INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on October 16-18, 2018, by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, ARS Of Lancaster, LP 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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715.6(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
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Observations
The facility submitted a methadone questionnaire as part of the presubmission process. The methadone questionnaire documented that at the time it was completed, the facility had 655 patients receiving narcotic treatment with methadone. The methadone questionnaire also documented that there was an average of only 52 narcotic treatment physician hours provided weekly at the facility, but at least 65 hours were required. These numbers were confirmed by staff interviews conducted at the time of the on-site inspection. These findings were reviewed with facility staff as part of the inspection process.
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Plan of Correction
The Medical Director was trained that he needs to provide 1/3 of the medical hours based on the census regardless of his personal commitments. The facility currently has substitute physician that can provide coverage when the Medical Director has a conflict. Additionally, the facility has hired a full time Physician Extender as of November 2018. The Executive Director and Director of Nursing will continue to monitor medical hours on a weekly basis to ensure that correct ratios are maintained for medical hours. |
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
The facility failed to document treatment plan updates at least once every 60 days in 2 of 6 applicable records reviewed during the on-site inspection. Patient #1 was admitted for treatment on June 22, 2017. There was treatment plan update documented for the patient on May 9, 2018, but the next update was not completed until August 6, 2018. Patient #2 was admitted for treatment on April 26, 2017. There was a treatment plan update documented for the patient on May 3, 2018, but the next update was not completed until September 13, 2018. These findings were reviewed with facility staff as part of the inspection process.
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Plan of Correction
The facility received clarification from DDAP on the expectations regarding completion of treatment plans every 60 days. For those non-exempt patients reviewed, that were not grandfather under the 120 days exception ARS currently holds, the facility experienced some confusion with interpreting the completion deadline, due to the date fields included on the treatment plans. The date fields included on the treatment plan include "print date", "create date", and "signature date". ARS Project Director and Facility Director will revise our process to clarify the interpretation of these dates and timing for counselor and patient sign off as well as physician and clinical supervisor review and sign off. Create date will be interpreted to be the date that the counselor started the treatment plan. Treatment plan updates shall be reviewed at least every 60 days from the date the comprehensive treatment plan was executed. The clinical supervisor will ensure continued compliance and compliance with these expectations. |