INITIAL COMMENTS
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This report is a result of an onsite plan of correction follow-up inspection conducted on March 27, 2024 and April 1, 2024 by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the onsite plan of correction follow-up 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:
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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 and the policy and procedure manual, the facility failed to follow their own written procedures for the management of treatment/rehabilitation services for clients in five of eight client records reviewed.
Per the facility's policy and procedures, comprehensive treatment plans are to be completed within 7 days of admission.
Client #2 was admitted into the outpatient maintenance activity on December 20, 2023 and was still active at the time of inspection. The comprehensive treatment plan was due to be completed by December 27, 2023; however, the plan was completed on January 8, 2024.
Client #3 was admitted into the outpatient maintenance activity on November 24, 2023 and was still active at the time of inspection. The comprehensive treatment plan was due to be completed by December 1, 2023; however, the plan was completed on December 7, 2023.
Client #6 was admitted into the outpatient maintenance activity on December 15, 2023 and was discharged on March 27, 2024. The comprehensive treatment plan was due to be completed by December 22, 2023; however, the plan was completed on January 2, 2024.
Client #7 was admitted into the outpatient maintenance activity on January 10, 2024 and was discharged on February 22, 2024. The comprehensive treatment plan was due to be completed by January 17, 2024; however, the plan was completed on February 7, 2024.
Client #8 was admitted into the outpatient maintenance activity on November 17, 2023 and was discharged on March 6, 2024. The comprehensive treatment plan was due to be completed by November 24, 2023; however, the plan was completed on December 1, 2023.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Clinical Supervisors will provide group supervision/re-educate on treatment management policies within Goldman staff to include documentation time frames of initial/comprehensive treatment plans.
Clinical Supervisors will monitor 10 random charts per month for 60 days for comprehensive treatment plan compliance with DDAP and BWC policy.
Clinical Supervisor will continue to provide supervision as regulated and disciplinary action protocols as applicable with respective staff with compliance deficits following re-education. |
715.9(e) LICENSURE Intake
(e) A narcotic treatment program shall secure a personal history from the patient within the first week of admission. The personal history shall be made a part of the patient record.
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Observations
Based on a review of patient records, the facility failed to secure a personal history from the patient within the first week of admission in one of seven applicable patient records reviewed.
Patient #6 was admitted into the outpatient maintenance activity on December 15, 2023 and was discharged on March 27, 2024. The patient's personal history was due to be completed by December 22, 2023; however, the history was completed on March 4, 2024.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
Clinical Supervisors will provide group supervision/re-educate on treatment management policies with Goldman staff to include documentation time frames for bio-psychosocial history.
Clinical Supervisors will monitor 10 random charts per month for 60 days for bio-psychosocial history compliance with DDAP and BWC policy.
Clinical Supervisors will continue to provide supervision as regulated and disciplinary action protocols as applicable with respective to staff with compliance deficits following re-education. |
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.
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Observations
Based on a review of patient records, the facility failed to complete a random urinalysis, at least monthly, for each patient in one of seven patient records reviewed.
Patient #6 was admitted into the outpatient maintenance activity on December 15, 2023 and was discharged on March 27, 2024. There was no documentation that a random urinalysis was conducted during the month of February 2024.
This is a repeat citation from the September 22, 2021 to September 23, 2021; September 26, 2022 to September 27, 2022; and September 19, 2023 to September 20, 2023 annual licensing renewal inspections.
The finding was reviewed with facility staff during the licensing process.
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Plan of Correction
Clinical supervisors will monitor 10 random charts per month for 60 days for required admission and random monthly urine drug screens as applicable per DDAP requirement.
Executive Director has worked with VP of Operations and IT to formulate EMR reports to identify list of individuals who are scheduled for UDS and individuals who have not received a UDS.
Counselors will review clients last UDS results in EMR and determine the need for random UDS when counselor meets with clients for individual counseling sessions and document respective UDS in progress notes.
Counselors will also documents clients receiving UDS on their monthly tracker and enter UDS in the care plan if the client has not received a random UDS by the third week of the month. |
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 each patient received an average of 2.5 hours of psychotherapy per month during the patient ' s first 2 years in treatment, with 1 hour of which shall be individual psychotherapy, in one of seven records reviewed.
Patient #3 was admitted into the outpatient maintenance activity on November 24, 2023 and was still active at the time of inspection. According to the record of service and progress notes, there were zero hours of psychotherapy provided to the patient during the month of February 2024.
