INITIAL COMMENTS
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This report is a result of an on-site methadone monitoring and licensure renewal inspection conducted on August 18, 2021 by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, Progressive Medical Services 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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704.7(b) LICENSURE Counselor Qualifications
704.7. Qualifications for the position of counselor.
(a) Drug and alcohol treatment projects shall be staffed by counselors proportionate to the staff/client and counselor/client ratios listed in 704.12 (relating to full-time equivalent (FTE) maximum client/staff and client/counselor ratios).
(b) Each counselor shall meet at least one of the following groups of qualifications:
(1) Current licensure in this Commonwealth as a physician.
(2) A Master's Degree or above from an accredited college with a major in chemical dependency, psychology, social work, counseling, nursing (with a clinical specialty in the human services) or other related field which includes a practicum in a health or human service agency, preferably in a drug and alcohol setting. If the practicum did not take place in a drug and alcohol setting, the individual's written training plan shall specifically address a plan to achieve counseling competency in chemical dependency issues.
(3) A Bachelor's Degree from an accredited college with a major in chemical dependency, psychology, social work, counseling, nursing (with a clinical specialty in the human services) or other related field and 1 year of clinical experience (a minimum of 1,820 hours) in a health or human service agency, preferably in a drug and alcohol setting. If a person's experience did not take place in a drug and alcohol setting, the individual's written training plan shall specifically address a plan to achieve counseling competency in chemical dependency issues.
(4) An Associate Degree from an accredited college with a major in chemical dependency, psychology, social work, counseling, nursing (with a clinical specialty in the human services) or other related field and 2 years of clinical experience (a minimum of 3,640 hours) in a health or human service agency, preferably in a drug and alcohol setting. If a person's experience was not in a drug and alcohol setting, the individual's written training plan shall specifically address a plan to achieve counseling competency in chemical dependency issues.
(5) Current licensure in this Commonwealth as a registered nurse and a degree from an accredited school of nursing and 1 year of counseling experience (a minimum of 1,820 hours) in a health or human service agency, preferably in a drug and alcohol setting. If a person's experience was not in a drug and alcohol setting, the individual's written training plan shall specifically address a plan to achieve counseling competency in chemical dependency issues.
(6) Full certification as an addictions counselor by a statewide certification body which is a member of a National certification body or certification by another state government's substance abuse counseling certification board.
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Observations
Based on the review of personnel records, the facility failed to ensure that each counselor meet the educational qualifications for the position of counselor in one of three personnel records.
Employee # 5 was hired on February 17, 2020 as a counselor assistant and was promoted to a counselor on February 18, 2021. The employee has a BA in History, which does not meet the educational qualification.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
On August 27, 2021 Project Director met with this staff member and explained reasoning for being considered a counselor assistant instead of a counselor. Staff member signed a new counselor assistant job description, reviewed yearly training hour requirements and created a new individual training plan with one of the goals being for the staff member to meet state counselor requirements/criteria. Staff member progress will be reviewed monthly by clinical supervisor and/or project director. These reviews will be found in the staff member's personnel chart.
This staff member is currently working on a Masters degree in Psychology, projected completion date is December 2022.
When hiring new counseling staff, if education/degree does not match licensing alert dated 2/19/2019-"Staffing qualifications/degree in a related field", a request for consideration will be completed by the clinical supervisor and/or project director and submitted to the department for review. This process will ensure we have hired clinical staff members with approved qualifications/education.
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709.30 (1) 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.
(1) A client receiving care or treatment under section 7 of the act (71 P. S. § 1690.107) shall retain civil rights and liberties except as provided by statute. No client may be deprived of a civil right solely by reason of treatment.
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Observations
Based on the review of client records, the facility failed to document written acknowledgement that the client was notified of the right that a client receiving care or treatment under section 7 of the act (71 P. S. 1690.107) shall retain civil rights and liberties except as provided by statute. No client may be deprived of a civil right solely by reason of treatment in eight of eight records reviewed.
Client # 1 was admitted on April 2, 2021 and was still an active client at the time of the inspection. There was no written documentation that the client was notified of these rights.
Client # 2 was admitted on November 2, 2020 and was still an active client at the time of the inspection. There was no written documentation that the client was notified of these rights.
