INITIAL COMMENTS
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Based on the concerns arising from COVID-19, The Department of Drug and Alcohol Programs, Bureau of Program Licensure, has implemented temporary procedures for conducting an annual renewal inspection. The inspection will be divided into two parts. 1, an abbreviated off-site inspection, will be conducted off site, and will require the submission of administrative information via email to a Licensing Specialist. 2, an abbreviated on-site inspection, will be conducted on-site at a later date and will include a review of client/patient records, and a physical plant inspection.This report is a result of Part 2, an abbreviated on-site inspection, the physical plant inspection was conducted on October 28, 2020 and the client records were reviewed on March 1-5, 2021 by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Not all regulations were reviewed, the remainder of the regulations were reviewed during Part 1.Based on the findings of Part 2, an abbreviated on-site inspection, Dolminis 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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705.24 (3) LICENSURE Bathrooms.
705.24. Bathrooms.
The nonresidential facility shall:
(3) Have hot and cold water under pressure. Hot water temperature may not exceed 120F.
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Observations
Based on a physical plant inspection conducted on October 28, 2020 the facility failed to ensure the hot water temperature did not exceed 120F.The water temperature in the outpatient women ' s bathroom was 121F at the time of the inspection and the outpatient men ' s bathroom was 126.2F.These findings were reviewed with the facility during the licensing process.
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Plan of Correction
Water temperature in the outpatient men's and women's restrooms was tested on 4/1/21 and did not exceed 120F.
Water temperature in the client restrooms will be monitored monthly by facility risk leaders to ensure temperature does not exceed 120F.Temperature results will be recorded on the facility safety inspection checklist.
Executive director will monitor facility checklist monthly to ensure completion.
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709.28 (c) LICENSURE Confidentiality
§ 709.28. Confidentiality.
(c) The project shall obtain an informed and voluntary consent from the client for the disclosure of information contained in the client record.
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Observations
Based on three of sixteen client records reviewed, the facility failed obtain an informed and voluntary consent from the client for the disclosure of information in client records # 2, 3, and 5.Client # 2 was re-admitted on July 21, 2020 and was discharged on August 4, 2020. An informed and voluntary consent from the client for the disclosure of information to a funding source had expired on April 22, 2020.Client # 3 was admitted on May 5, 2020 and was still active at the time of the inspection. There was not an informed and voluntary consent from the client for the disclosure of information to a legal entity prior to the release of information on June 30, 2020.Client # 5 was admitted on October 23, 2020 and was discharged on December 3, 2020. There was not an informed and voluntary consent from the client for the disclosure of information to a funding source prior to the disclosure of information.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Regional quality manager is scheduled to conduct a training on confidentiality regulations, disclosure of information and completion of consents on May 3, 2021. Also, a Lunch & Learn training on "Releasing information in the Write Way" is scheduled for June 2021. All clinical staff must attend trainings.
Clinical supervisor and lead counselor will monitor consents when signing off on the level of care assessment and during weekly/monthly chart reviews.
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709.28 (c) (2) LICENSURE Confidentiality
§ 709.28. Confidentiality.
(c) The project shall obtain an informed and voluntary consent from the client for the disclosure of information contained in the client record. The consent must be in writing and include, but not be limited to:
(2) Specific information disclosed.
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Observations
Based on one of sixteen client records reviewed, the facility failed to obtain an informed and voluntary consent from the client for the disclosure of information to include the specific information disclosed to not exceed pa. code 255.5 (b). Client # 3 was admitted on May 5, 2020 and was still active at the time of the inspection. An informed and voluntary consent from the client for the disclosure of information to a children and youth agency signed and dated on September 23, 2020 allowed for the release of lab results and psychiatric evaluations. These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
A corrected release for Children and Youth Services was completed on 1/20/21 and again on 4/15/21. Regional quality manager is scheduled to conduct a training on confidentiality regulations, disclosure of information and completion of consents on May 3, 2021. Also, a Lunch & Learn training on "Releasing information in the Write Way" is scheduled for June 2021. All clinical staff must attend trainings.
Clinical supervisor and lead counselor will monitor consents during clincial supervision and at time of weekly/monthly chart reviews. |
715.13(b) LICENSURE Patient identification
(b) A narcotic treatment program shall maintain onsite a photograph of each patient which includes the patient 's name and birth date. The narcotic treatment program shall update the photograph every 3 years.
