INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on July 19-20, 2021 by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the 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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705.23 (3) LICENSURE Counseling or activity areas and office space
705.23. Counseling or activity areas and office space.
The nonresidential facility shall:
(3) Ensure privacy so that counseling sessions cannot be seen or heard outside the counseling room. Counseling room walls shall extend from the floor to the ceiling.
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Observations
Based on a physical plant inspection, it was observed that the facility failed to ensure privacy so that counseling sessions cannot be seen or heard outside the counseling room as the group room on the methadone side of the facility had a door with a window that was not covered. These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Executive director added a window privacy film to the window on the group room door on 7/28/2021.
Executive Director will monitor to ensure window is covered with privacy film during monthly facility inspection.
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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 a review of client records and policy and procedure manual the facility failed to document written acknowledgement by clients that they have been notified that the project may not discriminate in the provision of services on the basis religion or creed. These finding were discussed with facility staff during the inspection process.
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Plan of Correction
The policy and procedures manual was updated on 7/12/2021 by the Policy and procedure committee to include religion, creed instead of the previously stated religious creed. The new policy was made available to staff on that date via the Pyramid Healthcare intranet. The compliance officer, via email, informed all programs of the change on that date and all handbooks and consents for treatment were amended to reflect the change. |
709.30 (4) 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.
(4) Clients have the right to appeal a decision limiting access to their records to the director.
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Observations
Based on a review of client records, the facility failed to include within their client rights policy that clients have the right to appeal a decision limiting access to their records to the director. These findings were discussed with facility staff during the inspection process.
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Plan of Correction
The PHC compliance officer will be responsible for making an amendment to the electronic health record, specifically the consent for treatment, to include the client's right to appeal the decision limiting access to their records. The PHC compliance officer will ensure this change occurs and is shared with all staff by 9/1/2021. |
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 seven patient records, the facility failed to provide one patient with 2.5 hours of psychotherapy per month during the patient ' s first 2 years of treatment. Patient # 10 was admitted on April 26, 2021 and still active at the time of the inspection. In May 2021, the patient had one hour of individual therapy. In June 2021, the client had 0 hours of therapy. There was no documentation of client no shows or cancellations during those time periods.These findings were discussed with facility staff during the inspection process. This is a repeat citation from the March 16, 2021 inspection.
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Plan of Correction
Client counseling hours will be added to the counselor caseload grid to assist clinical staff in monitoring of completed/incomplete hours per client per client month.
Client hours will be added to the counselor caseload grid and counselors will begin utilizing by October25,2021.
Clinical supervisor and lead counselors will monitor for completion of counseling hours during monthly supervision and chart reviews.
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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 seven patient records, the facility failed to document an annual physical examination of the patient in one patient record reviewed.Patient #12 was admitted on September 25, 20219 and was discharged on June 28, 2021. The most recent annual physical examination was due no later than September 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
Annual physicals will be added to the counselor caseload grid to assist clinical staff in monitoring of annual physical due dates. Once the annual physical has been completed, the counselor will mark it as complete on the caseload grid.
Annual physical will be added to the counselor caseload grid and counselors will begin utilizing by October 25,2021.
Clinical supervisor and lead counselors will monitor for completion of annual physicals during monthly supervision and chart reviews.
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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 a review of 14 client records, the facility failed to document treatment plan updates within the regulatory timeframe in four client records reviewed.Client #2 was admitted on February 18, 2021 and was still active at the time of the inspection. A treatment plan update was completed on March 4, 2021 and the next update was due no later than May 4, 2021; however, there was no update documented in the record until May 27, 2021. Client #4 was admitted on December 30, 2020 and was still active at the time of the inspection. A treatment plan update was completed on March 18, 2021 and the next update was due no later than May 18, 2021; however, there was no update documented in the record until May 24, 2021.Client #11 was admitted on August 31, 2015 and was still active at the time of the inspection. A treatment plan update was completed on January 20, 2021 and the next update was due no later than March 20, 2021; however, there was no update documented in the record until May 5, 2021. Client #12 was admitted on September 25, 2020 and was discharged on June 28, 2021. A treatment plan update was completed on March 6, 2021 and the next update was due no later than May 6, 2021; however, there was no update documented in the record until May 25, 2021.These findings were discussed with facility staff during the inspection process.This is a repeat citation from the March 16, 2021 inspection.
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Plan of Correction
A counselor caseload grid documenting treatment plan review due dates was implemented in May 2021. Since utilizing the documentation grid, treatment plan updates have been in compliance according to regulations.
Clinical supervisor is highlighting upcoming treatment plan reviews due and emailing to counselors weekly. Clinical supervisor is documenting the treatment plan review as completed on the counselor caseload grid upon signing off on the updated treatment plan.
Clinical supervisor and lead counselors will monitor for completion of treatment plan reviews during monthly supervision and chart reviews.
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