Client # 3 was admitted on June 21, 2021 and was still an active client at the time of the inspection. There was no written documentation that the client was notified of these rights.
Client # 4 was admitted on December 2, 2020 and was still an active client at the time of the inspection. There was no written documentation that the client was notified of these rights.
Client # 6 was admitted on October 7, 2020 and was discharged on March 21, 2021. There was no written documentation that the client was notified of these rights.
Client # 7 was admitted on June 8, 2020 and was discharged on April 15, 2021. There was no written documentation that the client was notified of these rights.
Client # 8 was admitted on November 16, 2020 and was discharged on July 6, 2021. There was no written documentation that the client was notified of these rights.
Client # 9 was admitted on December 23, 2020 and was discharged on May 11, 2021. There was no written documentation that the client was notified of these rights.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Based upon the surveyor's findings, Project Director reviewed Progressive Medical's current intake documentation, specifically our, "client rights", document. Our client rights documentation was revised to include that the project includes notification of the right that a client receiving care or treatment under section 7 of the act (71 P. S. 1690.107) shall retain civil rights and liberties except as provided by statute. No client may be deprived of a civil right solely by reason of treatment.
All Progressive Medical staff members were informed, (verbally and in writing), of this revision on August 18, 2021 by Project Director
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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 the review of client records, the facility failed to document written acknowledgement of this right that included creed, sex, color, national origin, marital status, and handicap in eight of eight records reviewed.
Client # 1 was admitted on April 2, 2021 and was still an active client at the time of the inspection. There was no written documentation that the client was notified of these rights.
Client # 2 was admitted on November 2, 2020 and was still an active client at the time of the inspection. There was no written documentation that the client was notified of these rights.
Client # 3 was admitted on June 21, 2021 and was still an active client at the time of the inspection. There was no written documentation that the client was notified of these rights.
Client # 4 was admitted on December 2, 2020 and was still an active client at the time of the inspection. There was no written documentation that the client was notified of these rights.
Client # 6 was admitted on October 7, 2020 and was discharged on March 21, 2021. There was no written documentation that the client was notified of these rights.
Client # 7 was admitted on June 8, 2020 and was discharged on April 15, 2021. There was no written documentation that the client was notified of these rights.
Client # 8 was admitted on November 16, 2020 and was discharged on July 6, 2021. There was no written documentation that the client was notified of these rights.
Client # 9 was admitted on December 23, 2020 and was discharged on May 11, 2021. There was no written documentation that the client was notified of these rights.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Based upon the surveyor's findings, Project Director reviewed Progressive Medical's current intake documentation, specifically our, "client rights", document. Our client rights documentation was revised to include that the project will not discriminate in the provisions of services on the basis of creed, sex, color, national origin, marital status, or handicap. (age, race, ethnicity, sexual orientation and religion were addressed in the client rights document).
All staff members were informed of this revision, (verbally and in writing), on August 18, 2021 by Project Director
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709.30 (6) 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.
(6) Clients have the right to submit rebuttal data or memoranda to their own records.
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Observations
Based on the review of client records, the facility failed to document written acknowledgement that the client was notified of the right that a client has the right to submit memoranda to their own record in eight of eight records reviewed.
Client # 1 was admitted on April 2, 2021 and was still an active client at the time of the inspection. There was no written documentation that the client was notified of this right.
Client # 2 was admitted on November 2, 2020 and was still an active client at the time of the inspection. There was no written documentation that the client was notified of this right.
Client # 3 was admitted on June 21, 2021 and was still an active client at the time of the inspection. There was no written documentation that the client was notified of this right.
Client # 4 was admitted on December 2, 2020 and was still an active client at the time of the inspection. There was no written documentation that the client was notified of this right.
Client # 6 was admitted on October 7, 2020 and was discharged on March 21, 2021. There was no written documentation that the client was notified of this right.
Client # 7 was admitted on June 8, 2020 and was discharged on April 15, 2021. There was no written documentation that the client was notified of this right.
Client # 8 was admitted on November 16, 2020 and was discharged on July 6, 2021. There was no written documentation that the client was notified of this right.
