INITIAL COMMENTS
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This report is a result of an on-site licensure renewal and methadone monitoring inspection conducted on November 21, 2024 through November 22, 2024, by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, The Healing Way 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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709.25 LICENSURE Fiscal Management
§ 709.25. Fiscal management.
The project shall obtain the services of an independent certified public accountant for an annual financial audit of activities associated with the project ' s drug/alcohol abuse services, in accordance with generally accepted accounting principles which include reference to the drug and alcohol treatment activities.
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Observations
Based on a review of administrative documents, the project failed to obtain the services of an independent certified public accountant for an annual financial audit of activities associated with the project's drug/alcohol abuse services, in accordance with generally accepted accounting principles which include reference to the drug and alcohol treatment activities. At the time of the inspection, there were no annual financial audits completed for the facility's fiscal years ending on December 31, 2021 or December 31, 2022.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
THW Program Director and CPA have differentiated revenue from DDAP programs, which falls under the threshold of $500,000.00. Program Director will submit an exception request. If the exception request is denied, our CPA now knows exactly what information is needed to complete the audit and will do so going forward. |
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 a review of eight client records, the facility failed to ensure that informed and voluntary consent to release information forms included the specific information to be disclosed in one record reviewed.
Client # 2 was admitted on January 8, 2024 and was discharged on May 13, 2024. The record contained a consent to release information form to the funding source signed by the client on January 11, 2024, that was missing the specific information to be disclosed.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Newly hired Quality Assurance/Clinical Supervisor will be reviewing all intake paperwork on the final Friday of every month to ensure that all clinical documents and consents forms are complete correctly.
Findings will be shared with Executive Staff during monthly meetings to review if additional trainings are needed and to see if staff is not meeting their job responsibilities efficiently. |
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 a review of eight patient records, the facility failed to maintain onsite a photograph of each patient which includes the patient ' s name and birth date in four records reviewed.
Patient # 1 was admitted on August 22, 2016 and was active at the time of the inspection. The record did not contain a photograph of the patient.
Patient # 4 was admitted on May 2, 2018 and was discharged on October 12, 2024. The record did not contain a photograph of the patient.
Patient # 5 was admitted on November 16, 2017 and was active at the time of the inspection. The record did not contain a photograph of the patient.
Patient # 8 was admitted on January 4, 2024 and was a discharged on April 29, 2024. The record did not contain a photograph of the patient.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
None of the missing IDs were from newly admitted patients, we have been working to import all documents including IDs into our new EHR system. Clinical Supervisor will complete importing IDs from our old EHR system to our current EHR system by 1/1/2025. On 1/1/2025 Clinical Supervisor will review all existing charts to ensure that everything has been imported with nothing missed. |
715.16(a)(2) LICENSURE Take-home privileges
(a) A narcotic treatment program shall determine whether a patient may be provided take-home medications.
(2) The narcotic treatment physician shall make this determination after consultations with staff involved in the patient's care.
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Observations
Based on a review of patient records, the facility failed to ensure that the narcotic treatment physician made the determination for take-home medication in one record reviewed.
Patient # 4 was admitted on May 2, 2018 and was discharged on October 12, 2024. Dosing history indicated that the patient received take-home medication on January 29, 2024 through February 4, 2024 and February 5, 2024 through February 11, 2024; however, the order signed by the physician only allowed for six days. The allowance for the seventh take-home dose was not determined by the physician.
This is a repeat citation from the December 1, 2023 annual renewal licensing inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Our EHR system has a functionality for physician orders that says "all take homes" which automatically lists their order as all take homes. This button was accidentally selected by the Medical Director when modifying the clients dosing order. We have already submitted a request to the underwriters of our EHR to de-activate this button so that it is not functional for our system. The request will be completed by Method One by 1.1.2025. Medical Director will verify that the button is unfunctional, and Quality Assurance/Clinical Supervisor will ensure during quarterly quality assurance reviews that the dosing orders are entered correctly. |
715.21(1)(i-iv) LICENSURE Patient termination
A narcotic treatment program shall develop and implement policies and procedures regarding involuntary terminations. Involuntary terminations shall be initiated only when all other efforts to retain the patient in the program have failed.
(1) A narcotic treatment program may involuntarily terminate a patient from the narcotic treatment program if it deems that the termination would be in the best interests of the health or safety of the patient and others, or the program finds any of the following conditions to exist:
(i) The patient has committed or threatened to commit acts of physical violence in or around the narcotic treatment program premises.
(ii) The patient possessed a controlled substance without a prescription or sold or distributed a controlled substance, in or around the narcotic treatment program premises.
(iii) The patient has been absent from the narcotic treatment program for 3 consecutive days or longer without cause.
(iv) The patient has failed to follow treatment plan objectives.
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Observations
Based on a review of patient records, the facility failed to ensure that patients were not involuntarily terminated for reasons other than stated in the regulation in one of one applicable record reviewed.
Patient # 2 was admitted on January 8, 2024 and was involuntarily discharged on May 13, 2024. The patient was terminated for failing to follow treatment plan objectives, and an administrative detox began on April 8, 2024. However, the treatment plan objective that resulted in termination was not added to the treatment plan until April 9, 2024.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
On 12/9 THW held a staff meeting updating all staff with with treatment plan protocol. During all upcoming treatment planning appointments clinicians will review and update treatment plans to include a goal of the client either: 1) ensuring that their insurance remains active and is accepted by THW or 2) that the self pay client is actively paying their bill.
