INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection and methadone monitoring conducted on September 26, 2022 through September 27, 2022 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:
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Plan of Correction
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704.6(c) LICENSURE Core Curriculum - Supervisor Training
704.6. Qualifications for the position of clinical supervisor.
(c) Clinical supervisors and lead counselors who have not functioned for 2 years as supervisors in the provision of clinical services shall complete a core curriculum in clinical supervision. Training not provided by the Department shall receive prior approval from the Department.
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Observations
Based on a review of personnel records, the facility failed to ensure that clinical supervisors who have not functioned for 2 years as a supervisor in the provision of clinical services completed a Department-approved core curriculum in clinical supervision in one of one applicable personnel record reviewed. Employee #4 was hired as a clinical supervisor on November 8, 2021 and did not have clinical supervision experience prior to being hired. There was no documentation of a Department- approved curriculum in clinical supervision training in the record 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 Executive Director will ensure that the Clinical Supervisor will complete an approved clinical supervisors training by December 1, 2022. The Clinical Supervisor will enroll in the approved training course and complete the course bye the aforementioned date. All new clinical supervisors will be required to complete the clinical supervisor training during the first 90 days in their role as clinical supervisor. |
704.6(e) LICENSURE Supervisory Meetings
704.6. Qualifications for the position of clinical supervisor.
(e) Clinical supervisors are required to participate in documented monthly meetings with their supervisors to discuss their duties and performance for the first 6 months of employment in that position. Frequency of meetings thereafter shall be based upon the clinical supervisor's skill level.
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Observations
Based on a review of personnel records, the facility failed to ensure that the clinical supervisor participated in documented monthly meetings with their supervisor to discuss their duties and performance for the first 6 months in that position in one of two applicable personnel records reviewed.Employee #5 was hired as a clinical supervisor on May 2, 2022. The personnel record did not include a documented monthly clinical supervision meeting for the month of July 2022.This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
The Executive Director will ensure that all new clinical supervisors will receive supervision on a monthly basis for at least six months. The Executive Director will schedule supervision and if supervision is missed due to vacation or illness, it will be rescheduled for the same month to ensure compliance. |
704.12(a)(6) LICENSURE OutPatient Caseload
704.12. Full-time equivalent (FTE) maximum client/staff and client/counselor ratios.
(a) General requirements. Projects shall be required to comply with the client/staff and client/counselor ratios in paragraphs (1)-(6) during primary care hours. These ratios refer to the total number of clients being treated including clients with diagnoses other than drug and alcohol addiction served in other facets of the project. Family units may be counted as one client.
(6) Outpatients. FTE counselor caseload for counseling in outpatient programs may not exceed 35 active clients.
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Observations
Based on a review of personnel records and the Staffing Requirements Facility Summary Report, the facility failed to ensure that the Full Time Equivalent (FTE) counselor caseload in outpatient programs did not exceed 35 active clients in seven of fourteen applicable counselor personnel records reviewed.The counselor Full Time Equivalent (FTE) is determined by dividing the total number of hours the counselor devotes to their clients by the facility's workweek. Then, in order to obtain the counselor's ratio, the total number of clients on the counselor's outpatient caseload is divided by the FTE.Employee #6 was hired as a counselor on June 8, 2021. The employee's ratio calculation was as follows: 40/40 = 1 (FTE); 40/1 = 40, which equals to a client/counselor FTE ratio of 40:1.Employee #7 was hired as a counselor on June 13, 2022. The employee's ratio calculation was as follows: 40/40 = 1 (FTE); 38/1 = 38, which equals to a client/counselor FTE ratio of 38:1.Employee #8 was hired as a counselor on May 2, 2022. The employee's ratio calculation was as follows: 40/40 = 1(FTE); 39/1 = 39, which equals to a client/counselor FTE ratio of 39:1.Employee #9 was hired as a counselor on June 13, 2022. The employee's ratio calculation was as follows: 40/40 = 1(FTE); 38/1 = 38, which equals to a client/counselor FTE ratio of 38:1.Employee #10 was hired as a counselor on December 13, 2022. The employee's ratio calculation was as follows: 40/40 = 1(FTE); 36/1 = 36, which equals to a client/counselor FTE ratio of 36:1.Employee #12 was hired as a counselor on October 16, 2000. The employee's ratio calculation was as follows: 40/40 = 1(FTE); 41/1 = 41, which equals to a client/counselor FTE ratio of 41:1.Employee #14 was hired as a counselor on December 13, 2021. The employee's ratio calculation was as follows: 40/40 = 1(FTE); 39/1 = 39, which equals to a client/counselor FTE ratio of 39:1.This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
The Executive Director along with the Human Resource personnel have recruited counselors to fill positions to ensure that the counselor ratios/client are in compliance and not exceeding 35:1. Since the inspection five counselors were hired, all caseloads have been reassessed and reassigned and all caseloads are under 35. We have two counselors starting the week of November 7th and will continue to monitor caseloads to ensure compliance. If we experience staffing changes we hold all admissions until we have adequate staffing to ensure participant/counselors ratios are adhered too. |
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, for each patient, at least monthly in three of eight patient records reviewed. Patient #3 was admitted into the outpatient maintenance activity on January 4, 2005 and was still active at the time of inspection. There was no documentation that a random urinalysis was conducted for the month of August 2022. Patient #4 was admitted into the outpatient maintenance activity on November 11, 2021 and was still active at the time of inspection. There was no documentation that a random urinalysis was conducted for the month of June 2022. Patient #7 was admitted into the outpatient maintenance activity on December 2, 2019 and was discharged August 8, 2022. There was no documentation that a random urinalysis was conducted for the months of May and June 2022.This is a repeat citation from the September 22, 2021 through September 23, 2021 annual licensing renewal inspection.The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Executive Director and Clinical Supervisors will work with counselors to monitor patient urine drug screens to ensure that they are being conducted at minimum on a monthly basis. Counselors will track UDS on their counseling tracker weekly and participants who have not submitted to urine drug screen will be flagged to submit a sample. Any participants who have not received a urine drug screen by the 15th of the month will be added to the Avatar system to have a urine completed before they receive their medication. Holds will be placed by the clinic coordinator. Monthly urine drug screens will be added to the quarterly chart audit ensuring compliance. The chart audit is reviewed by the Executive Director. |
