INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection and methadone monitoring conducted on August 15, 2017 through August 16, 2017 by staff from the Department of Drug and Alcohol Programs, Bureau of Quality Assurance for Prevention and Treatment, Program Licensure Division. Based on the findings of the on-site inspection, The Consortium 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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705.24 (7) LICENSURE Bathrooms.
705.24. Bathrooms.
The nonresidential facility shall:
(7) Maintain each bathroom in a functional, clean and sanitary manner at all times.
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Observations
Based on the physical plant inspection that was conducted on August 16, 2017, the facility failed to ensure that the first floor handicap men's bathroom (near the elevator) was maintained in a functional and safe manner as the sink was not properly connected to the wall and was pulling away from the drywall; thus, presenting the opportunity of the sink falling on a patient, staff, or visitor.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Plan of Correction:
The first floor handicap men's bathroom(near the elevator), where the sink was not properly connected to the wall and pulling away from the drywall; will be repaired by 9/15/17.
Responsible Party:
The Facilities Department is responsible for maintaining each bathroom in a functional, clean and sanitary manner at all times and for ensuring that all bathroom fixtures are safe and working properly.
Ongoing Monitoring:
Facilities Staff will ensure that all bathroom fixtures are safe and working properly as part of their daily rounds.
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709.28 (c) 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.
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Observations
Based on the review of 13 client records, the facility failed to document an informed and voluntary consent to release information form prior to the disclosure of information in 3 client records.
Client #2 was admitted on 9/23/16 and was still an active client at the time of the inspection. There was a letter sent on 4/10/17; however, the letter was addressed " to whom it may concern " and the recipient was unknown. There was no further documentation in the record stating who the letter was sent to as of the date of the inspection.
Client #9 was admitted on 5/16/16 and was still an active client at the time of the inspection. There were two consent to release forms, one to the funding source and the other to the urinalysis lab, signed and dated 5/16/16. Both consent forms expired on 5/16/17 and were not updated prior to expiring. There was documentation in the record, from both sources, after the 5/16/17 expiration date indicating information was shared.
Client #12 was admitted on 5/22/14 and was discharged on 7/13/17. There were two consent to release forms, one to the funding source and the other to the urinalysis lab, signed and dated 5/06/15. Both consent forms expired on 5/06/16 and were not updated prior to expiring and client ' s discharge. There was documentation in the record, from both sources, after the 5/06/16 expiration date indicating information was shared.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Staff will be retrained on the documentation of informed and voluntary consent to release information form prior to the disclosure of information by 9/29/17.
Expired consents for chart #9 will be updated by 9/22/17.
Responsible Party(s): Counselors are responsible for ensuring that all consents are updated within the required time frames.
Supervisors are responsible for ensuring that all consents are completely and accurately filled out.
Medical records will be responsible for faxing out documentation and will ensure an active release is in place prior to sending out to external parties.
Ongoing Monitoring: Supervisors will increase monitoring of deadlines for all releases of information.
Additionally supervisors will increase review of all consents submitted to ensure all elements are completely filled out
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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 patient records, the facility failed to provide documentation of at least 2.5 hours of therapy sessions per month, which is to include at least 1 hour of individual therapy in 5 of 13 records reviewed.
Patient #1 was admitted on 6/15/17 and was still active at the time of the inspection. There were no individual therapy sessions documented for the month of July 2017. There was no documentation of patient no-shows/cancellations during that month.
Patient #2 was admitted on 9/23/16 and was still active at the time of the inspection. There were no individual therapy sessions documented for the months of June 2017 and July 2017. There was no documentation of patient no-show/cancellation during those months.
Patient #3 was admitted on 4/07/17 and was still active at the time of the inspection. There were no individual therapy sessions documented for the month of June 2017. There was no documentation of patient no-shows/cancellations during that month.
Patient #5 was admitted on 2/24/16 and was still active at the time of the inspection. For the month of May 2017, there was only one 45-minute individual therapy session documented. For the month of June 2017, there were only two 1-hour individual therapy sessions documented. For the month of July 2017, there were only one 1-hour individual therapy session and one 25-minute individual therapy session documented. There was no documentation of patient no-shows/cancellations during that month.
Patient #7 was admitted on 12/20/16 and was discharged on 8/01/17. There were no individual sessions or group sessions documented for the month of July 2017. Additionally, there was only one 45-minute individual therapy session documented during the month of June 2017. There was no documentation of patient no-shows/cancellations during that month.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Staff will be trained on the required counseling sessions for those enrolled in the program by 9/29/17.
Responsible Party: Counselors have the responsibility of scheduling their members for, minimally, 2.5 hours of therapy sessions per month. Additionally, counselors are responsible for rescheduling appointments that are not kept to ensure that 2.5 hours per month is provided.
Ongoing Monitoring:
Supervisors will increase monitoring of their respective counselor's caseloads to ensure that members have participated in the recommended level of treatment sessions, as assessed and required. |
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 13 patient records, the facility failed to document an annual clinical evaluation of the patient in 3 of 4 applicable records reviewed.
Patient #5 was admitted on 2/24/16 and was still active at the time of the inspection. The annual evaluation was due no later than 02/24/17; however, it was not completed as of the date of the inspection.
Patient #9 was admitted on 5/16/16 and was still active at the time of the inspection. The annual evaluation was due no later than 05/16/17; however, it was not completed as of the date of the inspection.
Patient #12 was admitted on 5/22/14 and was discharged on 7/13/17. The annual evaluation was due no later than 5/22/17; however, it was not completed prior to patient ' s discharge.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Record #'s 5 and 9 will have outstanding annual evaluations completed by 9/15/17.
