INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on October 29, 2020 by staff from the Department of Drug and Alcohol Programs, Bureau of Quality Assurance for Prevention and Treatment. Based on the findings of the on-site inspection, Center for Behavioral Health - HA, Inc. 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
Based on the review of the physician timesheets for the months of July, August, September, and October 2020, the facility failed to provide at least one hour of physician time a week, on site for every ten patients during the month of July 2020, September 2020 and October 2020.
During the week of July 5-11, 2020, the patient census was 423. The facility was required to provide at least 14.1 physician hours. There were 14 physician hours documented.
During the week of September 20-26, 2020, the patient census was 434. The facility was required to provide at least 14.4 physician hours. There were 14 physician hours documented.
During the week of October 4 - 10, 2020, the patient census was 433. The facility was required to provide at least 14.4 physician hours. There were 14 physician hours documented.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Clinic Director will ensure that all weekly required medical hours are calculated using the formula that the Licensing Specialist reviewed with Clinic Director on site during the inspection. Clinic Director will calculate these weekly based on the current census and will communicate hours that need to be worked to the Medical Director, Physician, and Physician's Assistant. |
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 a review of client records on October 29, 2020, the facility failed to document an annual clinical evaluation with the medical director's dated signature in client #7.
Client #7 was admitted on June 7, 2018 and was discharged on September 30, 2019. The most recent annual evaluation was completed on May 31, 2019 and did not include the medical director's dated signature.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Clinic Director will review this deficiency with all clinical staff during the Weekly Staff Meeting on 11/19/20. Clinical staff will be reminded that the Annual Clinical Evaluation service needs to include completion of the Annual Clinical Evaluation form in the Clinical Forms section of the patient's EHR. This is the form that captures the Medical Director's signature. Clinical Supervisor and/or Clinic Director will review monthly for compliance. |