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 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 applicable records reviewed. Patient #4 was admitted into the outpatient maintenance activity on November 11, 2021 and was still active at the time of inspection. There was documentation in the record that indicated the patient received a total of 1 hour of psychotherapy services for the month of June 2022.This is a repeat citation from the September 22, 2021 through September 23, 2021 and May 4, 2021 annual licensing renewal inspections.The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Clinical Supervisors will monitor counseling sessions on our counselor tracking excel spread sheet to ensure that participants are receiving at least 2.5 hours of psychotherapy groups or individual sessions on a monthly basis during the participants first year in treatment. The hold system in Avatar will be utilized for participants who have not received therapy by week 3 to ensure that they attend sessions as required. |
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 #4 was transferred in and admitted to the outpatient maintenance activity on November 10, 2021 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 of the initial dose given.This is a repeat citation from the September 22, 2021 through September 23, 2021 annual licensing renewal inspection.This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
When a participant is transferred to The Behavioral Wellness Center/Goldman Clinic the Admissions Coordinator will notify the transferring treatment program that the participant has been admitted. The Admissions Coordinator will inform the transferring treatment program the date of admission and initial dose given within 24 hours of admission. The Admission Coordinator will document in the participants chart date of notification and name of the staff member notified from the transferring treatment program. |
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 patient records, the facility failed to document the results of an annual physical examination given by the narcotic treatment program and includes an annual reevaluation by the narcotic treatment physician in two of eight patient records reviewed.Patient #3 was admitted into the outpatient maintenance activity on January 4, 2005 and was still active at the time of inspection. The last documented physical exam was performed on July 26, 2021.Patient #7 was admitted into the outpatient maintenance activity on December 2, 2019 and was discharged August 8, 2022. The last documented physical exam was performed on June 19, 2021.This is a repeat citation from the September 22, 2021 through September 23, 2021 annual licensing renewal inspection.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Executive Director will work with the Office Manager to develop a tracking system for annual physicals to ensure that they are flagged and scheduled at least sixty days prior to the annual due date.
With respect to outstanding deficiencies, we will flag participants to schedule an appointment with the medial provider for annual physicals to be completed.
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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 of each patient's status, which is to be completed by the patient ' s counselor and reviewed, signed, and dated by the medical director, in one of ten applicable records reviewed. Patient #3 was admitted into the outpatient maintenance activity on January 4, 2005 and was still active at the time of inspection. The last annual clinical evaluation was completed on July 19, 2021.This is a repeat citation from the September 22, 2021 through September 23, 2021 annual licensing renewal inspection.The findings were discussed with facility staff during the licensing process.
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Plan of Correction
The tracking system that will be developed to track annual physicals will be also used to track and flag annual evaluations. Notification will be provided to The Clinical Supervisor and Counselor at least 60 days prior to when the annual evaluation is due to ensure compliance. This area of compliance will be added to the quarterly chart audits as a way to monitor compliance to avoid repeat occurrences. The quarterly chart audits are conducted by the clinical supervisors and reviewed by the Executive Director.
All outstanding deficiencies identified will be flagged for completion of annual evaluation. |
709.93(a)(11) 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:
(11) Follow-up information.
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Observations
Based on a review of client records, the facility failed to document a complete client record, which is to include follow-up information, in one of one applicable record reviewed. Patient #7 was admitted into the outpatient maintenance activity on December 2, 2019 and was discharged August 8, 2022. There was no follow-up information documented at the time of the inspection.The findings were discussed with facility staff during the licensing process.
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Plan of Correction
The CRS' is responsible for sending post discharge follow up letters. The CRS' receives a discharge report on a weekly basis and drafts the letter to be sent within 30 days. The CRS will submit a copy of the post discharge letter to the Clinical Supervisor to ensure cross reference the report, ensuring all participants received a letter. The Clinical Supervisor will then submit the post discharge follow letter to medical records to be scanned in the participants chart. Post discharge follow up letters will be added to the internal chart audit check that is conducted on a quarterly basis and reviewed by the Executive Director. |
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. Plans of correction for providing 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 22, 2021 through September 23, 2021 and May 4, 2021 annual licensing inspections. Failing to ensure that all applicable clients received at least 2.5 hours of psychotherapy services was again found to be a deficiency in the September 26, 2022 through September 27, 2022 licensing inspection. Plans of correction for having an annual evaluation of each patient's status, which is to be completed by the patient's counselor and reviewed, signed, and dated by the medical directorwere submitted and approved by the Department from the September 22, 2021 through September 23, 2021 and May 4, 2021 annual licensing inspections. Failing to ensure that all applicable clients received an annual evaluation was again found to be a deficiency in the September 26, 2022 through September 27, 2022 licensing inspection. These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Executive Director will work with Net smart and the IT department to create a report that will identify participants who have not received clinical services on a monthly basis. This report will run every month on the 15th. Participants who have been identified as not receiving clinical services will have a hold placed on them by their counselor to engage in individual and group therapy as required. The report will be disbursed to the counselors who will be responsible to place holds. Clinical Supervisors will be responsible to monitor compliance. |