INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection and methadone monitoring conducted on October 24, 2023 through October 25, 2023 by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, John F. Kennedy Behavioral Health Center 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 patient records, the narcotic treatment program failed to provide each patient an average of 2.5 hours of psychotherapy per month during the patient's first 2 years in one of five applicable patient records reviewed.
Patient # 2 was admitted on February 1, 2023 and was active at the time of inspection. The record of service and progress notes documented that there was 1 hour of psychotherapy provided to the patient during the month of April 2023.
This is a repeat citation from the November 2, 2021 and October 27, 2022 through October 28, 2022 annual licensing renewal inspections.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
715.19 (1)
Effective 01/02/24, every client will receive an average of 2.5 hours of psychotherapy per month during their first 2 years, 1 hour of which will be individual psychotherapy. Additional hours of individual and/or group psychotherapy will be provided based on the client's ongoing treatment needs.
We will add a new column to our Quality Assurance Tracker to capture the number of psychotherapy hours provided to new clients each month. The QA Tracker will enable Counselors to continuously monitor psychotherapy hours for new clients.
In addition, the Clinical Supervisor will maintain a list of all clients in treatment for less than 2 years and review their records monthly for compliance. Persons who have completed their counseling requirement by the 20th day of each month will be reminded and or assisted to meet this responsibility.
Finally, documentation will be noted in the records for clients who are inaccessible and cannot meet their counseling responsibility due to brief absences caused by an at-home illness; absence due to covid-19; brief absence due to d/a relapse; etc. Outreach efforts to re-engage clients in the treatment process will be documented in client records.
709.17. (a) (3)
We do realize this deficiency was noted in the past. However, we believe the current plan of action will enable us to be successfully meet this licensing requirement.
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709.17(a)(3) LICENSURE Subchapter B.Licensing Procedures.Refusal/rev
709.17. Refusal or revocation of license.
(a) The Department may revoke or refuse to issue a license for any of the following reasons:
(3) Failure to comply with a plan of correction approved by the Department, unless the Department approves an extension or modification of the plan of correction.
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Observations
Based on a review of administrative documents, the facility failed to comply with plans of correction that were approved by the Department.
A plan of correction for ensuring the narcotic treatment program provided each patient an average of 2.5 hours of psychotherapy per month during the patient's first 2 years were submitted and approved by the Department for the October 27, 2022 through October 28, 2022 and November 2, 2021 annual licensing inspections. Failing to ensure the narcotic treatment program provided each patient an average of 2.5 hours of psychotherapy per month during the patient's first 2 years was again found to be a deficiency in the October 24, 202 through October 25, 2023 licensing inspection.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
we are implementing an electronic monitoring/tracking system that involves staff. the clinical supervisor and the Quality assurance officer, which will alert to all involved the required number of psychotherapy visits per month per client. The clinical supervisor will be responsible for implementation and will report to the facility director any deviations from the tracker. |