INITIAL COMMENTS
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Based on the concerns arising from COVID-19, The Department of Drug and Alcohol Programs, Bureau of Quality Assurance for Prevention and Treatment, has implemented temporary procedures for conducting an annual renewal inspection.
The inspection will be divided into two parts.
1, an abbreviated off-site inspection, will be conducted off site, and will require the submission of administrative information via email to a Licensing Specialist.
2, an abbreviated on-site inspection, will be conducted on-site at a later date and will include a review of client/patient records, and a physical plant inspection.
This report is a result of Part 2, an abbreviated on-site inspection, conducted on September 24, 2020 by staff from the Department of Drug and Alcohol Programs, Bureau of Quality Assurance for Prevention and Treatment. Not all regulations were reviewed, the remainder of the regulations were reviewed during Part 1.
Based on the findings of Part 2, an abbreviated on-site inspection, PA Treatment and Healing 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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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 client records on September 24, 2020, the facility failed to provide patient #'s 1 and 2 with 2.5 hours of psychotherapy per month during the patient's first two years of treatment.
Patient #1 was admitted on March 9, 2020 and was still active at the time of the inspection. In June and July 2020, the client had 1.5 hours of individual each of the months. In August 2020, the client received one hour of individual therapy and did not show for one appointment.
Patient #2 was admitted on February 6, 2020 and was still active at the time of the inspection. In June 2020, the client had 1.5 hours of individual therapy. In July 2020, the client had 1.5 hours of individual therapy. In August 2020, the client had 2.25 hours of individual therapy. There was no documentation of client no shows or cancellations during those time periods.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
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.
The facility failed to provide patient #'s 1 and 2 with 2.5 hours of psychotherapy per month during the patient's first two years of treatment.
The program director will retrain all counselors regarding the required provision of service for all clients admitted into the MAT program and will monitor compliance through supervision and quality review of client files.
The agency will be in compliance with this standard as of 10/23/2020 |
709.91(b)(6) LICENSURE Intake and admission
709.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(6) Psychosocial evaluation.
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Observations
Based on a review of client records on September 24, 2020, the facility failed to document a completed psychosocial evaluation with the 15-day time frame from date of admission as outlined in the facility's policy and procedure manual in client #'s 1 and 6.
Client #1 was admitted on March 9, 2020 and was still active at the time of the inspection. The biopsychosocial was completed on August 13, 2020.
Client #6 was admitted on January 7, 2020. The biopsychosocial was completed on January 27, 2020.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Based on a review of client records on September 24, 2020, the facility failed to document a completed psychosocial evaluation with the 15-day time frame from date of admission as outlined in the facility's policy and procedure manual in client #'s 1 and 6.
The program director will review the policy and procedure manual timeline for completion of the psychosocial evaluation with all counselors during supervision.
The program director and Lead Counselor will ensure compliance with this regulation through ongoing supervision and quality review of client files.
The agency will be in compliance with this standard as of 10/23/2020 |
709.92(a)(2) 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:
(2) Type and frequency of treatment and rehabilitation services.
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Observations
Based on a review of client records on September 24, 2020, the facility failed to document a definitive frequency of therapy in the individual treatment plan. Client #'s 1, 3, 5, 6 and 7 stated the range of individual therapy as "1-2X weekly".
Client #1 was admitted on March 9, 2020 and was still active at the time of service. The comprehensive treatment plan was dated August 13, 2020.
Client #3 was admitted on April 7, 2020 and discharged on July 27, 2020. The comprehensive treatment plan was dated April 21, 2020.
Client #5 was admitted on February 14, 2020 and discharged on May 7, 2020. The comprehensive treatment plan was dated February 24, 2020.
Client #6 was admitted on January 7, 2020 and discharged on March 11, 2020. The comprehensive treatment plan was dated January 27, 2020.
Client #7 was admitted on March 18, 2020 and discharged on August 28, 2020. The comprehensive treatment plan was dated April 3, 2020.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The facility failed to document a definitive frequency of therapy in the individual treatment plan. Client #'s 1, 3, 5, 6 and 7 stated the range of individual therapy as "1-2X weekly".
The program director will update the treatment plans to remove the range of frequency and provide the counselor the ability to indicate an exact frequency of provision of services for each client.
The Program Director and Lead Counselor will ensure compliance with this regulation through ongoing supervision and quality review of client files.
The agency will be in compliance with this standard as of 10/23/2020 |
709.92(c) LICENSURE Treatment and rehabilitation services
709.92. 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 on September 24, 2020, there was no documentation that the clients received counseling services according to their individual comprehensive treatment plan in client #'s 1, 2, 4 and 6.
Client #1 was admitted on March 9, 2020 and was still active at the time of the inspection. The comprehensive treatment plan dated August 13, 2020 indicated individual sessions 1 - 2X weekly. The record of service and progress notes indicated that the client did not receive any individual sessions between August 14, and September 2, 2020.
Client #2 was admitted on February 6, 2020 and was still active at the time of the inspection. The comprehensive treatment plan dated February 20, 2020 indicated individual sessions two times per month. During July 2020, the record of service and progress notes indicated that the client was seen one time for individual therapy on July 23, 2020.
Client #4 was admitted on October 15, 2019 and discharged on March 24, 2020. The comprehensive treatment plan dated November 5, 2019 indicated one individual and one group session per week. The record of service and progress notes indicated that the client did not receive individual sessions between January 25 - February 13, and February 15 - March 12, 2020.
Client #6 was admitted on January 7, 2020 and discharged on March 11, 2020. The comprehensive treatment plan dated January 27, 2020 indicated 1-2x weekly for individual sessions. The record of service and progress notes indicated that the client did not receive individual sessions between January 14 - January 26, January 28 - February 9, and February 11 - 23, 2020.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The project shall assure that counseling services are provided according to the individual treatment and rehabilitation plan. The agency failed to provide documentation that the clients received counseling services according to their individual comprehensive treatment plan in client #'s 1, 2, 4 and 6.
The Program Director and Lead Counselor will review the policies and procedures for required chart documentation with all counselors during supervision and will monitor compliance with this regulation through continued supervision and quality review of client files.
The agency will be in compliance with this standard as of 10/23/2020 |
709.93(a)(5) 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:
(5) Progress notes.
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Observations
Based on a review of client records on September 24, 2020, the facility failed to document a progress note for completed therapy sessions in client #'s 1, 2 and 4.
Client #1 was admitted on March 9, 2020 and was still active at the time of the inspection. The client's record was missing progress notes for individual sessions on June 4, June 18 and July 2, 2020.
Client #2 was admitted on February 6, 2020 and was still active at the time of the inspection. The client's record was missing a progress note for an individual session on July 23, 2020.
Client #4 was admitted on October 15, 2019 and discharged on March 24, 2020. The client's record was missing a progress note for a group session on February 14, 2020.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
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: (5) Progress notes.
The facility failed to document a progress note for completed therapy sessions in client #'s 1, 2 and 4.
The Counselor that was responsible for that documentation had resigned from service at this agency. The Program Director and Lead Counselor will review with all counselors during supervision the policies and procedures regarding required documentation for all clients participation in treatment. The Program Director and Lead Counselor will monitor compliance with these standards through continued supervision and quality review of client files.
The agency will be in compliance with this standard as of 10/23/2020 |