INITIAL COMMENTS
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This report is a result of an on-site licensure renewal and methadone monitoring inspection conducted on November 8, 2021 by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, ARS of Lancaster 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 twelve personnel records, the facility failed to ensure that one employee hired as the clinical supervisor that had not functioned for 2 years as a supervisor in the provision of clinical services completed a core curriculum in clinical supervision within six months of hire. Employee #2 was hired on December 14, 2020 as the clinical supervisor and has not functioned for 2 years as supervisors in the provision of clinical services. At the time of the inspection, employee #2 did not complete a core curriculum in clinical supervision training until August 27, 2021. These findings were discussed with facility staff during the inspection process.
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Plan of Correction
Effective immediately when a new clinical supervisor is hired or promoted the executive director will be responsible to ensure they will be scheduled for the appropriate core curriculum training within 30 days of date hire/promotion effective date. Executive Director will ensure all future candidates have the appropriate required credentials and level of training required to meet regulation 704.6(c).
Employee #2 completed the DDAP clinical supervisor training on 08/23-08/27/2021.
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705.28 (d) (4) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(4) Maintain a written fire drill record including the date, time, the amount of time it took for evacuation, the exit route used, the number of persons in the facility at the time of the drill, problems encountered and whether the fire alarm or smoke detector was operative.
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Observations
Based on a review of fire drills from December 2020 thru September 2021 the facility failed to ensure that the fire drills included exit route used and whether the fire alarm or smoke detector was operative for the fire drills for December 2020, May 2021 and September 2021. These findings were discussed with facility staff during the inspection process.
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Plan of Correction
Fire/Emergency drill log was updated on 11/3/2021 to include check boxes identifying whether the fire alarm was sounded, and a line was added to identify which exits were used during the drill. This log was disseminated to all PA locations for immediate implementation. Executive Director reviews the form each month to ensure completion and review the findings of the drill(s). As of 12/03/2021 this will be implemented. |
705.28 (d) (7) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(7) Set off a fire alarm or smoke detector during each fire drill.
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Observations
Based on a review of fire drills from December 2020 thru September 2021 the facility failed to document if the facility Set off a fire alarm or smoke detector during fire drills for the months of December 2020, May 2021, and September 2021. These findings were discussed with facility staff during the inspection process.
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Plan of Correction
Fire/Emergency drill log was updated on 11/3/2021 to include check boxes identifying whether the fire alarm was sounded, and a line was added to identify which exits were used during the drill. This log was disseminated to all PA locations for immediate implementation. Health and safety officer is responsible for filling out this form each month during emergency/fire drills. Executive Director reviews the form each month to ensure completion and review the findings of the drill(s). This will be implemented as of 12/03/2021.
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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 the physician timesheets for the months of June, July, August and September 2021, the facility failed to provide at least one hour of physician time a week, on site for every ten patients during the month of June, July, and August 2021. During the week of June 20-26, 2021, the patient census was 669. The facility was required to provide at least 66.9 physician hours. There were only 62 physician hours documented. During the week of July 11-17, 2021, the patient census was 652. The facility was required to provide at least 65.2 physician hours. There were only 64.25 physician hours documented. During the week of September 26- October 2, 2021, the patient census was 646. The facility was required to provide at least 64.6 physician hours. There were only 48 physician hours documented. These findings were discussed with facility staff during the inspection process.
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Plan of Correction
Starting 12/07/2021, Executive Director will meet with Medical Director to complete a review of the required physician hours for that month and the next month. Executive Director and Medical Director will review that month's schedule to ensure all required physician's hours are being provided and if they are not, a plan will be created for coverage immediately. The following month's physician schedule will be reviewed to ensure that all needed hours are being provided and coverage will be scheduled if it is not. Executive Director and Medical Director will have a back-up physician identified for each month to provide coverage should there be an emergency and emergency coverage is needed or when a physician is on vacation and coverage is needed. |
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 June, July, August and September 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 26-October 2, 2021, the patient census was 646. The facility was required to provide at least 64.6 physician hours with at least 21.53 hours provided by a narcotic treatment physician. The facility only provided 8 hours. These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
Starting 12/07/2021, Executive Director will meet with Medical Director to complete a review of the required physician hours for that month and the next month. Executive Director and Medical Director will review that month's schedule to ensure all required physician's hours are being provided and if they are not, a plan will be created for coverage immediately. The following month's physician schedule will be reviewed to ensure that all needed hours are being provided and coverage will be scheduled if it is not. Executive Director and Medical Director will have a back-up physician identified for each month to provide coverage should there be an emergency and emergency coverage is needed or when a physician is on vacation and coverage is needed. |
715..23(b)(1) LICENSURE Patient records
(b) Each patient file shall include the following information:
(1) A complete personal history.