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Observations
Based on one of eight patient records reviewed, the facility failed to provide an onsite photograph with the patient's name and birth date that was updated every three years.Patient # 6 was re-admitted on October 27, 2020 and discharged December 3, 2020. The onsite photograph provided was from August 8, 2017.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Program will capture an updated client identification photo every 3 years. Photo will include the client name, date of birth and date the photo was taken. This photo will be uploaded into the client's electronic health record.
AA will begin reviewing and updating client identification photos on 4/12/21. Clinical supervisor and lead counselor will review client identification photo during monthly chart monitors to ensure that it has been updated within the last 3 years.
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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 one of seven applicable patient records reviewed, the facility failed to provide a random urinalysis at least monthly in patient record # 7.Patient # 7 was admitted on January 30, 2020 and was still active at the time of the inspection. There was no urinalysis documented the month of December 2020. These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Collection dates of urine drug screens will be made available during the inspection process in a location that is consistent. Urinalysis collection dates are located under the "Detailed View" section of the Lab Results Report located on the client face sheet in the EHRS.
Director will ensure that drug screen collection dates are available under the "Detailed View" section of the Lab Results Report at time of inspection. |
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 five of eleven applicable patient records reviewed, the facility failed to provide documentation of at least 2.5 hours of the required psychotherapy hours per month during the patient ' s first two years in patient records # 3, 5, 7, 10, and 12.Patient # 3 was admitted on May 5, 2020 and was still active at the time of the inspection. After a review of the patient record and record of service, there was only one hour of psychotherapy the months of October and January and no hours of psychotherapy hours the months of November and December. Patient # 5 was admitted on October 26, 2020 and discharged December 3, 2020. After a review of the patient record and record of service, there was no documentation of psychotherapy hours in the patient record.Patient # 7 was admitted on January 30, 2020 and was still active at the time of the inspection. After a review of the patient record and record of service, there was only one hour of psychotherapy the month January, March, and June, thirty minutes the month of May and August and no sessions the month of February. Patient # 10 was admitted on July 1, 2019 and was still active at the time of the inspection. After a review of the patient record and record of service, there was no documentation of psychotherapy hours in the patient record the months of November, December, January, and February.Patient # 12 was admitted on January 15, 2020 and discharged June 24, 2020. After a review of the patient record and record of service, there was no documentation of psychotherapy hours in the patient record the months of April and May 2020.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
On 4/6/21, Executive director and clinical supervisor will review regulations regarding individualized psychotherapy service hours with clinical team and reinforce expectation that clients must receive at least 2.5 hours of psychotherapy per month which includes 1 hour of individual therapy during the first 2 years of treatment.
Clinical supervisor will monitor individual psychotherapy hours monthly during clinical supervision and through random chart monitoring. Discrepancies in hours will be reported to executive director. |
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 one of two applicable patient records reviewed, the facility failed to provide documentation 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.Patient # 7 was admitted on January 30, 2020 and was still active at the time of the inspection. There was no documentation notifying the transferring facility of admission or dose.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Verification of contact with referring facility to confirm client dose amount and the last day dosed along with notification of client transfer will be made available during the inspection process in a location that is consistent. Transfer Verification form and documentation of contact with referring facility will be located in the client medical chart.
Director will ensure that transferring documentation is placed in the client medical chart and available at time of inspection. |
709.91(b)(6) LICENSURE Intake and admission
709.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(6) Psychosocial evaluation.
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Observations
Based on six of fourteen applicable client records reviewed, the facility failed to provide a complete client record to include documentation of a psychosocial evaluation.Client # 5 was readmitted on October 26, 2020 and was discharged on December 3, 2020. A psychosocial evaluation had been developed on February 2, 2018 however, the client was discharged and when readmitted, the psychosocial evaluation had not been updated.Client # 6 was readmitted on October 27, 2020 and was discharged on December 3, 2020. A psychosocial evaluation had been developed on March 20, 2018 however, the client was discharged and when readmitted, the psychosocial evaluation had not been updated.Client # 9 was admitted on January 23, 2020 and was discharged on April 3, 2020. There was no documentation of a psychosocial evaluation in the client record. Client # 12 was admitted on January 15, 2020 and was discharged on June 24, 2020. There was no documentation of a psychosocial evaluation in the client record. Client # 13 was admitted on June 17, 2020 and was discharged on August 4, 2020. There was no documentation of a psychosocial evaluation in the client record. Client # 15 was admitted on October 22, 2020 and was still active at the time of the inspection. There was no documentation of a psychosocial evaluation in the client record. These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Beginning 8/20, the Comprehensive Psychosocial Evaluation was added to the level of care assessment and is now being completed at time of assessment.
