INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection, methadone monitoring inspection and complaint investigation conducted on August 16-17, 2021 by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site complaint investigation, the allegations against Progressive Medical Services were determined to be unsubstantiated. Based on the findings of the on-site licensure renewal inspection and methadone monitoring inspection, Progressive Medical Services 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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709.30 (1) LICENSURE Client rights
§ 709.30. Client rights.
The project shall develop written policies and procedures on client rights and document written acknowledgement by clients that they have been notified of those rights.
(1) A client receiving care or treatment under section 7 of the act (71 P. S. § 1690.107) shall retain civil rights and liberties except as provided by statute. No client may be deprived of a civil right solely by reason of treatment.
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Observations
Based on the review of client records, the facility failed to document written acknowledgement that the client was notified of the right that a client receiving care or treatment under section 7 of the act (71 P. S. 1690.107) shall retain civil rights and liberties except as provided by statute. No client may be deprived of a civil right solely by reason of treatment in seven of seven records reviewed.
Client # 1 was admitted on November 6, 2020 and was still an active client at the time of the inspection. There was no written documentation that the client was notified of this right.
Client # 2 was admitted on April 14, 2021 and was still an active client at the time of the inspection. There was no written documentation that the client was notified of this right.
Client # 3 was admitted on December 17, 2020 and was still an active client at the time of the inspection. There was no written documentation that the client was notified of this right.
Client # 6 was admitted on November 24, 2020 and was discharged on May 25, 2021. There was no written documentation that the client was notified of this right.
Client # 7 was admitted on March 2, 2021 and was discharged on August 11, 2021. There was no written documentation that the client was notified of this right.
Client # 8 was admitted on February 28, 2020 and was discharged on April 22, 2021. There was no written documentation that the client was notified of this right.
Client # 9 was admitted on March 5, 2020 and was discharged on March 11, 2021. There was no written documentation that the client was notified of this right.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Based upon the surveyor's findings, Project Director reviewed Progressive Medical's current intake documentation, specifically our, "client rights", document. Our client rights documentation was revised to include that the project includes notification of the right that a client receiving care or treatment under section 7 of the act (71 P. S. 1690.107) shall retain civil rights and liberties except as provided by statute. No client may be deprived of a civil right solely by reason of treatment.
All Progressive Medical staff members were informed, (verbally and in writing), of this revision on August 17, 2021 by Project Director
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709.30 (2) LICENSURE Client rights
§ 709.30. Client rights.
The project shall develop written policies and procedures on client rights and document written acknowledgement by clients that they have been notified of those rights.
(2) The project may not discriminate in the provision of services on the basis of age, race, creed, sex, ethnicity, color, national origin, marital status, sexual orientation, handicap or religion.
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Observations
Based on the review of client records, the facility failed to document written acknowledgement of this right that included creed, sex, color, national origin, marital status, and handicap in seven of seven records reviewed.
Client # 1 was admitted on November 6, 2020 and was still an active client at the time of the inspection. There was no written documentation that the client was notified of these rights.
Client # 2 was admitted on April 14, 2021and was still an active client at the time of the inspection. There was no written documentation that the client was notified of these rights.
Client # 3 was admitted on December 17, 2020 and was still an active client at the time of the inspection. There was no written documentation that the client was notified of these rights.
Client # 6 was admitted on November 24, 2020 and was discharged on May 25, 2021. There was no written documentation that the client was notified of these rights.
Client # 7 was admitted on March 2, 2021 and was discharged on August 11, 2021. There was no written documentation that the client was notified of these rights.
Client # 8 was admitted on February 28, 2020 and was discharged on April 22, 2021. There was no written documentation that the client was notified of these rights.
Client # 9 was admitted on March 5, 2020 and was discharged on March 11, 2021. There was no written documentation that the client was notified of these rights.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Based upon the surveyor's findings, Project Director reviewed Progressive Medical's current intake documentation, specifically our, "client rights", document. Our client rights documentation was revised to include that the project will not discriminate in the provisions of services on the basis of creed, sex, color, national origin, marital status, or handicap. (age, race, ethnicity, sexual orientation and religion were addressed in the client rights document).
All staff members were informed of this revision, (verbally and in writing), on August 17, 2021 by Project Director
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709.30 (6) LICENSURE Client rights
§ 709.30. Client rights.
The project shall develop written policies and procedures on client rights and document written acknowledgement by clients that they have been notified of those rights.
(6) Clients have the right to submit rebuttal data or memoranda to their own records.
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Observations
Based on the review of client records, the facility failed to document written acknowledgement that the client was notified of the right that a client has the right to submit memoranda to their own record in seven of seven records reviewed.
Client # 1 was admitted on November 6, 2020 and was still an active client at the time of the inspection. There was no written documentation that the client was notified of this right.
Client # 2 was admitted on April 14, 2021 and was still an active client at the time of the inspection. There was no written documentation that the client was notified of this right.
Client # 3 was admitted on December 17, 2020 and was still an active client at the time of the inspection. There was no written documentation that the client was notified of this right.
Client # 6 was admitted on November 24, 2020 and was discharged on May 25, 2021. There was no written documentation that the client was notified of this right.
Client # 7 was admitted on March 2, 2021 and was discharged on August 11, 2021. There was no written documentation that the client was notified of this right.
Client # 8 was admitted on February 28, 2020 and was discharged on April 22, 2021. There was no written documentation that the client was notified of this right.
Client # 9 was admitted on March 5, 2020 and was discharged on March 11, 2021. There was no written documentation that the client was notified of this right.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Based upon the surveyor's findings, Project Director reviewed Progressive Medical's current intake documentation, specifically our, "client rights", document. Our client rights documentation was revised to include a client's right to submit rebuttal data or memoranda to their own record.
All staff members were informed of this revision, (verbally and in writing), on August 17, 2021 by Project Director
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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
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Observations
Based on the review of administrative documents, the facility failed to document that the narcotic treatment physician provided services of at least 1 hour per week onsite for every ten patients.
During the week of April 11, 2021, the census was 276 and required 27.6 hours. There were only 27.25 hours documented.
During the week of April 18, 2021, the census was 276 and required 27.6 hours. There were only 26.5 hours documented.
During the week of April 25, 2021, the census was 275 and required 27.5 hours. There were only 25.5 hours documented.
During the week of May 16, 2021, the census was 278 and required 27.8 hours. There were only 26.5 hours documented.
During the week of May 23, 2021, the census was 279 and required 27.9 hours. There were only 27 hours documented.
During the week of June 6, 2021, the census was 274 and required 27.4 hours. There were only 19. 5 hours documented.
During the week of June 13, 2021, the census was 273 and required 27.3 hours. There were only 26 hours documented.
During the week of June 20, 2021, the census was 276 and required 27.6 hours. There were only 20. 5 hours documented.
During the week of June 27, 2021, the census was 276 and required 27.6 hours. There were only 22 hours documented.
During the week of July 16, 2021, the census was 278 and required 27.8 hours. There were only 26.5 hours documented.
During the week of July 23, 2021, the census was 279 and required 27.9 hours. There were only 27 hours documented.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Due to Covid-19 and misunderstanding of the alert that gave suspension of on site medical hours, Progressive Medical did not completely obtain required on site medical hours for eleven weeks in 2021; that has since been rectified. As of 9/9/2021, Progressive Medical has hired another medical doctor that will provide on site hours at each location. With three medical doctors and one physician assistant, the project and medical directors will ensure that a weekly schedule is created that meets the required medical hours based on our active caseload, (1 hour for every 10 clients). |