, signatures will be obtained.
Follow-up contact after discharge. The Clinical Supervisor(s) will retrain clinicians on 10/16/2024 on how to use EHR reports "Scheduled Events" to identify when the first and second follow-up contacts are due and where to locate the forms. The CS will review how to complete the form and give examples to assist with the process.
The CS will monitor compliance by conducting monthly chart audits. Non-compliance will be discussed during supervision.
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709.28 (d) LICENSURE Confidentiality
§ 709.28. Confidentiality.
(d) A copy of a client consent shall be offered to the client and a copy maintained in the client record.
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Observations
Based on a review of client records, the facility failed to document that a copy of a client consent was offered to the client and a copy maintained in the client record in two out of ten client records reviewed.
Client #5 was admitted on November 21, 2023 and was a still active at the time of the inspection. There was no documentation that a copy of an informed and voluntary consent to release information form for a funding source, that was signed and dated November 21, 2023, was offered to the client.
Client #7 was admitted on April 4, 2024 and was still active at the time of the inspection. There was no documentation that a copy of an informed and voluntary consent to release information form for a funding source, that was signed and dated, April 4, 2024 was offered to the client.
These findings were reviewed with the facility staff during the licensing process.
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Plan of Correction
The Facility Director reviewed the citation pertaining to confidentiality.
To safeguard against patient confidentiality being breached, the Clinical Supervisor(s) will retrain clinicians by 10/16/24 on how to complete a consent to release thoroughly, ensuring the patient is offered a copy and checking the appropriate box, using examples and checking completed ROI's.
Clinicians will complete the following Relias trainings: Confidentiality, ROI's, and Coordination of Care.
The Clinical Supervisor will conduct chart audits monthly for compliance and will address any issues during supervision. The Clinical Supervisor(s) will refer to PTC policies as needed.
Patient #5 was discharged on 9/19/2024. Unable to have patient sign ROI for funding source.
Patient #7, ROI for CCBH was signed 10/16/24. |
715.6(e) LICENSURE Physician Staffing
(e) A physician assistant or certified registered nurse practitioner may perform functions of a narcotic treatment physician in a narcotic treatment program if authorized by Federal, State and local laws and regulations, and if these functions are delegated to the physician assistant or certified registered nurse practitioner by the medical director, and records are properly countersigned by the medical director or a narcotic treatment physician. One-third of all required narcotic treatment physician time shall be provided by a narcotic treatment physician. Time provided by a physician assistant or certified registered nurse practitioner may not exceed two-thirds of the required narcotic treatment physician time.
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Observations
Based on a review of patient records, the facility failed to ensure that documentation of duties delegated to the physician assistant or certified registered nurse practitioner (CRNP) were properly countersigned in one of six applicable records reviewed. The written agreement between the physician assistant and the narcotic treatment physician indicates that orders written by the physician assistant will be countersigned within 72 hours.
Patient #6 was admitted on August 1, 2016 and was active at the time of the inspection. The record contained documentation of an annual physical completed by the physician assistant on July 26, 2024, which was not countersigned by the narcotic treatment physician until August 6, 2024. This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
The Program Director reviewed the citation pertaining to physician countersigning PA/CRNP records within 72 hours.
Plan of correction was completed on 10/16/2024. The Program Director will ensure the documentation duties delegated to the PA/CRNP are counter signed by the prescribing physician in 72 hours. The PD will review MD digital signing on a regular basis to ensure documents are being signed in a timely manner. PD will contact physician as needed for signatures. |
715.12(1-5) LICENSURE Informed patient consent
A narcotic treatment program shall obtain an informed, voluntary, written consent before an agent may be administered to the patient for either maintenance or detoxification treatment. The following shall appear on the patient consent form:
(1) That methadone and LAAM are narcotic drugs which can be harmful if taken without medical supervision.
(2) That methadone and LAAM are addictive medications and may, like other drugs used in medical practices, produce adverse results.
(3) That alternative methods of treatment exist.
(4) That the possible risks and complications of treatment have been explained to the patient.
(5) That methadone is transmitted to the unborn child and will cause physical dependence.
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Observations
Based on a review of patient records, the facility failed to obtain an informed, voluntary, written consent prior to administering an agent in one out of three applicable records.
Patient #7 was admitted on April 4, 2024 and was still active at the time of the inspection. There was no documentation that an informed, voluntary, written consent was signed.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
The Program Director reviewed the citation pertaining to obtaining informed, voluntary, written consent to treatment on admission.
Plan of correction was completed on 10/25/2024. The CRNP/PA/MD will review the form with patient during the admission process and a signature will be obtained. The nursing staff will ensure the patient has signed the informed consent form before medicating on the day of admission. During the admission chart audit process, the clinical supervisor will ensure the informed consent form in 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.