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Observations
Based on a review of eight patient records and the facility policy and procedure manual, the facility failed to complete a personal history within 14 days of admission in two patient records. Patient #1 was admitted on September 24, 2021 and was still active at the time of the inspection. No personal history was documented in the record at the time of the inspection Patient #2 was admitted on October 14, 2020 and was still active at the time of the inspection. A personal history was not completed and documented in the patient record until January 28, 2021. These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
The clinical supervisor will provide a training to all counselors on when clinical documentation is due including personal histories in the form of ARS's biopsychosocial which are to be completed within 14 days of the patient's admission. This training will occur on 12/7/2021 during group clinical supervision.
Quarterly peer review audits will be conducted on patient charts to ensure continued compliance with appropriately completing clinical paperwork in appropriate timeframes including completing personal histories in the form of the biopsychosocial within 14 days of admission.
Patient #1 Is scheduled to complete the personal history by 12/06/2021.
Patient #2 Is scheduled to complete the personal history by 12/06/2021.
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715.23(b)(2) LICENSURE Patient records
(b) Each patient file shall include the following information
(2) A complete drug and alcohol history.
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Observations
Based on a review of eight patient records and the facility policy and procedure manual, the facility failed to complete a drug and alcohol history within 14 days of admission in two patient records. Patient #1 was admitted on September 24, 2021 and was still active at the time of the inspection. No drug and alcohol history were documented in the record at the time of the inspection Patient #2 was admitted on October 14, 2020 and was still active at the time of the inspection. A drug and alcohol history were not completed and documented in the patient record until January 28, 2021. These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The clinical supervisor will provide a training to all counselors on when clinical documentation is due including Drug and Alcohol History in the form of ARS's biopsychosocial which are to be completed within 14 days of the patient's admission. This training will occur on 12/7/2021 during group clinical supervision.
Quarterly peer review audits will be conducted on patient charts to ensure continued compliance with appropriately completing clinical paperwork in appropriate timeframes including completing personal histories in the form of the biopsychosocial within 14 days of admission.
Patient #1 Is scheduled to complete the drug and alcohol history by 12/06/2021.
Patient #2 Is scheduled to complete the drug and alcohol history by 12/06/2021.
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715.23(b)(3) LICENSURE Patient records
(b) Each patient file shall include the following information:
(3) A complete medical history
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Observations
Based on a review of patient records and the facility policy and procedure manual, the facility failed to complete a medical history within 14 days of admission in two patient records. Patient #1 was admitted on September 24, 2021 and was still active at the time of the inspection. No medical history was documented in the record at the time of the inspection Patient #2 was admitted on October 14, 2020 and was still active at the time of the inspection. A medical history was not completed and documented in the patient record until January 28, 2021. These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The clinical supervisor will provide a training to all counselors on when clinical documentation is due including medical history in the form of ARS's biopsychosocial which are to be completed within 14 days of the patient's admission. This training will occur on 12/7/2021 during group clinical supervision.
Quarterly peer review audits will be conducted on patient charts to ensure continued compliance with appropriately completing clinical paperwork in appropriate timeframes including completing medical histories in the form of the biopsychosocial within 14 days of admission.
Patient #1 Is scheduled to complete the medical history by 12/06/2021.
Patient #2 Is scheduled to complete the medical history by 12/06/2021.
