INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on September 16-17, 2024 by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, ARS of Ephrata, LLC 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)(6) LICENSURE OutPatient Caseload
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.
(6) Outpatients. FTE counselor caseload for counseling in outpatient programs may not exceed 35 active clients.
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Observations
Based on the review of the Staffing Requirements Facility Summary Report, the facility failed to keep client/staff ratios at or below the regulation limit of 35/1.
The counselor Full Time Equivalent (FTE) is determined by dividing the total number of hours the counselor devotes to their clients by facility ' s work week. Then, in order to obtain the counselor ' s ratio, the total number of clients on the counselor ' s caseload is divided by the FTE.
Employee #3 was hired as a counselor on March 18, 2024 and was still acting in that position. Employee #3 was reported to have 40 hours per week devoted to their 49 clients on their caseload.
The FTE counselor's caseload calculation is as follows: 40/40 = 1 (FTE); 49/1= 49, which equals to a client/counselor ratio of 49:1.
Employee #4 was hired as a counselor on April 15, 2024 and was still acting in that position. Employee #4 was reported to have 40 hours per week devoted to their 55 clients on their caseload.
The FTE counselor's caseload calculation is as follows: 40/40 = 1 (FTE); 55/1= 55, which equals to a client/counselor ratio of 45:1.
Employee #5 was hired as a counselor on July 22, 2024 and was still acting in that position. Employee #3 was reported to have 40 hours per week devoted to their 45 clients on their caseload.
The FTE counselor's caseload calculation is as follows: 40/40 = 1 (FTE); 45/1= 45, which equals to a client/counselor ratio of 45:1.
These findings were reviewed with facility staff during the licensing process.
This is a repeat citation from the September 12, 2023 licensing inspection.
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Plan of Correction
704.12(a)(6) ? Caseloads:
The Clinical Supervisor (CS) or the Executive Director (ED), in the absence of the CS, will review and monitor counselor caseloads on a weekly basis, starting 10/1/2024, to ensure that they do not exceed the client to counselor ratio of 35:1. The CS/ED will also ensure that the client's status is correctly identified as exempt vs non-exempt to ensure that this is correctly reflected in client to counselor ratio of 35:1. Additionally, new counselors have been identified to begin employment with ARS, one started on 9/23/2024 and an additional to start 10/7/2024.
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705.26 (2) LICENSURE Heating and cooling.
705.26. Heating and cooling.
The nonresidential facility:
(2) May not permit in the facility heaters that are not permanently mounted or installed.
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Observations
Based on a physical plant inspection, the facility failed to not permit in the facility heaters that are not permanently mounted or installed. Portable space heaters were in an office closet.
This finding was reviewed with the facility staff during the licensing process.
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Plan of Correction
705.26 (2) ? Heating and Cooling:
All portable heaters have been removed from the facility on 09/18/2024. All staff have been educated on the dangers of use of portable heaters. All staff have been made aware that moving forward that at no time portable heaters may be used within the facility. The Health & Safety officer for the facility will inspect all areas of the facility during the monthly inspection of the facility to ensure continued compliance and to avoid a repeat occurrence.
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715.14(a) LICENSURE Urine testing
(a) A narcotic treatment program shall complete an initial drug-screening urinalysis for each prospective patient and a random urinalysis at least monthly thereafter.
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Observations
Based on a review of the patient records, the facility failed to ensure that a random urinalysis is completed at least monthly.
Patient #5 was admitted on March 20, 2024 and was still active at the time of the inspection. No urinalysis was completed during the month of June, 2024.
This finding was reviewed with facility staff during the licensing inspection.
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Plan of Correction
715.14(a) ? Urine Testing:
The Executive Director meet with all staff at the all staff meeting held on 10/1/2024 and reviewed the Drug Screening policy and obtaining Monthly Urine Drug Screens (UDS) for existing patients. The dispensing staff will document when the UDS has been collected each month, if the UDS has been refused dispensing staff will document every attempt that is made to collect the UDS throughout the month. All staff were retrained that clients will be asked more than one time to provide a UDS throughout the month, even if a documented refusal is received multiple times in the month, this is to ensure that this deficiency does not reoccur. The Executive Director will do an audit of all patients charts the first week of every month to ensure that all patients provide a UDS and those with multiple refusals throughout the month have all attempts to collected documented as well.
