INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on July 17-18, 2024 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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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 an annual physical examination within the regulatory timeframe in two out of four applicable records.Patient #6 was admitted on September 12, 2019 and was still active at the time of the inspection. The annual physical examination was due no later than September 12, 2023; however, it was completed on October 25, 2023. Patient #7 was admitted on November 24, 2017 and was still active at the time of the inspection. The annual physical examination was due no later than November 24, 2023; however, it was completed on November 27, 2024. These findings were reviewed with facility staff during the licensing inspection process.
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Plan of Correction
Beginning 7/25/24, lead counselor will track annual H&P due dates and monitor for completion. Lead counselor will inform counselors via email of H&P's that are coming due at least 2 months in advance to ensure it is completed by the client's anniversary date. Medical staff will inform lead counselor, clinical supervisor and executive director any time an appointment is missed to ensure there is follow-up with the client to re-schedule the appointment. Clinical supervisor will monitor for timely completion of H&P's during monthly supervision.
In addition, the Quality Team reviews quality and compliance indicators on a monthly basis and reviews during monthly key performance indicator meetings with site leadership. A random sample of charts is monitored each month. The Quality team monitors the following indicator each month with a benchmark goal of 80%. Site leadership will work with the quality team to address any indicator below the benchmark score and will provide additional training and resources as needed. |
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 clinical evaluation within the regulatory timeframe and ensure that the evaluation was signed by the medical director in one out of four applicable records. Patient #6 was admitted on September 12, 2019 and was still active at the time of the inspection. The annual clinical evaluation was due no later than September 12, 2023; however, it was completed on December 21, 2023. This finding was reviewed with facility staff during the licensing inspection.
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Plan of Correction
Beginning 7/25/24, along with the annual H&P, lead counselor will track annual clinical evaluation due dates and monitor for completion. Lead counselor will inform counselors via email of clinical evaluations that are coming due at least 2 months in advance to ensure it is completed by the client's anniversary date. Clinical supervisor will monitor for timely completion of the annual clinical evaluation and H&P during monthly supervision.
In addition, the Quality Team reviews quality and compliance indicators on a monthly basis and reviews during monthly key performance indicator meetings with site leadership. A random sample of charts is monitored each month. The Quality team monitors the following indicator each month with a benchmark goal of 80%. Site leadership will work with the quality team to address any indicator below the benchmark score and will provide additional training and resources as needed. |
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 patient records, the facility failed to document a treatment plan updates within guidelines established by the facility's policy and procedures manual in two out of five applicable records reviewed. The facility's policy and procedures manual states the treatment plan updated must be every 60 days following for the first two years than 120 days thereafter.Patient #5 was admitted on March 30, 2023 and was discharged on May 1, 2024. A treatment plan update was completed on December 8, 2023 and the next one was due no later than February 8, 2024; however, it was not completed until February 20, 2024. Patient #6 was admitted on September 12, 2019 and was still active at the time of the inspection. A treatment plan update was completed on January 19, 2024 and the next update was due no later than May 19, 2024; however, it was not completed until May 24, 2024.These findings were reviewed with facility staff during the licensing inspection. This is a repeat citation from the August 2, 2023 licensing inspection.
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Plan of Correction
Clinical supervisor reviewed treatment plan update timeline with staff during treatment team meeting on 7/25/24. Beginning 8/5/2024, clinical supervisor will monitor the "Expiring Treatment Plans" alerts and email the list to counselors at the beginning of every week. Lead counselor will pull the "Treatment Plans Expired" report and email the list to the counselors, clinical supervisor and executive director at the beginning of every week. Counselors will be expected to complete reviews prior to or on the due date. Clinical Supervisor will monitor for compliance and discuss any late documentation during monthly supervision. Disciplinary action will be taken if late documentation continues.
In addition, the Quality Team reviews quality and compliance indicators on a monthly basis and reviews during monthly key performance indicator meetings with site leadership. A random sample of charts is monitored each month. The Quality team monitors the following indicator each month with a benchmark goal of 80%. Site leadership will work with the quality team to address any indicator below the benchmark score and will provide additional training and resources as needed. |