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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.Client #8 was admitted on July 19, 2018 and was discharged on July 13, 2021. The last documented annual physical evaluation was dated July 15, 2019. An annual physical evaluation was due no later than July 15, 2020; 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
Effective immediately the Director of Nursing will put a flag in patient chart to schedule annual medical appointment with the doctor at admission. The annual appointment should be scheduled 1-2 months prior to due date of the appointment to ensure completion prior to 1 year mark.
Quarterly peer review audits will be conducted on patient charts to ensure continued compliance with ensuring that annual medical appointments are completed on time as needed in compliance with regulation 715.23(b)(5).
Client #8 as previously noted has been discharged.
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715.23(b)(15) LICENSURE Patient records
(b) Each patient file shall include the following information:
(15) Psychosocial evaluations of the patient.
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Observations
Based on a review of eight patient records and the facility policy and procedure manual, the facility failed to complete a psychosocial evaluation within 14 days of admission in two patient records. Patient #1 was admitted on September 24, 2021 and was still active at the time of the inspection. No psychosocial evaluation was documented in the record at the time of the inspection Patient #2 was admitted on October 14, 2020 and was still active at the time of the inspection. A psychosocial evaluation was not completed and documented in the patient record until January 28, 2021. These findings were reviewed with facility staff during the licensing process. '
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Plan of Correction
The clinical supervisor will provide a training to all counselors on the timeline of when ARS's biopsychosocial need to be completed which is within 14 days of the patient's admission. This training will occur on 12/7/2021 during group clinical supervision.
Quarterly peer review audits will be conducted on patient charts to ensure continued compliance with appropriately completing clinical paperwork in appropriate timeframes in the form of the biopsychosocial within 14 days of admission.
Patient #1 Is scheduled to complete the BPS by 12/06/2021.
Patient #2 Is scheduled to complete the BPS by 12/06/2021.
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715.23(b)(22) LICENSURE Patient records
(b) Each patient file shall include the following information:
(22) Aftercare plan, if applicable.
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Observations
Based on a review of eight patient records, the facility failed to document and compete record to include an aftercare plan in one of one applicable patient records reviewed. Client #8 was admitted on July 19, 2018 and was discharged on July 13, 2021. There was no documentation of an aftercare plan being completed in the patient record. These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The clinical supervisor will provide a training to all counselors on the purpose of the aftercare plan, what information needs to be entered into the aftercare plan, and when the aftercare plan needs to be completed. This training will occur on 12/15/2021 during group clinical supervision.
Quarterly peer review audits will be conducted on patient charts to ensure continued compliance with appropriately completing clinical paperwork in appropriate timeframes including completing aftercare plans as needed.
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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 eight patient records, the facility failed to document an annual clinical evaluation of the patient in one patient record reviewed.Client #8 was admitted on July 19, 2018 and was discharged on July 13, 2021. The last annual evaluation documented was dated July 18, 2019; there was not a documented evaluation for July 2020.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The clinical supervisor will provide a training to all counselors on the purpose of the annual evaluation, what information needs to be in the annual evaluation, and when the annual evaluation needs to be completed. This training will occur on 12/15/2021 during group clinical supervision.
Quarterly peer review audits will be conducted on patient charts to ensure continued compliance with appropriately completing clinical paperwork in appropriate timeframes including completing annual evaluations yearly.
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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 a review of eight client records, the facility failed to document and compete and follow up information in three of three applicable client records reviewed. Client #6 was admitted on August 12, 2020 and was discharged on June 17, 2021. There was no documentation of follow up information being completed in the client record. Client #7 was admitted on January 8, 2020 and was discharged on September 29, 2021. There was not documentation of follow up information being completed in the client record. Client #8 was admitted on July 19, 2018 and was discharged on July 13, 2021. There was no documentation of follow up being completed in the client record. These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The clinical supervisor will provide a training to all counselors, admissions coordinator, and intake coordinator on the purpose of post-discharge follow up calls including the timeframe in which they are to be completed (within 14 days of the patient being discharged). This training will occur on 12/21/2021 during group clinical supervision. Clinical supervisor reviews that these calls are made as discharges are entered into the monthly discharge report |