INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on June 27, 2023 by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, PHMC Health Management Corporation d/b/a PHMC Pathways to Recovery 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)(5) LICENSURE Partial Hosp Ratio
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.
(5) Partial hospitalization. Partial hospitalization programs shall have a minimum of one FTE counselor who provides direct counseling services to every ten clients.
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Observations
Based on a review of the Staffing Requirements Facility Summary Report, the facility failed to ensure that partial hospitalization programs have a minimum of one Full Time Equivalent (FTE) counselor who provides direct counseling services to every ten clients. The FTE is determined by dividing the total number of hours counselors devoted to their clients (112.50) by the project workweek (37.50) = 3. Then, to obtain the overall ratio, the total number of clients on the partial hospitalization caseload (50) is divided by the FTE (3) = 16.66 or 16:1. These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
All counseling staff will be trained by the Program Director and Clinical Director on the requirements of the 704.12(a)(5) Partial Hosp Ratio by 8/30/2023. Staff participation in this training will be kept on-site in staff training files.
Pathways to Recovery will use contracted temporary hire agencies to employ counselors to meet the 1:10 counselor to client ratio. Pathways to Recovery, with assistance from Public Health Management Corporation (PHMC) Human Resources (HR) Department and PHMC Behavioral Health Administration (BHA) department will place public ads and hire counselors. The Program Director and Clinical Director will ensure that there are adequate counselors on staff to meet the required ratio. On a daily basis, The Program Director and/or Clinical Director will review the staff daily schedules every morning and for the upcoming 2 weeks, to ensure that there are adequate counselor staff to meet the required 1:10 counselor to client ratio.
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709.30 (2) LICENSURE Client rights
§ 709.30. Client rights.
The project shall develop written policies and procedures on client rights and document written acknowledgement by clients that they have been notified of those rights.
(2) The project may not discriminate in the provision of services on the basis of age, race, creed, sex, ethnicity, color, national origin, marital status, sexual orientation, handicap or religion.
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Observations
Based on a review of client records, the facility failed to document the written acknowledgement by clients that they have been notified that the project may not discriminate in the provision of services basis of age, race, creed, sex, ethnicity, color, national origin, marital status, sexual orientation, handicap or religion.In every client record reviewed, the non-discrimination rights acknowledgement form was missing creed and ethnicity.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
All staff will be trained by the Program Director and Clinical Director on the requirements of the § 709.30. Client rights by 8/30/2023. Staff participation in this training will be kept on-site in staff training files.
The Client Rights Notification will be revised to state that the project does not discriminate in the provision of services on the basis of age, race, creed, sex, ethnicity, color, national origin, marital status, sexual orientation, handicap or religion.
All previous versions of the Client Rights Notification on site at Pathways to Recovery facility will be disallowed to be used and will be destroyed.
All active clients will receive a copy of the revised Client Rights Notification, and a copy of the Notification will be placed in their record .
Per Pathways to Recovery policy, every new client at intake will receive a copy of the (revised) Client Rights Notification.
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709.82(a) LICENSURE Treatment and rehabilitation services
709.82. 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 document that the individual treatment and rehabilitation plan was developed with the client and/or completed according the facility policy and procedure in five of seven client records reviewed.The facility's policy and procedure manual stated that the individual treatment and rehabilitation plan will be completed within 3 days of admission.Client #1 was admitted on March 31, 2023 and was active at the time of inspection. The individual treatment and rehabilitation plan was due no later than April 3, 2023; however, the plan was completed on April 14, 2023.Client #2 was admitted on April 13, 2023 and was active at the time of inspection. The individual treatment and rehabilitation plan was due no later than April 16, 2023; however, the plan was completed on April 28, 2023. Client #4 was admitted on September 8, 2022 and was discharged on January 3, 2023. The individual treatment and rehabilitation plan was due no later than September 11, 2023; however, the plan was completed on October 11, 2022.Client #5 was admitted on November 7, 2022 and was discharged on February 6, 2023. The individual treatment and rehabilitation plan was due no later than November 10, 2022; however, the plan was completed on November 21, 2022. Client #6 was admitted on December 20, 2022 and was discharged on February 21, 2023. There was no individual treatment and rehabilitation plan, in the record, at the time of inspection. These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
ll staff will be trained by the Program Director and Clinical Director on the requirements of 709.82(a) Treatment and rehabilitation services by 8/30/2023. Staff participation in this training will be kept on-site in staff training files.
The Clinical Director and/or Program Director will review treatment plan completion and due-date status every morning on the Pathways to Recovery Treatment Plan tracker, which is kept in the Clinical Director's office, and will consult staff on a daily basis about treatment plan completions.
The Clinical Director and/or Program Director will review treatment plan completion and due-date status at every (e.g. weekly) Clinical Team Meeting using the Pathways to Recovery Treatment Plan tracker, and will consult staff about treatment plan completions during that meeting.
