INITIAL COMMENTS
|
This report is a result of an on-site licensure renewal inspection and methadone monitoring conducted on September 19, 2023 through September 20, 2023 by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, The Behavioral Wellness Center at Girard Goldman Clinic 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
|
715.14(a) LICENSURE Urine testing
(a) A narcotic treatment program shall complete an initial drug-screening urinalysis for each prospective patient and a random urinalysis at least monthly thereafter.
|
Observations
Based on a review of patient records, the facility failed to complete a random urinalysis, for each patient, at least monthly in one of two patient records reviewed.
Patient #3 was admitted into the outpatient maintenance activity on April 14, 2023 and was active at the time of inspection. There was no documentation that a random urinalysis was conducted during the month of June 2023.
This is a repeat citation from the September 26, 2022 through September 27, 2022 and September 22, 2021 through September 23, 2021 annual licensing renewal inspections.
The finding was reviewed with facility staff during the licensing process.
|
Plan of Correction
Goldman administrative team worked with the IT department to get create a crystal report for participants who have not had monthly urine drug screens. The crystal report will be run on the 20th of each month. Any participant who has not had a urine drug screen will be placed on hold for urine. Administrative and clinical staff will be notified. The clinical supervisors along with executive director will monitor this process for three (3) consecutive months beginning November 2023 thru January 2024 with a benchmark of 100% compliance, after which there will be periodic monitoring to ensure that compliance is being sustained and that all participants receive random monthly drug screen.
|
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 document that each patient received at least 2.5 hours of psychotherapy group or individual sessions per month during the patient's first year in treatment in one of two records reviewed.
Patient #3 was admitted into the outpatient maintenance activity on April 14, 2023 and was still active at the time of inspection. There was documentation in the record that indicated the patient received a total of 30 mins of psychotherapy during the month of May 2023; no hours of psychotherapy during the month of June 2023; 30 minutes of psychotherapy during the month of July 2023; and 1 hour of psychotherapy during the month of August 2023.
This is a repeat citation from the September 26, 2022 through September 27, 2022; September 22, 2021 through September 23, 2021 and May 4, 2021 annual licensing renewal inspections.
The finding was reviewed with facility staff during the licensing process.
|
Plan of Correction
Goldman administrative staff worked with the IT department to create a crystal report for participants who have not received services. Every Thursday, the office manager will pull the report and any participant who missed their scheduled appointment will be called and rescheduled and placed on a hold. Clinical supervisors along with the Executive Director will monitor this process for three (3) consecutive months beginning November 2023 thru January 2024 with a benchmark of 100% compliance, after which there will be periodic monitoring to ensure that compliance is being sustained to ensure that all participants are adhering to 2.5 minimum clinical therapy hours |
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.
|
Observations
Based on a review of patient records, the facility failed to comply with plans of correction that were approved by the Department.
Plans of correction for ensuring each patient received at least 2.5 hours of psychotherapy group or individual sessions per month during the patient's first year in treatment were submitted and approved by the Department from the September 26, 2022 through September 27, 2022; September 22, 2021 through September 23, 2021; and May 4, 2021 annual licensing inspections. Failing to ensure that all applicable patients received at least 2.5 hours of psychotherapy services was again found to be a deficiency in the September 19, 2023 through September 20, 2023 licensing inspection.
Plans of correction for completing a random monthly urinalysis for each patient were submitted and approved by the Department from the September 26, 2022 through September 27, 2022 and September 22, 2021 through September 23, 2021 annual licensing inspections. Failing to ensure that all applicable patient records documented a random monthly urinalysis was again found to be a deficiency in the September 19, 2023 through September 20, 2023 licensing inspection.
These findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
Implementing reports for urine drug screens and clinical therapy will help us to identify participants who have not received a urine drug screen monthly or participants who have not had a minimum of 2.5 hours of clinical therapy. It is important that we abate this citation and comply with the licensing standard 715.14(a) and 715.19(1). The implementation of this process will be monitored bi-weekly beginning November 15, 2023, by the Executive Director or designee to ensure that we are in adherence to the regulation. |