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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 two out of four applicable records reviewed.
Patient #1 was admitted on January 5, 2024 and was still active at the time of the inspection. In June 2024, the patient only received a half hour of individual psychotherapy session and one hour of group therapy.
Patient #5 was admitted on November 21, 2023 and was still active at the time of the inspection. In May 2024, the patient only received one hour and fifteen minutes of individual psychotherapy.
This is a repeat citation from the November 14, 2022 and October 27, 2023 licensing inspections.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Program Director reviewed the citation pertaining to providing 2.5 hours of psychotherapy per month during the patients firsts 2 years of treatment.
The Clinical Supervisor(s) will re-train clinicians on 10/16/2024 on how to use Methasoft HER reports "Scheduled Events", the Scheduler, Daily Activities, and dose delay (dose delay is an alert in the EHR that stops the patient when checking-in indicating the patient is required to see a counselor before medicating), to assist patients with meeting the required 2.5 hours of psychotherapy monthly. Utilize phone, video, and/or group counseling as needed to help patient's complete the 2.5 hours.
The Clinical Supervisor(s) will monitor compliance via monthly chart audits and reviewing tableau dashboards, completed scheduled events, and monthly requirement reports. Non-compliance will be addressed in supervision. |
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 provide patients with one hour per month of therapy during the third and fourth year of treatment in one out of two applicable records.
Patient #8 was admitted on May 9, 2022 and was discharged on January 24, 2024. In December 2023, the patient did not receive any hours of psychotherapy.
This is a repeat citation from the October 27, 2023 licensing inspection.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
The Program Director reviewed the citation pertaining to providing 1 hour of psychotherapy per month during the third and fourth year of treatment.
The Clinical Supervisor(s) will re-train clinicians on 10/16/2024 on how to use Methasoft HER reports "Scheduled Events", the Scheduler, Daily Activities, and dose delay (dose delay is an alert in the EHR that stops the patient when checking-in indicating the patient is required to see a counselor before medicating), to assist patients with meeting the required 1 hour of psychotherapy monthly. Utilize phone, video, and/or group counseling as needed to help patient's complete units.
The Clinical Supervisor(s) will monitor compliance via monthly chart audits and reviewing tableau dashboards, completed scheduled events, and monthly requirement reports. Non-compliance will be addressed in supervision. |
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.
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Observations
Based on a review of patient records, the facility failed to document that it notified a patient's previous facility of the patient's admission including the date of initial dose in one out of one applicable record.
Patient #1 was admitted on January 5, 2024 and was still active at the time of the inspection. There was no written documentation that the facility notified the transferring facility of the patient's admission including the date of initial dose.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
The Program Director reviewed the citation pertaining to informing the transferring program the transfer was completed including the date of initial dose.
To ensure all transfer documents are uploaded into the EHR, the CS will retrain the clinicians on the importance of record keeping and compliance standards.
The Clinical Supervisor(s) will re-train the staff by 10/16/2024 on patient transfer regulations and policies and procedures. The training is focused on ensuring the clinical team members submit all required information to transferring treatment programs utilizing Methasoft EHR "Transfer Acknowledgment letter" and scan into the chart after faxed with confirmation. Clinical Supervisor(s) will audit discharge charts monthly to monitor compliance. Compliance concerns will be address in supervision. |
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 evaluation within the regulatory timeframe in one out of five applicable records.
Patient #6 was admitted on August 1, 2016 and was still active at the time of the inspection. The annual evaluation was due no later than August 1, 2024; however, it was not completed until August 13, 2024. Additionally, the medical doctor did not counter sign the document until August 27, 2024.
This is a repeat citation from the October 27, 2023 licensing inspection.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
The Program Director reviewed the citation pertaining to obtaining a co-signature by the medical director on completed annual evaluations.
Plan of correction was completed on 10/28/2024. Tableau dashboards are used to determine which patient annual evaluations are due. The clinical supervisors will provide counselors a list to complete and follow-up to ensure all signatures are obtained. The PD will review MD digital signing on a regular basis to ensure documents are being signed in a timely manner. The Clinical Supervisors will monitor compliance via monthly chart audits and address any issues or concerns during supervision. |
709.91(b)(7) LICENSURE Intake and admission
709.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(7) Preliminary treatment and rehabilitation plan.
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Observations
Based on a review of client records, the facility failed to document a preliminary treatment plan per the facility ' s policy and procedure manual timeframe, within seven days of admission, in one out of three applicable records reviewed.