Responsible Party(s): The Counselors are responsible for ensuring that all annual evaluations are fully documented at the anniversary date of the client's admission date each year.
The Supervisors are responsible for monitoring the submission of annual evaluations by the anniversary dates.
Ongoing Monitoring: Supervisors will increase monitoring of the due dates of all annual evaluations and will request submission one week prior to due date.
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709.91(b)(7) LICENSURE Intake and admission
709.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(7) Preliminary treatment and rehabilitation plan.
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Observations
Based on a review of 13 patient records, the facility failed to document preliminary treatment plan in 1 of 5 applicable patient records.
Patient #8 was admitted on 06/12/2017 and was discharged on 07/20/2017.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Preliminary Treatment plans will be completed on the date of admission; as well as be signed and filed in the chart within 14 days of a person's admission date.
Staff will be retrained on the deadlines for the completion of preliminary treatment plans by 9/29/17.
Responsible Party:
Admissions staff/or designee are required to ensure preliminary treatment plans are completed within appropriate deadlines.
Ongoing Monitoring:
Admissions records will be reviewed by a clinical manager within 48 hours of admission date. |
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 13 patient records, there were treatment plan updates either completed after the regulatory timeframe or missing at the time of the inspection in 6 of 10 applicable records.
Patient #2 was admitted on 9/23/16 and was still active at the time of the inspection. A treatment plan update was completed on 05/23/17 and the next update was due no later than 07/23/17. There was no update completed prior to the date of the inspection.
Patient #3 was admitted on 4/07/17 and was still active at the time of the inspection. The comprehensive treatment plan was completed 5/04/17 with an update due no later than 7/04/17, however the update was completed 7/12/17.
Patient #7 was admitted on 12/20/16 and was discharged on 8/01/17. A treatment plan update was completed on 05/18/17 and the next update was due no later than 07/18/17. There was no update completed prior to the patient's discharge.
Patient #9 was admitted on 5/16/16 and was still active at the time of the inspection. A treatment plan update was completed on 3/13/17 and the next update was due no later than 5/13/17, however the update was completed on 6/14/17.
Patient #10 was admitted on 5/11/17 and was still active at the time of the inspection. The comprehensive treatment plan was completed on 6/14/17 with an update due no later than 8/14/17. There was no update completed prior to the date of the inspection.
Patient #13 was admitted on 9/22/16 and was discharged on 6/2/17. A treatment plan update was completed on 3/1/17 and the next update was due no later than 5/1/17. There was no update completed prior to the patient's discharge.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Treatment plan updates will be completed, signed and filed in the chart within the required treatment plan deadlines. Records # 2,3 and 10, if not done so previous to today, will have a treatment plan update completed and filed in the record by 9/15/17
Staff will be retrained on the deadlines for the completion of treatment plans by 9/29/17.
Responsible Party:
Therapists are required to ensure treatment plans are completed within appropriate deadlines.
Ongoing Monitoring:
Treatment plan deadlines will be monitored with use of documentation tracker as well as discussion of deadlines in staff meetings and clinical supervision.
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709.93(a) 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:
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Observations
Based on a review of patient records, the facility failed to provide documentation of a complete patient record in 2 of 13 records reviewed.
Patient #8 was admitted on 6/12/17 and was discharged on 7/20/17. The patient record did not contain documentation of any progress notes during the treatment episode. Additionally, there was no documentation of a discharge summary.
Patient #13 was admitted on 9/22/16 and was discharged on 6/2/17. The patient record did not contain documentation of case consultation notes. Additionally, there was no documentation of any follow-up information after the patient's discharge.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Each client record will include a completed client record.
Chart #8's status will be reviewed by the assigned counselor of record. If the person is still active, all deficient documentation will be completed and filed into the record by 9/22/17. If person is not active, a discharge will be completed by 9/15/17.
Responsible Party:
Therapists are required to ensure all documentation to ensure a complete client record are present in the medical record.
Ongoing Monitoring:
Documentation which is required to be in the complete client record will be monitored by supervisors and therapists on a daily basis to ensure awareness of all deadlines of paperwork. Deadlines will also be reviewed in clinical supervision at least monthly.
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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 the physical plant inspection conducted on August 16, 2017 and a review of areas of non-compliance identified during the April 25-26, 2017 licensing inspection that had previously been cited, the facility failed to comply with prior plans of correction which were approved by the Department.
1. The roofing issue cited previously was not in complete compliance at the time of this inspection, despite the facility stating in their 06/01/17 corrective action plan that all the roofing work would be completed prior to 06/30/17.
2. The front entrance door (near the reception area) was not in complete compliance at the time of this inspection. The door was inoperable and roped off with caution tape both inside and out; however, the facility's 06/01/17 corrective action plan stated that the door and frame would be repaired by 06/15/17.
** It should be noted that at the time of this inspection, there was active construction going on with the exterior of the building, as well as the grounds of the property. There was construction scaffolding surrounding each side of the building and any area deemed unsafe for patient, staff, and visitors was taped off. **
This is a repeat citation from prior licensing renewal inspections.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The roofing issue cited previously continues to be worked on by an external contractor. Although the work has not yet been completed, the CEO and COO are expected to meet with the engineers of the project to determine the scope of the work to be completed and the timelines for completion. An update on the status of the project will be submitted to DDAP by 9/26/17.
The front entrance door, will be fully operable by 9/15/17.
Responsible Party: The Facilities Staff is responsible for ensuring that the internal and external grounds of the physical plant are maintained, and in good repair to ensure safety of all persons in and around the plant.
Ongoing Monitoring:
The Facilities Staff will ensure that all physical plant issues are assessed as a part of their daily rounds.
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