INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on September 29, 2022, 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 Ephrata, LLC 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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704.12(a)(6) LICENSURE OutPatient Caseload
704.12. Full-time equivalent (FTE) maximum client/staff and client/counselor ratios.
(a) General requirements. Projects shall be required to comply with the client/staff and client/counselor ratios in paragraphs (1)-(6) during primary care hours. These ratios refer to the total number of clients being treated including clients with diagnoses other than drug and alcohol addiction served in other facets of the project. Family units may be counted as one client.
(6) Outpatients. FTE counselor caseload for counseling in outpatient programs may not exceed 35 active clients.
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Observations
Based on a review of the Staffing Requirements Facility Summary Report form, the facility failed to ensure that the FTE counselor caseload for counseling in outpatient programs may not exceed 35 active clients.
Employee #3 was hired as a counselor on September 12, 2022 and was still acting in that position. Employee #3 was reported to have 16 hours per week devoted to their 29 clients on their caseload.
The counselor Full Time Equivalent (FTE) is determined by dividing the total number of hours the counselor devotes to their clients by 40. Then, in order to obtain the counselor ' s ratio, the total number of clients on the counselor ' s caseload is divided by the FTE.
The FTE counselor ' s caseload calculation is as follows: 16/40 =.40(FTE); 29/.40 = 73/1, which equals to a client/counselor ratio of 73/1.
Employee #4 was hired as a counselor on April 11, 2022 and was still acting in that position. Employee #4 was reported to have 40 hours per week devoted to their 47 clients on their caseload.
The counselor Full Time Equivalent (FTE) is determined by dividing the total number of hours the counselor devotes to their clients by 40. Then, in order to obtain the counselor ' s ratio, the total number of clients on the counselor ' s caseload is divided by the FTE.
The FTE counselor ' s caseload calculation is as follows: 40/40 =1(FTE); 47/1 = 47/1, which equals to a client/counselor ratio of 47/1
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Clinical supervisor will review all counselor's caseloads in weekly supervisions to determine counselor to patient ratios. Clinical supervisor will identify the number of patients with exempt status versus non-exempt status in order to ensure that counselor to patient ratio is remaining within the 1:35 ratio that is required. Caseloads will be adjusted as needed based on incoming admissions and patients moving to exempt status. In times when there are vacant counselor positions, all attempts to keep caseloads within ratio will be made and will be kept as close to the ratio as possible until the position(s) are filled. |
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 September 2021 thru September 2022 the facility failed to ensure that the fire drill record included the exit route used and whether the fire alarm or smoke detector was operative.
There findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Fire/Emergency Drill Report was updated on 10/5/2022 to include check boxes identifying weather the fire alarm was sound and operative/no operative. A line was also added to identify which exits were used during the drill. Executive Director will ensure updated forms are utilized monthly. |
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 September 2021 thru September 2022, the facility failed to document if the facility set off a fire alarm or smoke detector during each fire drill.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Fire/Emergency Drill Report was updated on 10/5/2022 to include check boxes identifying weather the fire alarm was sound and operative/no operative. Executive Director will ensure updated forms are utilized monthly. |
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 eight patient records, the facility failed to provide three applicable patients an average of 2.5 hours of psychotherapy per month during the patient 's first 2 years, 1 hour of which is individual psychotherapy.
Patient # 1 was admitted on June 22, 2022 and was still active at the time of the inspection. In July 2022, the patient received 0 hours of psychotherapy. In August 2022, the patient received 0 hours psychotherapy. There was no documentation of patient no shows or cancellations during those time periods.
Patient # 3 was admitted on December 3, 2021 and was an active client at the time of inspection. In July 2022, the patient received 0 hours of psychotherapy. In August 2022, the patient received 0 hours of psychotherapy. In September 2022, the patient received 0 hours of psychotherapy There was no documentation of patient no shows or cancellations during those time periods.
Patient #5 was admitted on April 7, 2022 and was still an active client at the time of the inspection. In July 2022, the patient only received 30 minutes of individual therapy. In August 2022, the patient only received 1.5 hours of individual therapy. There was no documentations of patient no shows or cancellation during those time periods.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Clinical Supervisor will train clinical staff regarding the required 2.5 hours of counseling per month. Primary Counselors will review Patient Engagement report to identify any patients that did not attend group sessions and/or individual sessions by the third Friday of every month. Primary Counselor and Clinical Supervisor will discuss any engagement concerns in supervision and improvement plans will be created on at least a quarterly basis addressing areas to improve engagement that identify each counselors' individual strengths that will help improve patient engagement. |
715.20(3) 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.