The Supervisors (e.g. Clinical Director and/or Program Director) will review treatment plan completion and due-date status at every (e.g. weekly) Counselor and Intake Coordinator Individual staff meeting, using the Pathways to Recovery Treatment Plan tracker, and will consult staff about their treatment plan completions during that meeting. Staff issues with compliance with meeting due dates for Treatment Plans will be documented on Individual Staff Supervision Notes and non-compliance will be handled and documented according to staff HR disciplinary policies and procedure.
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709.82(b) LICENSURE Treatment and rehabilitation services
709.82. Treatment and rehabilitation services.
(b) Treatment and rehabilitation plans shall be reviewed and updated at least every 30 days.
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Observations
Based on a review of client records, the facility failed to ensure partial hospitalization treatment and rehabilitation plans were reviewed and updated at least every thirty days in two of six applicable client records reviewed.Client #4 was admitted on September 8, 2022 and discharged on January 3, 2023. A treatment plan update was completed on October 17, 2022 and the next update was due no later than November 17, 2022; however, the update was completed on December 9, 2022. Client #5 was admitted on November 7, 2022 and was discharged on February 6, 2023. A treatment plan update was completed on December 20, 2022 and the next update was due no later than January 20, 2023; however, the update was not completed prior to discharge.This is a repeat citation from the July 14, 2022 annual licensing renewal inspection.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
All staff will be trained by the Program Director and Clinical Director on the requirements of 709.82(b) Treatment and rehabilitation services by 8/30/2023. Staff participation in this training will be kept on-site in staff training files.
The Clinical Director and/or Program Director will review treatment plan completion and due-date status every morning on the Pathways to Recovery Treatment Plan tracker, which is kept in the Clinical Director's office, and will consult staff on a daily basis about treatment plan completions.
The Clinical Director and/or Program Director will review treatment plan completion and due-date status at every (e.g. weekly) Clinical Team Meeting using the Pathways to Recovery Treatment Plan tracker, and will consult staff about treatment plan completions during that meeting.
The Supervisors (e.g. Clinical Director and/or Program Director) will review treatment plan completion and due-date status at every (e.g. weekly) Counselor and Intake Coordinator Individual staff meeting, using the Pathways to Recovery Treatment Plan tracker, and will consult staff about their treatment plan completions during that meeting. Staff issues with compliance with meeting due dates for Treatment Plans will be documented on Individual Staff Supervision Notes and non-compliance will be handled and documented according to staff HR disciplinary policies and procedure.
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709.82(c) LICENSURE Treatment and rehabilitation services
709.82. Treatment and rehabilitation services.
(c) The project shall assure that counseling services are provided according to the individual treatment and rehabilitation plan.
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Observations
Based on a review of client records, the facility failed to ensure that counseling services were being provided according to the individual treatment and rehabilitation plan in four of six applicable client records reviewed. Client #1 was admitted on March 31, 2023 and was active at the time of inspection. The individual treatment and rehabilitation plan dated April 14, 2023, and treatment plan updates dated May 15, 2023 and June 12, 2023, all specified 1-2 individual counseling services per week. There was no documentation, in the record, of individual counseling services occurring during the weeks of April 2, 2023 through April 15, 2023, April 23, 2023 through June 3, 2023, and June 11, 2023 through June 17, 2023. Client #2 was admitted on April 13, 2023 and was active at the time of inspection. The individual treatment and rehabilitation plan dated April 28, 2023, and treatment plan updates dated May 26, 2023, June 23, 2023, and June 26, 2023, all specified 2 individual counseling services per week. There was no documentation, in the record, of individual counseling services occurring throughout the treatment episode. Client #3 was admitted on April 28, 2023 and was active at the time of inspection. The individual treatment and rehabilitation plan dated April 28, 2023, and treatment plan updates dated May 13, 2023 and June 12, 2023, all specified 2 individual counseling services per week. There was no documentation, in the record, of individual counseling services occurring throughout the treatment episode. Client #7 was admitted on February 20, 2023 and was discharged on May 19, 2023. The individual treatment and rehabilitation plan dated February 20, 2023 and treatment plan updates dated March 7, 2023, April 3, 2023, and May 4, 2023, all specified 1-2 individual counseling services per week. There was no documentation, in the record, of individual counseling services during the weeks of March 5, 2023 through April 1, 2023, April 9, 2023 through April 29, 2023 and May 7, 2023 through May 13, 2023. These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
All staff will be trained by the Program Director and Clinical Director on the requirements of 709.82(c) Treatment and rehabilitation services by 8/30/2023. Staff participation in this training will be kept on-site in staff training files.
The Clinical Director and Program Director will develop a daily program schedule for clinical activities, to include all required treatment and rehabilitation counseling services, as per client individual treatment and rehabilitation plan.
The Clinical Director and Program Director will ensure that the daily program schedule adequately addresses Treatment and rehabilitation counseling services to meet the needs of clients according to their treatment and rehabilitation plans.
On a daily basis, The Program Director and/or Clinical Director will review the staff daily schedules and daily program schedules every morning and for the upcoming 2 weeks, to ensure that there are adequate counselor services being planned.