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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 direct observation of medication administration, the facility failed to ensure medication was administered according to their policy by asking the patient to verify their dosing amount.
This finding was reviewed with facility staff during the licensing inspection.
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Plan of Correction
715.17(c)(1)(i-vi) - Medication control:
The Executive Director along with DON reviewed #4.20 Dispensing of Methadone policy with the Dispensing nurse. DON will complete a written supervision to review how to verify a dose with a patient including the using the Five R's, prior to medicating. Patients will be identified using, PT ID number, dose and DOB of the patient to identify themselves by asking the patient to state their patient ID number, their dose, and the day and month of their birth. This should be done in a manner to protect the confidentiality of the patient. The DON will review policy 4.20 with the dispensing nurse on a quarterly basis, as well as, complete observation of dosing of patients to ensure that all 5 R's are in place prior to dispensing medication, to ensure that a repeat occurrence does not occur.
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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 facility failed to provide patients with 2.5 hours of psychotherapy per month during the patient's first two years of treatment, one hour of which shall be individual psychotherapy, in four out of four applicable records reviewed.
Patient #2 was admitted on December 18, 2023 and was still active at the time of the inspection. In August, 2024, the patient received 30 minutes of individual psychotherapy. In July, 2024 the patient received 60 minutes of individual psychotherapy.
Patient #4 was admitted on December 2, 2022 and was still active at the time of the inspection. In July, 2024, the patient received 60 minutes of individual psychotherapy. In August, 2024, the patient received 90 minutes of individual psychotherapy and in September, 2024 the patient received 60 minutes of individual psychotherapy.
Patient #5 was admitted on March 20, 2024 and was still active at the time of the inspection. In May, 2024 the patient did not receive any individual psychotherapy sessions. In June 2024, the patient received 104 minutes of individual psychotherapy.
Patient #8 was admitted on July 21, 2023 and discharged on September 5, 2024. In May and June, 2024, the patient did not receive any individual psychotherapy sessions.
These findings were reviewed with facility staff during the licensing inspection.
This is a repeat citation from the September 12, 2023 licensing inspection.
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Plan of Correction
715.91 (1) - Psychotherapy Services:
The Clinical Supervisor (CS) or the Executive Director (ED), in the absence of the CS, will retrain the clinical staff regarding clients need to have 2.50 hours of counseling in the first 0-2 years of treatment, 1 hour of counseling for patients in 2-4 years of treatment and 1 hour of counseling every other month for patients in treatment more than 4 years. The CS/ED will review each counselor's engagement on a monthly basis and discuss how improvements can be made. The CS/ED will train each counselor on how to monitor their own engagement through the course of the month by viewing their KIPU BI dashboard to see which patients are still in need of being seen. The CS/ED will also review this report and discuss areas of concern/improvement during bi-weekly supervision.
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715.20(4) LICENSURE Patient transfers
A narcotic treatment program shall develop written transfer policies and procedures which shall require that the narcotic treatment program transfer a patient to another narcotic treatment program for continued maintenance, detoxification or another treatment activity within 7 days of the request of the patient.
(4) The receiving narcotic treatment program shall document in writing that it notified the transferring narcotic treatment program of the admission of the patient and the date of the initial dose given to the patient by the receiving narcotic treatment program.
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Observations
Based on a review of patient records, the facility failed to document the notification to the previous narcotic treatment program of the admission and initial dose of the patient in one out of one applicable record.
Patient #7 was admitted on June 3, 2024 and was still active at the time of the inspection.
This finding was reviewed with facility staff during the licensing inspection.
This is a repeat citation from the September 12, 2023 licensing inspection.
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Plan of Correction
715.20(4) ? Patient Transfer:
The Executive Director reviewed with all staff at the all-staff meeting held on 10/1/2024 what documentation is required for a client to transfer into the clinic upon admission, as well as what notification must be made to the prior facility to ensure a safe transfer of the patient to ARS Ephrata. The primary counselor or the DON will ensure all clients admitted as a transfer from another facility complete an ROI from their previous treatment facility. A member of the medical team will also complete the Patient Transfer Acknowledgement Form in KIPU to document the MAT dose upon admission from their prior facility. The Clinical Supervisor will audit all new patient charts on a weekly basis to ensure that all necessary documentation has been received and completed.