This is a repeat citation from the May 4, 2021; September 22, 2021 to September 23, 2021; September 26, 2022 to September 27, 2022; and September 19, 2023 to September 20, 2023 annual licensing renewal inspections.
The finding was reviewed with facility staff during the licensing process.
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Plan of Correction
Clinical Supervisors will monitor 10 random charts per month for 60 days for required 2.5 minimum hours per DDAP and BWC policy.
Clinical Supervisors will continue to review counselor client caseload for psychotherapy hours during supervision.
Clinical Supervisors and Executive Director will utilize EMR reports to ascertain client billed hours.
Individual therapy sessions will be scheduled for one hour intervals in efforts to improve quality care, maximize individual sessions and comply with 2.5 minimum hour requirement. |
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 narcotic treatment program failed to document, in writing, that it notified the transferring narcotic treatment program of the date of the admission of the patient and the date of the initial dose given to the patient in one of one applicable patient records reviewed.
Patient #1 was transferred in and admitted to the outpatient maintenance activity on February 26, 2024 and was still active at the time of inspection. There was no documentation, in the record, that indicated the transferring narcotic treatment program was notified of the date of admission and the date the initial dose was given.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
Admissions Coordinator will provide former clinic of transferring admitting client dose and intake verification within 7 days, and place into clients EMR faxed proof of verification.
Admissions Coordinator will document required information in the client's EMR note of coordination for admission transfer of client.
The Director of BIU will review all transfers weekly to ensure that verification has been sent and proof of verification has been uploaded into the EMR. |
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
BBased on a review of client records, the facility failed to ensure treatment and rehabilitation plans are reviewed and updated every 60 days in three of five applicable client records reviewed.
Client #3 was admitted into the outpatient maintenance activity on November 24, 2023 and was still active at the time of the inspection. The comprehensive treatment plan was completed on December 7, 2023 and an update was due no later than February 7, 2024; however, the update was completed on March 11, 2024.
Client #5 was admitted into the outpatient maintenance activity on December 8, 2023 and was discharged on March 26, 2024. The comprehensive treatment plan was completed on December 15, 2023 and an update was due no later than February 15, 2024; however, the update was not completed prior to discharge.
Client #8 was admitted into the outpatient maintenance activity on November 17, 2023 and was discharged on March 6, 2024. The comprehensive treatment plan was completed on December 1, 2023 and an update was due no later than February 1, 2024; however, the update was completed on February 26, 2024.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Clinical Supervisors will provide group supervision and re-educate on treatment management policies with Goldman staff to include documentation timelines for treatment planning.
Clinical Supervisors will monitor 10 random charts per month of 60 days for treatment planning compliance with DDAP and BWC policy.
Supervisor will continue to provide supervision as required and disciplinary action protocols as applicable with staff with compliance deficits following re-education. |
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 patient records, the facility failed to comply with plans of correction that were approved by the Department.
Plans of correction for not ensuring each patient received at least 2.5 hours of psychotherapy per month during the patient ' s first 2 years in treatment were submitted and approved by the Department from the September 19, 2023 through September 20, 2023; September 26, 2022 through September 27, 2022; September 22, 2021 through September 23, 2021; and May 4, 2021 annual licensing inspections. Failing to ensure each patient received at least 2.5 hours of psychotherapy per month during the patient ' s first 2 years in treatment was again found to be a deficiency in the March 27, 2024 and April 1, 2024 plan of correction follow-up inspection.
Plans of correction for not completing a random monthly urinalysis for each patient were submitted and approved by the Department from the September 19, 2023 through September 20, 2023; September 26, 2022 through September 27, 2022 and September 22, 2021 through September 23, 2021 annual licensing inspections. Failing to ensure each patient received a random monthly urinalysis was again found to be a deficiency in the March 27, 2024 and April 1, 2024 follow-up inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
With respect to 2.5 minimum counseling hours, random chart reviews for 60 days. Review of counselor client caseload during supervision (on-going). Utilize reports in EMR to ascertain individuals who have not met the 2.5 minimum requirement. Reports will be pulled mid month in efforts to identify clients who have not met the 2.5 minimum requirement.
With respect to monthly UDS, random chart reviews for 60 days. Utilize EMR report for random UDS to identify client who have not met monthly requirement. Utilize counselors tracking system to identify clients who have not met the requirement by the 3rd week of the month. Clients who have not submitted a UDS by week three will have a manual entry for random UDS to meet compliance. |