The Clinical Director and/or Program Director will review counseling service provision at every (e.g. weekly) Clinical Team Meeting using reports from the Pathways to Recovery Client Registry Service (CRS), and will consult staff about counseling service provision per Client Treatment Plans during that meeting.
The Supervisors (e.g. Clinical Director and/or Program Director) will review counseling service completions at every (e.g. weekly) Counselor Individual staff meeting, using reports from the Pathways to Recovery Client Registry Service (CRS), and will consult staff about their counseling service and service notes completions during that meeting. Staff issues with compliance with conducting counseling services per client Treatment and rehabilitation Plans will be documented on Individual Staff Supervision Notes and non-compliance will be handled and documented according to staff HR disciplinary policies and procedure.
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709.82(d)(1) LICENSURE Treatment and rehabilitation services
709.82. Treatment and rehabilitation services.
(d) Counseling shall be provided to a client on a regular and scheduled basis. The following services shall be included and documented:
(1) Individual counseling, at least twice weekly.
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Observations
Based on a review of client records, the facility failed to ensure that clients admitted to the partial hospitalization program received individual counseling services at least twice a week in five of seven client records reviewed.Client #1 was admitted on March 31, 2023 and was active at the time of inspection. The record's progress notes indicated that the client received one individual session on April 21, 2023, for the week of April 16, 2023 through April 22, 2023, and one individual session on June 8, 2023, for the week of June 4, 2023 through June 10, 2023.Client #2 was admitted on April 13, 2023 and was active at the time of inspection. There was no documentation, in the record, of individual counseling sessions occurring throughout the treatment episode. Client #3 was admitted on April 28, 2023 and was active at the time of inspection. There was no documentation, in the record, of individual counseling sessions occurring throughout the treatment episode. Client #6 was admitted on December 20, 2022 and was discharged on February 21, 2023. There was no documentation, in the record, of individual counseling sessions occurring throughout the treatment episode. Client #7 was admitted on February 20, 2023 and was discharged on May 19, 2023. The record's progress notes indicated that the client received only four individual sessions throughout treatment on February 22, 2023, March 3, 2023, April 3, 2023, and May 1, 2023. This is a repeat citation from the July 14, 2022 annual licensing renewal inspection.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
All staff will be trained by the Program Director and Clinical Director on the requirements of 709.82(d)(1) Treatment and rehabilitation services by 8/30/2023. Staff participation in this training will be kept on-site in staff training files.
The Clinical Director and Program Director will develop a daily program schedule for clinical activities, to include all required treatment and rehabilitation counseling services, including individual counseling sessions, to occur at least twice weekly for every client. The Clinical Director and Program Director will ensure that the daily program schedule adequately addresses Treatment and rehabilitation counseling services to meet the needs of clients according to the twice-weekly individual counseling service requirement.
On a daily basis, The Program Director and/or Clinical Director will review the staff daily schedules and daily program schedules every morning and for the each upcoming 2 weeks, to ensure that there are adequate individual counsling services being planned.
The Clinical Director and/or Program Director will review counseling service provision at every (e.g. weekly) Clinical Team Meeting using reports from the Pathways to Recovery Client Registry Service (CRS), and will consult staff about individual counseling service provision according to the twice-weekly individual counseling service requirement.
The Supervisors (e.g. Clinical Director and/or Program Director) will review counseling service completions at every (e.g. weekly) Counselor Individual staff meeting, using reports from the Pathways to Recovery Client Registry Service (CRS), and will consult staff about their individual counseling services and service notes completions during that meeting. Staff issues with compliance with conducting counseling services per client Treatment Plans will be documented on Individual Staff Supervision Notes and non-compliance will be handled and documented according to staff HR disciplinary policies and procedure.
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709.83(a)(11) LICENSURE Client records
709.83. 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:
(11) Follow-up information.
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Observations
Based on a review of client records, the facility failed to maintain a complete client record, which is to include follow-up information, in three of four applicable client records reviewed.Client #4 was admitted on September 8, 2022 and was discharged on January 3, 2023. There was no documentation of follow-up information, in the record, at the time of inspection.Client #5 was admitted on November 7, 2022 and was discharged on February 6, 2023. There was no documentation of follow-up information, in the record, at the time of inspection.Client #6 was admitted on February 20, 2023 and was discharged on May 19, 2023. There was no documentation of follow-up information, in the record, at the time of inspection.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
All follow-up staff and counselor staff will be trained by the Program Director and Clinical Director on the requirements of 709.83(a)(11) Client Records by 8/30/2023. Staff participation in this training will be kept on-site in staff training files.
The Clinical Director and/or Program Director will review Client Discharges at every (e.g. weekly) Clinical Team Meeting using reports from the Pathways to Recovery Client Registry Service (CRS), and will consult case management and follow-up staff about individual following-up with those discharges.
Staff issues with compliance with conducting follow-up services per the requirement and per agency policy, will be documented on Individual Staff Supervision Notes and non-compliance will be handled and documented according to staff HR disciplinary policies and procedure.
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