INITIAL COMMENTS
|
This report is a result of an on-site licensure renewal inspection and methadone monitoring inspection conducted on November 17 & 18, 2022 by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, Center for Behavioral Health-PA, Inc. 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:
|
Plan of Correction
|
715.6(d) LICENSURE Physician Staffing
(d) A narcotic treatment program shall provide narcotic treatment physician services at least 1 hour per week onsite for every ten patients
|
Observations
Based on the review of physician timesheets, the facility failed to provide at least one hour of physician time a week, onsite for every ten patients.
During the week of July 3-9, 2022, the patient census was 321. The facility was required to provide at least 32.1 physician hours. There were 27.25 physician hours documented.
During the week of August 7-13, 2022, the patient census was 317. The facility was required to provide at least 31.7 physician hours. There were 28 physician hours documented.
During the week of August 14-20, 2022, the patient census was 316. The facility was required to provide at least 31.6 physician hours. There were 12.25 physician hours documented.
During the week of August 28-September 3, 2022, the patient census was 315. The facility was required to provide at least 31.5 physician hours. There were 27.75 physical hours documented.
During the week of September 4-10, 2022, the patient census was 313. The facility was required to provide at least 31.3 physician hours. There were 31 physician hours documented.
During the week of October 16-22, 2022, the patient census was 310. The facility was required to provide at least 31 physician hours. There were 12 physician hours documented.
This finding was reviewed with facility staff during the licensing process.
|
Plan of Correction
In order to meet the requirements of this regulation, the Medical Director has agreed to work the hours missed by CRNP due to call off, holiday, or vacation each week. We will ensure we have one hour of physician time for every ten patients each week.
Clinic director will work in collaboration with medical director to monitor and ensure hours set by regulation are obtained each week. |
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.
|
Observations
Based on a review of patient records, the facility failed to complete an annual evaluation of each patient's status by the patient's counselor in one out of one applicable record reviewed.
Patient #6 was admitted on July 19, 2019 and was still active at the time of the inspection. The annual clinical evaluation was due no later than July 19, 2022; however, it was not documented until July 26, 2022.
This finding was reviewed with facility staff during the licensing process.
|
Plan of Correction
This finding was shared with the clinical team on 12/6/22. In order to complete annual evaluations on time, the counselor will pull services due report and complete a service before the due date. Clinical supervisor will monitor services due daily and follow up with clinicians to ensure all work is completed in a timely manner.
Clinic director will oversee to ensure this regulation is upheld and maintained. |
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:
|
Observations
Based on the review of client records, the facility failed to develop an individual treatment and rehabilitation plan with the client within their policy's set time frame of 8-30 days in one out of three applicable records reviewed.
Client #3 was admitted on March 17, 2022 and was still active at the time of the inspection. A comprehensive treatment plan was due no later than April 17, 2022; however, it was not documented until April 19, 2022.
This finding was reviewed with facility staff during the licensing process.
|
Plan of Correction
This finding was shared with the clinical team on 12/6/22. In order to complete comprehensive treatment plans on time, the counselor will pull services due report and complete the comprehensive treatment plan early to ensure all signatures are captured by staff and patient before the due date. Clinical supervisor will monitor services due daily and follow up with clinicians to ensure all work is completed in a timely manner.
Clinic director will oversee to ensure this regulation is upheld and maintained. |
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.
|
Observations
Based on a review of client records, the facility failed to document treatment plan updates within the regulatory timeframe in five out of eight records reviewed.
Client #2 was admitted on January 28, 2020 and was still active at the time of the inspection. A treatment plan update was completed on March 21, 2022, and the next update was due no later than May 21, 2022; however, the next update was not documented until May 25, 2022. The next update was due no later than, July 25, 2022; however, was not documented until July 26, 2022.
Client #3 was admitted on March 17, 2022 and was still active at the time of the inspection. A treatment plan update was completed on May 13, 2022, and the next update was due no later than July 13, 2022; however, it was not documented until July 19, 2022.
Client #5 was admitted on January 26, 2016 and was still active at the time of the inspection. A treatment plan update was completed on May 25, 2022, and the next update was due no later than September 25, 2022; however, it was not documented until September 29, 2022.
Client #6 was admitted on July 19, 2019 and was still active at the time of the inspection. A treatment plan update was completed on March 4, 2022, and the next update was due no later than May 4, 2022; however, it was not documented until July 13, 2022.
Client #9 was admitted on August 1, 2019 and discharged on May 18, 2022. A treatment plan update was completed on March 14, 2022, and the next update was due no later than May 14, 2022. The client record did not have documentation that one was completed.
These findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
This finding was shared with the clinical team on 12/6/22. In order to complete treatment plan updates on time, the counselor will pull services due report and complete a treatment plan update early in order to capture signatures from staff and patients before the due date. Clinical supervisor will monitor services due daily and follow up with clinicians to ensure all work is completed in a timely manner.
Clinic director will oversee to ensure this regulation is upheld and maintained. |