(3) The transferring narcotic treatment program shall document what materials were sent to the receiving narcotic treatment program.
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Observations
Based on a review of eight patient records, the facility failed to document what materials were sent to the receiving narcotic treatment program in one patient record reviewed.
Patient #6 was admitted on January 14, 2022 and was transferred to another narcotic treatment program on March 1, 2022. There was no documentation of material sent to the receiving narcotic treatment program in the patient record at the time of the inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Director of Clinical Services will complete a clinical training on 11/17/22. This training will include a review of required discharge paperwork including what paperwork is required to be sent to a patient's new treatment facility when they transfer their care following discharge from our program as well as the timeframe in which this documentation needs to be sent. Primary Counselor will ensure all patients with a planned discharge complete a ROI for their new treatment provider. If an ROI was not obtained prior to discharge, a blank ROI will be faxed to the new treatment provider to obtain a signature so files can be sent as soon as possible. Clinical Supervisor will audit all discharge charts within 5 business days of discharge to ensure deficiency does not reoccur. |
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, the facility failed to complete and document a complete personal history in two patient records reviewed.
Patient #5 was admitted on April 7, 2022 and was still active at the time of the inspection. There was no documentation that a personal history was completed within the patient record.
Patient #6 was admitted on January 14, 2022 and was discharged on March 1, 2022. There was no documentation that a personal history was completed within the patient record.
These findings were discussed with facility staff during the licensing process.
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Plan of Correction
The Director of Clinical Services will be conducting a training with 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 11/17/2022.
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.
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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, the failed to complete and document a complete drug and alcohol history in two patient records reviewed.
Patient #5 was admitted on April 7, 2022 and was still active at the time of the inspection. There was no documentation that a complete drug and alcohol history was completed within the patient record.
Patient #6 was admitted on January 14, 2022 and was discharged on March 1, 2022. There was no documentation that a complete drug and alcohol history was completed within the patient record.
These findings were discussed with facility staff during the licensing process.
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Plan of Correction
The Director of Clinical Services will be conducting a training with 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 11/17/2022.
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.
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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 eight patient records, the failed to complete and documented a complete medical history in two patient records reviewed.
Patient #5 was admitted on April 7, 2022 and was still active at the time of the inspection. There was no documentation that a complete medical history was completed within the patient record.
Patient #6 was admitted on January 14, 2022 and was discharged on March 1, 2022. There was no documentation that a complete medical history was completed within the patient record.
These findings were discussed with facility staff during the licensing process.
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Plan of Correction
The Director of Clinical Services will be conducting a training with 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 11/17/2022.
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.
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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, the failed to complete and documented a psychosocial evaluation of each patient in four appliable patient records.
Patient #2 was admitted on January 6, 2022 and still active at the time of the inspection. There was no documentation that a psychosocial evaluation was completed within the patient record.
Patient #5 was admitted on April 7, 2022 and was still active at the time of the inspection. There was no documentation that a psychosocial evaluation was completed within the patient record.
Patient #6 was admitted on January 14, 2022 and was discharged on March 1, 2022. There was no documentation that a psychosocial evaluation was completed within the patient record.
Patient #7 was admitted on November 21, 2021 and was discharged on August 5, 2022. There was no documentation that a psychosocial evaluation was completed within the patient record.
These findings were discussed with facility staff during the inspection process.
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Plan of Correction
The Director of Clinical Services will be conducting a training with 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 11/17/2022.
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.
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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 provide a complete patient record, which is to include an aftercare plan in one applicable patient records reviewed.
Patient #8 was admitted on December 3, 2021 and was discharged on February 24, 2022. There was not 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
Director of Clinical Services will complete a clinical training on 11/17/22. This training will include a review of aftercare planning. Primary Counselor will ensure all patients with a planned discharge receive an aftercare plan prior to discharge reviewing all necessary components of the aftercare plan. Clinical Supervisor will audit all discharge charts within 5 business days of discharge to ensure deficiency does not reoccur. |