Client #5 was admitted on November 21, 2023 and was still active at the time of the inspection. There was no documentation of a preliminary treatment plan at the time of the inspection.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
The Program Director reviewed the citation pertaining to completing preliminary treatment plans within 7 days of admission.
To safeguard against treatment plans not being completed on admission the Clinical Supervisors will retrain clinicians on 10/16/24 on how to utilize the EHR to identify the documents that are required to be completed and reviewed with the patient and signed. Clinicians have a cheat sheet they use that lists all forms to complete during the admission process.
CS will utilize the pending/late treatment plan tableau dashboard and inform the clinical team via email or teams chat what plans are due or late. Also, during the intake process, the CS reviews the chart to ensure all documents are completed. In the event the tx plan is missed, the clinician is contacted via email or teams to complete the document as soon as possible. CS will follow-up to ensure the plan is complete and signed.
Review completed treatment plans during the digital signing process. Send back to the clinician to complete revisions as needed.
All clinicians will complete the Relias training on "Treatment Planning".
The clinical supervisor will conduct a chart audit on all admissions in I-Auditor to maintain compliance and address any issues during individual and group supervision
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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 document treatment plan updates within the regulatory timeframe in six out of nine applicable records reviewed.
Client #2 was admitted on November 5, 2021 and was still active at the time of the inspection. A treatment plan update was completed on June 24, 2024, and the next update was due no later than August 24, 2024; however, it was not completed until August 29, 2024.
Client #3 was admitted on May 17, 2011 and was still active at the time of the inspection. A treatment plan update was completed on December 12, 2023, and the next update was due no later than February 13, 2024; however, it was not completed until February 19, 2024.
Client #4 was admitted on June 21, 2021 and was still active at the time of the inspection. A treatment plan update was completed on July 9, 2024, and the next update was due no later than September 9, 2024; however, there was no documentation that one was completed.
Client #5 was admitted on November 21, 2023 and was still active at the time of the inspection. A treatment plan was completed on November 21, 2023, and the next update was due no later than January 21, 2024; however, it was not completed until March 13, 2024.
Client #6 was admitted on August 1, 2016 and was still active at the time of the inspection. A treatment plan update was completed on February 28, 2024, and the next update was due no later than April 28, 2024; however, it was not completed until May 1, 2024.
Client #10 was admitted on November 24, 2020 and was still active at the time of the inspection. A treatment plan update was completed on February 8, 2024, and the next update was due no later than April 8, 2024; however, it was not completed until April 15, 2024. A treatment plan update was completed on June 10, 2024, and the next update was due no later than August 10, 2024; however, it was not completed until August 19, 2024.
This is a repeat citation from the October 27, 2023 licensing inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Program Director reviewed the citation pertaining to completing treatment plan updates within the regulatory guidelines.
To safeguard against treatment plans not being completed based on regulatory standards, the Clinical Supervisors will retrain clinicians on 10/16/24 on how to utilize the EHR and tableau dashboards to identify treatment plan due dates. CS will show clinicians how to use collaborative documentation to developed the plans with the patient. Signatures will be obtained.
CS will utilize the pending treatment plan tableau dashboard and inform the clinical team via email or teams chat what plans are due. CS will follow-up to ensure the plan is complete and signed.
Review completed treatment plans during the digital signing process. Send back to the clinician to complete revisions as needed.
All clinicians will complete the Relias training on "Treatment Planning".
The clinical supervisor will conduct chart audits to maintain compliance and address any issues during individual and group supervision
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709.17(a)(3) LICENSURE Subchapter B.Licensing Procedures.Refusal/rev
709.17. Refusal or revocation of license.
(a) The Department may revoke or refuse to issue a license for any of the following reasons:
(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.
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Observations
Based on a review of client records, the facility failed to comply with plans of correction that were approved by the Department.
A plan of correction for providing 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
per month was submitted and approved by Department for the November 14, 2022, and October 27, 2023 annual licensing inspection. Providing 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 per month was again found to be a deficiency in the September 11 & 12, 2024 licensing inspection.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
The Program Director reviewed the citation pertaining to the facility failing to comply with POC that was approved by the department.
The Facility Director will ensure the plans of correction is implemented by the corrective action date (10/16/2024) and the clinical supervisors will assist in the monitoring process. Clinical Supervisors will monitor progress of the plan and quarterly reviews of plans of correction implantation will occur during staff/supervision meetings. Additional monitoring will occur monthly through chart audits completed by the PTC compliance team and if deficiencies are noted they will be reviewed within the month. If the plan of correction appears to be not working as written, a supervisory meeting will occur to adjust the current plan. The Facility Director will report to the Project Director the findings each quarter during PTCs regional operations meeting. |