All new staff will be oriented to this process upon hire, and during supervision appointments supervisors will remind clinicians and review treatment plan objectives to ensure that they are following procedure.
Quality Assurance/Clinical Supervisor will review treatment plans on a quarterly basis to ensure that there is a financial objective. |
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 the review of patient records, the facility failed to document a completed annual evaluation signed by the medical director in two of four applicable records.
Patient # 1 was admitted on August 22, 2016 and was active at the time of the inspection. The annual evaluation was due to be completed by August 22, 2024; however, an annual evaluation was not completed as of the date of the inspection.
Patient # 3 was admitted on January 8, 2020 and was discharged on February 21, 2024. The annual evaluation was due to be completed by January 8, 2024; however, the most recent annual evaluation was completed on June 26, 2023.
This is a repeat citation from the January 18, 2022, July 6, 2022, December 16, 2022, and December 1, 2023 annual licensing renewal inspections.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
At the time of inspection we came to the conclusion with the inspector that our procedure for annual justifications was incorrect. THW was historically doing the justification after the annual physical, as one long appointment with the client. When the physical was rescheduled, and late, it automatically made the justification late the following year, even if we did it on time with the physical - because it was no longer coinciding with their admission anniversary.
On 12/9 THW held a staff meeting updating all staff with the correct procedure - all justifications are to be done by the anniversary date of the clients enrollment. All new staff will be trained correctly at orientation. Clinical Supervisors will review justifications on a monhtly basis. |
709.92(a) LICENSURE Treatment and rehabilitation services
709.92. Treatment and rehabilitation services.
(a) An individual treatment and rehabilitation plan shall be developed with a client. This plan shall include, but not be limited to, written documentation of:
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Observations
Based on a review of client records, the facility failed to ensure that an individual treatment and rehabilitation plan was developed with the client within 30 days of admission, per the facility policy, in two of four applicable records reviewed.
Client # 6 was admitted on March 21, 2024 and was active at the time of the inspection. The individual treatment and rehabilitation plan was due to be completed by April 19, 2024; however, it was not completed until April 29, 2024.
Client # 7 was admitted on May 15, 2024 and was active at the time of the inspection. The individual treatment and rehabilitation plan was due to be completed by June 13, 2024; however, it was not completed until July 1, 2024.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
On 12/9 THW executive staff held a staff meeting updating all staff with with treatment plan protocol. As of 1/1/2025, if a client misses their scheduled treatment planning session, their dose will be put on hold the next day, or the next day that they return for dosing, rather then the client rescheduling for the next available therapy appointment. If their clinician is unable or out that day, another counselor will step in to review and update their treatment with them.
Program Director will review how this process is working on April 1, 2025 and then quarterly thereafter. |
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 client records, the facility failed to document treatment plan updates within the regulatory timeframe in five of seven applicable records reviewed.
Client # 1 was admitted on August 22, 2016 and was active at the time of the inspection. A treatment plan update was completed on February 6, 2024, and the next treatment plan update was due no later than April 6, 2024; however, the next treatment plan update was not completed until April 12, 2024. The next treatment plan update was due to be completed by June 11, 2024; however, it was not completed until July 5, 2024.
Client # 4 was admitted on May 2, 2018 and was discharged on October 12, 2024. A treatment plan update was completed on December 5, 2023, and the next treatment plan update was due no later than February 3, 2024; however, the treatment plan update was not completed until February 8, 2024. Another treatment plan update was completed on June 4, 2024, and the next update was due to be completed by August 3, 2024; however, it was not completed until August 7, 2024.
Client # 5 was admitted on November 16, 2017 and was active at the time of the inspection. A treatment plan update was completed on March 8, 2024, and the next treatment plan update was due no later than May 7, 2024; however, the treatment plan update was not completed until May 13, 2024.
Client # 6 was admitted on March 21, 2024 and was active at the time of the inspection. The individual treatment and rehabilitation plan was completed on April 29, 2024, and the treatment plan update was due no later than June 28, 2024; however, the treatment plan update was not completed until July 1, 2024.
Client # 7 was admitted on May 15, 2024 and was active at the time of the inspection. The individual treatment and rehabilitation plan was completed on July 1, 2024, and the treatment plan update was due no later than August 30, 2024; however, the treatment plan update was not completed until September 3, 2024.
This is a repeat citation from the December 1, 2023 annual renewal licensing inspection.
These findings were discussed with facility staff during the inspection process.
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Plan of Correction
On 12/9 THW executive staff held a staff meeting updating all staff with with treatment plan protocol. As of 1/1/2025, if a client misses their scheduled treatment planning session, their dose will be put on hold the next day, or the next day that they return for dosing, rather then the client rescheduling for the next available therapy appointment. If their clinician is unable or out that day, another counselor will step in to review and update their treatment with them. This way all treatment plans will be completed within 60 days of the previous treatment plan.
Program Director will review how this process is working on April 1, 2025 and then quarterly thereafter. |
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 patient records, the facility failed to comply with plans of correction that were approved by the Department.
A plan of correction to ensure that counselors completed an annual evaluation that was signed by the medical director was submitted and approved by the Department for the January 18, 2022, July 6, 2022, December 16, 2022, and December 1, 2023 licensing inspections. Annual evaluations were again found to be a deficiency in the November 21, 2024 through November 22, 2024 annual licensing inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Program Director will be responsible to ensure that citations not be repeated by conducting his own quarterly audits specifically to address previous citations and ensure that current processes are hitting the correct metrics to avoid citation and follow regulations. |