Clinical supervisor and lead counselor will review the regulation concerning the completion and updating of the psychosocial evaluation during treatment team meeting on 4/12/21 & 4/13/21 and during monthly supervision. The clinical supervisor and lead counselor will monitor for completion of the comprehensive psychosocial evaluation and psychosocial evaluation updates
during monthly chart audits. This area of compliance has been added to the facility monitoring tool.
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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
Based on four of eleven applicable client records reviewed, the facility failed to provide treatment and rehabilitation plan updates at least every sixty days in client records # 4, 7, 8, and 10. Client # 4 was admitted on March 2, 2020 and was still active at the time of the inspection. A treatment plan update occurred on November 18, 2020. An update was due no later than January 18, 2021. There was no update documented in the client record. Client # 7 was admitted on January 30, 2020 and was still active at the time of the inspection. A treatment plan occurred on March 9, 2020. An update was due no later than May 9, 2020. An update occurred July 20, 2020. A treatment plan update was due to occur no later than September 20, 2020. There was no update documented in the client record until January 8, 2021. Client # 8 was admitted on July 1, 2019 and was discharged on October 5, 2020. A treatment plan occurred on October 30, 2019. A treatment plan update was due no later than December 30, 2020. The next treatment plan update occurred on February 25, 2020. A treatment plan update was due no later than April 25, 2020. The next treatment plan update occurred on June 25, 2020. There were no more treatment plan updates documented in the client record. Client # 10 was admitted on July 1, 2019 and was still active at the time of the inspection. A treatment plan occurred on October 14, 2019. There were no treatment plan updates documented in the client record.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
On 4/12/21 & 4/13/21, clinical supervisor and lead counselor will review regulations regarding treatment plans and treatment plan updates with clinical team and reinforce expectation of timely review and completion of documentation. Clinical supervisor and lead counselor will monitor counselor alerts for upcoming treatment plan reviews in the electronic health record system and follow-up with counselor to ensure timely completion of updates.
Treatment plan updates will be reviewed. by clinical supervisor and lead counselor during supervision and during monthly chart audits.
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709.93(a)(10) 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:
(10) Discharge summary.
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Observations
Based on four of nine applicable client records reviewed, the facility failed to provide a complete client record to include a discharge summary in client records # 2, 8, 12, and 14.Client # 2 was admitted on July 21, 2020 and was discharged on August 4, 2020. There was not a discharge summary in the client record.Client # 8 was admitted on July 1, 2019 and was discharged on October 5, 2020. There was not a discharge summary in the client record.Client # 12 was admitted on January 15, 2020 and was discharged on June 24, 2020. There was not a discharge summary in the client record.Client # 14 was admitted on August 4, 2020 and was discharged on November 2, 2020. There was not a discharge summary in the client record.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Clinical supervisor and lead counselor will review the regulation and expectation concerning the completion of the client discharge summary within 7 days of discharge with the counselors during treatment team meeting on 4/12/21 & 4/13/21.
Clinical supervisor and lead counselor will print a list of client discharges bi-weekly to monitor for completion of discharge summary.
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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 five of nine applicable client records reviewed, the facility failed to provide a complete client record to include follow-up information in client records # 1, 2, 8, 12, and 14.Client # 1 was admitted on September 17, 2019 and was discharged on January 22, 2020. There was no documentation of follow-up information in the client record.Client # 2 was admitted on July 21, 2020 and was discharged on August 4, 2020. There was no documentation of follow-up information in the client record.Client # 8 was admitted on July 1, 2019 and was discharged on October 5, 2020. There was no documentation of follow-up information in the client record.Client # 12 was admitted on January 15, 2020 and was discharged on June 24, 2020. There was no documentation of follow-up information in the client record.Client # 14 was admitted on August 4, 2020 and was discharged on November 2, 2020. There was no documentation of follow-up information in the client record.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Director and clinical supervisor will review the regulation concerning client follow-up after discharge and documentation of contact or attempts at contact with clinical staff on 4/12/21 & 4/13/21.
This area of compliance has been added to the facility monitoring tool. Clinical director and lead counselor will monitor for follow-up contact monthly during clinical supervision and through random chart monitoring. areas of non-complince will be reported to executive director.
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