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715.23(b)(5) LICENSURE Patient records
(b) Each patient file shall include the following information:
(5) The results of all annual physical examinations given by the narcotic treatment program which includes an annual reevaluation by the narcotic treatment physician.
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Observations
Based on the review of patient records, the facility failed to document an annual reevaluation by the narcotic treatment physician within the regulatory timeframe in one out of three applicable records reviewed.
Patient #1 was admitted on October 22, 2020 and was still active at the time of the inspection. An annual physical was due by January 26, 2024; however, it was not completed until March 7, 2024.
This finding was reviewed with facility staff during the licensing inspection.
This is a repeat citation from the September 12, 2023 licensing inspection.
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Plan of Correction
715.23(b)(5) ? Patient Records:
The Executive Director will run a report monthly on all current patients to determine which patients are in need of annual/bi-annual physical examinations by a medical provider. This document will be shared with the DON and the medical provider. The DON and/or medical provider will then place a flag on the clients chart the month the clients physical exam is due to be completed. The provider will meet with the client prior to the client receiving their medication. The Executive Director will run a report monthly to ensure that all patients obtain an annual/bi-annual physical to ensure compliance and that a repeat citation doesn not occur.
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715.23(c)(1-7) LICENSURE Patient records
(c) An annual evaluation of each patient 's status shall be completed by the patient 's counselor and shall be reviewed, dated and signed by the medical director. The annual evaluation period shall start on the date of the patient 's admission to a narcotic treatment program and shall address the following areas:
(1) Employment, education and training.
(2) Legal standing.
(3) Substance abuse.
(4) Financial management abilities.
(5) Physical and emotional health.
(6) Fulfillment of treatment objectives.
(7) Family and community supports.
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Observations
Based on the review of patient records, the facility failed to document an annual clinical evaluation with all areas of regulation addressed within the regulatory timeframe in two out of three applicable records reviewed.
Patient #1 was admitted on October 22, 2020 and was still active at the time of the inspection. An annual clinical evaluation was due by September 1,2024; however, none was completed.
Patient #4 was admitted on December 2, 2022 and was still active at the time of the inspection. An annual clinical evaluation was completed on September 27, 2023; however, it was not signed by the medical director.
This finding was reviewed with facility staff during the licensing inspection.
This is a repeat citation from the September 12, 2023 licensing inspection.
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Plan of Correction
715.23(c)(1-7) ? Patient Records:
The Clinical Supervisor (CS) or the Executive Director (ED), in the absence of the CS, will conduct an audit of client charts to identify those who are past due for annual clinical evaluations by 10/31/2024. The Primary Counselor will then have a two-week period to then address those patients who have been identified as needing a clinical evaluation. Moving forward the Primary Counselors will be required to review their clients on a monthly basis to ensure that all client charts are clinically reviewed within 30 days of the anniversary of the client's admission to the facility. This will be monitored during the quarterly peer audit review process, as well as bi-weekly supervisions with the CS.
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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 the review of client records, the facility failed to document a complete psychosocial evaluation in three out of four applicable records.
Patient #2 was admitted on December 18, 2023 and was still active at the time of the inspection.
Patient #5 was admitted on March 20, 2024 and was still active at the time of the inspection.
Patient #7 was admitted on June 3, 2024 and was still active at the time of the inspection.
These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
709.91(b)(6) ? Intake and admission:
The Clinical Supervisor (CS) or the Executive Director (ED), in the absence of the CS, on 10/1/2024 has retrained the clinical staff on Non-Mat Outpatient and IOP Patient Bio-Psychosocial Assessment policy 3.11 for clients in the Outpatient or intensive Outpatient Program. The CS/ED will do a complete review of all existing client's charts and place a KIPU flag on those client charts to have Bio-Psychosocial Assessment completed by the 10/31/2024. Moving forward the Primary Counselors will be required to review their clients on a monthly basis to ensure that all client charts have a Bio-Psychosocial Assessment completed upon admission. This will be monitored during the quarterly peer audit review process, as well as bi-weekly supervisions with the CS.
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709.92(a) 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:
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Observations
Based on a review of client records, the facility failed to document a comprehensive treatment plan within guidelines established by the facility's policy and procedures manual in two out of four applicable records reviewed. The facility's policy and procedures manual states the comprehensive treatment plan must be completed within 30 days following admission.