Client # 9 was admitted on December 23, 2020 and was discharged on May 11, 2021. There was no written documentation that the client was notified of this right.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Based upon the surveyor's findings, Project Director reviewed Progressive Medical's current intake documentation, specifically our, "client rights", document. Our client rights documentation was revised to include a client's right to submit rebuttal data or memoranda to their own record.
A written revision was made to Progressive Medical's client rights document and all staff members were informed of this revision on August 18, 2021 by Project Director
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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
Based on the review of administrative documents, the facility failed to document that the narcotic treatment physician provided services of at least 1 hour per week onsite for every ten patients.
During the week of April 11, 2021, the census was 207 and required 20.7 hours. There were only 19.5 hours documented.
During the week of April 18, 2021, the census was 206 and required 20.6 hours. There were only 19 hours documented.
During the week of May 9, 2021, the census was 202 and required 20.2 hours. There were only 19 hours documented.
During the week of June 27, 2021, the census was 204 and required 20.4 hours. There were only 19.5 hours documented.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Due to Covid-19 and misunderstanding of the suspension of on site medical hours, Progressive Medical did not completely obtain on site medical hours for four weeks in 2021; that has since been rectified. As of 9/9/2021, Progressive Medical has hired another medical doctor that will provide on site hours at each location. With three medical doctors and one physician assistant, the project and medical directors will ensure that a weekly schedule is created that meets the required medical hours based on our active caseload, (1 hour for every 10 clients). |
715.17(c)(1)(i-vi)) LICENSURE Medication control
(c) A narcotic treatment program shall develop and implement written policies and procedures regarding the medications used by patients which shall include, at a minimum:
(1) Administration of medication.
(i) A narcotic treatment physician shall determine the patient 's initial and subsequent dose and schedule. The physician shall communicate the initial and subsequent dose and schedule to the person responsible for the administration of medication. Each medication order and dosage change shall be written and signed by the narcotic treatment physician.
(ii) An agent shall be administered or dispensed only by a practitioner licensed under the appropriate Federal and State laws to dispense agents to patients.
(iii) Only authorized staff and patients who are receiving medication shall be permitted in the dispensing area.
(iv) There shall be only one patient permitted at a dispensing station at any given time.
(v) Each patient shall be observed when ingesting the agent.
(vi) Administering and dispensing shall be conducted in a manner that protects the patient from disruption or annoyance from other individuals.
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Observations
Based on the review of patient records, the facility to ensure that the narcotic treatment physician determined the patient 's initial dose in four of eight patient records.
Client # 1 was admitted on April 2, 2021 and was still an active patient at the time of the inspection. The initial dose was ordered on April 2, 2021. Documentation of the initial order did not verify that the narcotic treatment physician determined the patient's initial dose.
Client # 3 was admitted on June 15, 2021 and was still an active patient at the time of the inspection. The initial dose was ordered on June 16, 2021. Documentation of the initial order did not verify that the narcotic treatment physician determined the patient's initial dose.
Client # 4 was admitted on December 2, 2020 and was still an active patient at the time of the inspection. The initial dose was ordered on December 2, 2020. Documentation of the initial order did not verify that the narcotic treatment physician determined the patient's initial dose.
Client # 6 was admitted on October 6, 2020 and was discharged on March 5, 2021. The initial dose was ordered on October 6, 2020. Documentation of the initial order did not verify that the narcotic treatment physician determined the patient's initial dose.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Progressive Medical Specialists switched to a computer software program that we were able to customize allowing us to use some of our own documentation. Due to this change from paper chart to computer chart some of the documents we used in our paper charts did not transfer clearly to the software program.
Our MD always determines and completes the initial methadone dose order for a new client but that was not clear on a few charts that were reviewed, as a result we made changes to our software medial intake "packet" that makes it clear without any confusion or question, that our MDs are ordering a methadone dose.
Project director worked with software company and removed the initial dose order document from the medical intake packet and made it a stand alone document. This change will ensure that is it clearly identified that an MD ordered the initial methadone dose.
Project director will monitor this new process for effectiveness by chart review and meeting with medical staff to discuss any concerns or issues. The medical director will ensure that correction plan is followed by reviewing all medical intake documentation during their face to face meeting to ensure all documentation is completed, specifically the dosage order, (if intake physical is completed by our PA).
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