INITIAL COMMENTS
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This report is a result of an on-site licensure renewal and methadone monitoring inspection conducted on January 3, 2022, 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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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 the review of the physician timesheets for the months of September, October November and December 2021, the facility failed to ensure that one-third of all required narcotic treatment physician time shall be provided by a narcotic treatment physician.
During the week of September 12-18, 2021, the patient census was 385. The facility was required to provide at least 38.5 physician hours with at least 12.83 hours provided by a narcotic treatment physician. The facility only provided 12 hours.
During the week of October 24-30, 2021, the patient census was 383. The facility was required to provide at least 38.3 physician hours with at least 12.76 hours provided by a narcotic treatment physician. The facility only provided 12 hours.
During the week of November 7-13, 2021, the patient census was 383. The facility was required to provide at least 38.3 physician hours with at least 12.76 hours provided by a narcotic treatment physician. The facility only provided 12 hours.
During the week of December 5-11, 2021, the patient census was 380. The facility was required to provide at least 38 physician hours with at least 12.6 hours provided by a narcotic treatment physician. The facility only provided 12 hours.
These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
The Facility Director reviewed the citation and PA regulation 715.6 (d) pertaining to physician staffing.
To ensure physician staffing maintains adequate service hours, the Facility Director will retrain the MD/CRNP/PA on the physician services requirements as being at least one hour per week for every ten patients by 2/10/2022.
The Facility Director will review time sheets and patient census weekly to maintain compliance. |
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 seven patient records, the facility failed to complete and document random drug screens at least monthly in one patient record.
Patient #2 was admitted on October 11, 2021 and was still active at the time of the inspection. A December 2021 drug screen was not documented in the patient record.
These findings were discussed with facility staff during the inspection process.
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Plan of Correction
The Facility Director reviewed the citation and PA regulation 715.14(a)pertaining to patient urine testing.
To safeguard against patient urine testing, the clinical supervisors will retrain all staff on how to enter scheduled urine screens in patients EHR at admission and going forward until discharge. Counselors will review patients profile monthly to verify random urine screens are scheduled, if necessary change the setting accordingly to prevent missed samples.
Pennsylvania Associates is making every effort to follow CDC guidelines during the COVID pandemic. When a patient reports a positive COVID test result, they are dosed in their car and unable to enter the facility in efforts to stop the spread of the virus. When a patient is unable to submit a urine test due to being positive for the virus, he/she will submit one as soon as they are able to re-enter the facility without the possibility of infecting other patients or staff.
To maintain compliance with licensing standards, the clinical supervisors will conduct monthly record reviews for compliance. |
715.20(3) 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.
(3) The transferring narcotic treatment program shall document what materials were sent to the receiving narcotic treatment program.
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Observations
Based on a review of seven patient records, the transferring facility failed to complete and document what materials were sent to the receiving narcotic treatment program.
Patient #5 was admitted on October 7, 2013 and was transferred on October 6, 2021. No documentation regarding materials sent were in the patient record.
These findings were discussed with facility staff during the inspection process.
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Plan of Correction
The Facility Director reviewed the citation and PA regulation 715.20(3) pertaining to patient transfers. To ensure all transfer documents are uploaded in the patient's electronic health record, all staff will be retrained by the Clinical Supervisors on the importance of record keeping and compliance standards.
Counselors will complete the ROI and external transfer documents in Methasoft. When all documents are faxed and a confirmation is received the documents will be uploaded into the patients EHR. Counselors and CS will review patient EHR monthly to verify all transfer documents were processed and scanned into the EHR.
Training will be completed by 2/28/22. Clinical Supervisor will monitor compliance through monthly chart audits and supervision. |
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.
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Observations
Based on a review of eight patient records, the facility failed to document an annual physical examination of the patient in one patient record reviewed.
Patient #7 was admitted on January 25, 2016 and was discharged on June 2, 2021. The most recent annual physical evaluation was due no later than January 25, 2021; however, it was not documented as of the date of the inspection.
These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
The Facility Director reviewed the citation and PA regulation pertaining to715.23 (b)(5) annual physical exams. To ensure annual physical exams are completed within the time frames indicated in the patient chart, the Executive Director will retrain the medical staff by 2/28/2022 on utilizing reports and the scheduler in Methasoft to schedule and complete annual physical exams prior to the due date.
Nursing supervisor will run monthly scheduled events reports to determine who is scheduled for an annual exam, flag the patient to schedule an appt with the provider, complete the exam, and sign the document. Nursing supervisor will mark annual exams as completed in the patient EHR the day the exam was provided.
The Executive Director will monitor compliance through monthly chart audit and 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 clinical evaluation of the patient in one of the three applicable patient records reviewed.
Patient #4 was admitted on November 2, 2020 and was still active at the time of the inspection. The most recent annual evaluation was due no later than November 2, 2021; however, it was not documented as of the date of the inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Facility Director reviewed the citation and PA regulation pertaining to 715.23 (c)(1-7) annual evaluations. To ensure annual evaluations are completed within the time frames indicated in the patient chart and signed by the Medical Director, the Clinical Supervisors will retrain the clinical staff by 2/28/2022 on utilizing reports and in Methasoft to complete annual evaluations prior to the due date.
Counselors will utilize monthly scheduled events in the pt EHR to determine who is due for an annual evaluation. Counselor will complete the evaluation, clinical supervisor will review and sign, MD will review and sign completed form. Counselor will make the evaluation as completed in the daily activities. CS will monitor compliance via monthly chart audits and address any missing or incomplete documents in supervision.
Training will be completed by 2/28/22. Clinical Supervisor will monitor compliance through monthly chart audits and supervision.
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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.
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Observations
Based on a review of client records, the facility failed to ensure that one appliable client record contained an aftercare plan.
Client #7 was admitted on January 25, 2016 and discharged successfully on June 16, 2020. There was no documentation of an aftercare plan in the client record.
These findings were discussed with facility staff during the inspection process.
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Plan of Correction
The Facility Director reviewed the citation and PA regulation pertaining to 709.93 (a)(9) aftercare plans. To ensure aftercare plans are completed on admission and aftercare recommendations on discharge, the Clinical Supervisors will retrain the clinical staff by 2/28/2022 on utilizing the documents and reports in Methasoft.
Aftercare plans are completed on the day of admission with the patient. On the day of admission, CS audits the EHR to verify the aftercare plan is completed before being medicated. If the plan is not completed the CS requires the clinician to complete before medicating and leaving he facility.
If a patient is available to complete the discharge summary before terminating treatment, the primary counselor will review aftercare recommendations with the patient.
The Clinical Supervisors will monitor compliance through monthly chart audits. |