Patient #2 was admitted on December 18, 2023 and was still active at the time of the inspection. A comprehensive treatment plan was due no later than January 18, 2024; however, it was completed on February 23, 2024.
Patient #7 was admitted on June 3, 2024 and was still active at the time of the inspection. A comprehensive treatment plan was due no later than July 3, 2024; however, it was not completed until August 12, 2024.
These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
709.92(a) Treatment and rehabilitation services:
The Clinical Supervisor (CS) or the Executive Director (ED), in the absence of the CS, on 10/1/2024 has retrained the clinical staff on Treatment Plan and Master Problem List Policy #8.10. The CS/ED will do a complete review of all existing client's charts and place a KIPU flag on those client charts to have Bio-Psychosocial Assessment completed by the 10/31/2024. Moving forward the Primary Counselors will be required to review their clients on a monthly basis to ensure that all client charts have a Treatment Plan completed every 60 days. This will be monitored during the quarterly peer audit review process, as well as weekly by the CS during the quality assurance review process.
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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
Based on a review of outpatient client records, the facility failed to document treatment plan updates within the regulatory timeframe in five out of six records reviewed.
Patient #1 was admitted on October 22, 2020 and was still active at the time of the inspection. A treatment plan update was completed on October 16, 2023 and an update was due no later than December 16, 2023; however, none was completed.
Patient #2 was admitted on December 18, 2023 and was still active at the time of the inspection. A treatment plan update was completed on May 30, 2024 and an update was due no later than July 30, 2024; however, it was not completed until August 15, 2024.
Patient #4 was admitted on December 2, 2022 and was still active at the time of the inspection. A treatment plan update was completed on April 2, 2024 and the next update was due no later than June 2, 2024; however, it was not completed until August 15, 2024.
Patient #5 was admitted on March 20, 2024 and was still active at the time of the inspection. A treatment plan update was completed on April 11, 2024 and an update was due no later than June 11, 2024; however, it was not completed until July 8, 2024.
Patient #8 was admitted on July 21, 2023 and was discharged September 5, 2024. A treatment plan update was completed on April 11, 2024 and an update was due no later than June 11, 2024; however, none was completed.
These findings were reviewed with facility staff during the licensing inspection.
This is a repeat citation from the September 12, 2023 licensing inspection.
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Plan of Correction
709.92(b) Treatment and rehabilitation services:
The Clinical Supervisor (CS) or the Executive Director (ED), in the absence of the CS, on 10/1/2024 has retrained the clinical staff on Treatment Plan and Master Problem List Policy #8.10. The CS/ED will do a complete review of all existing client's charts and place a KIPU flag on those client charts to have Bio-Psychosocial Assessment completed by the 10/31/2024. Moving forward the Primary Counselors will be required to review their clients on a monthly basis to ensure that all client charts have a Treatment Plan completed every 60 days. This will be monitored during the quarterly peer audit review process, as well as weekly by the CS during the quality assurance review process.
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709.93(a)(11) 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:
(11) Follow-up information.
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Observations
Based on a review of client records, the facility failed to document follow up information within guidelines established by the facility's policy and procedures manual in one out of one applicable records reviewed. The facility's policy and procedures manual states the that follow up must be completed 7 days following discharge.
Patient #3 was admitted on October 30, 2020 and was discharged on January 12, 2024. A follow up was due no later than January 19, 2024; however, it none was completed.
This finding was reviewed with facility staff during the licensing process.
This is a repeat citation from the September 12, 2023 licensing inspection.
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Plan of Correction
709.93(a)(11) Client Records:
The Executive Director reviewed with all staff at the all-staff meeting held on 10/1/2024 what documentation is required for a client to transfer out of ARS Clinic to another MAT clinic, as well as what notification must be made to the future facility to ensure a safe transfer of the patient from ARS Ephrata. The primary counselor or the DON will ensure all client's requested records are forwarded to the future facility as well as complete an ROI to their future treatment facility. A member of the medical team will also complete the Patient Transfer Acknowledgement Form in KIPU to document the MAT dose upon admission from their future facility. All discharged patients will be tracked on the discharged analysis tracker, that is completed by the Executive Director, who will follow up with the patients who have been discharged within 7 days of their discharge from ARS Ephrata. All documented attempts to reach patient after discharge will be documented in a case management note in KIPU, to avoid any further discrepancies in this area.
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