INITIAL COMMENTS
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This report is a result of an on-site licensure renewal and methadone monitoring inspection conducted on August 2, 2023 - August 3, 2023, by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, Dolminis 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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715.14(a)(1) 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.
(1) Each test shall be for opiates, methadone, amphetamines, barbiturates, cocaine and benzodiazepines.
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Observations
Based on one of eight patient records reviewed, the facility failed to provide documentation of a complete random drug-screening urinalysis for each patient at least monthly in patient record # 1.Patient # 1 was admitted on September 13, 2022 and was still active at the time of the inspection. There was no documentation of a random drug-screening urinalysis for the month June 2023.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Beginning 8/28/23, nursing staff will pull the Methasoft report, Scheduled Events, that list all patients with outstanding UDS for the month. This report will be pulled prior to the end of the month to ensure that a UDS is requested for all clients listed.
Nursing staff will document in a memo to chart anytime a UDS is missed and identify the reason why i.e., hospital stay etc.
Executive Director will pull the Scheduled Events report on the last day of the month to ensure there are no outstanding UDS for that month.
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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 five of seven applicable patient records reviewed, the narcotic treatment program failed to provide 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 in patient records # 4, # 7, and # 8.Patient # 4 was admitted on December 27, 2022 and was still active at the time of the inspection. There was not at least 2.5 hours of psychotherapy documented. The month April 2023 had only 75 minutes, May 2023 only had 40 minutes, June 2023 only had 40 minutes, and July 2023 only had 60 minutes of therapy documented.Patient # 7 was admitted on September 27, 2022 and was discharged June 9, 2023. There was not at least 2.5 hours of psychotherapy documented. The month of February 2023 only had 90 minutes, March 2023 only had 60 minutes, April 2023 had 30 minutes, and May 2023 had 0 hours of therapy documented.Patient # 8 was admitted on March 28, 2022 and was discharged November 21 2022. There was not at least 2.5 hours of psychotherapy documented. The month of September 2022 had only 30 minutes and October 2022 had only 60 minutes of therapy documented.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
During treatment team meeting on 8/24/23
clinical supervisor reviewed regulations regarding individualized psychotherapy service hours with clinical team and reinforced expectation that clients must receive at least 2.5 hours of psychotherapy per month which includes 1 hour of individual therapy during the first 2 years of treatment. The importance of completing a call log and/or memo when a client does not show for or cancels a scheduled appointment was also reviewed. Counselors were instructed to document all missed and cancelled appointments in a call log or memo to identify attempts to contact the client and re-engage in the treatment process.
Clinical supervisor and lead counselors will monitor individual psychotherapy hours and completion of call logs and/or memos for missed appointments.
Clinical supervisor will review this information with counselors during monthly supervision.
In addition, the Quality Team reviews quality and compliance indicators on a monthly basis and reviews during monthly key performance indicator meetings with site leadership. A random sample of charts is monitored each month. The Quality team monitors the following indicator each month with a benchmark goal of 80%. Site leadership will work with the quality team to address any indicator below the benchmark score and will provide additional training and resources as needed.
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715.20(1) 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.
(1) The transferring narcotic treatment program shall transfer patient files which include admission date, medical and psychosocial summaries, dosage level, urinalysis reports or summary, exception requests, and current status of the patient, and shall contain the written consent of the patient.
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Observations
Based on one of one applicable patient record reviewed, the facility failed to provide documentation of admission date, medical and psychosocial summaries, dosage level, urinalysis reports or summary, exception requests, and current status of the patient to the receiving facility in patient record # 5.Patient # 5 was admitted on June May 18, 2023 and discharged on July 20, 2023. Patient # 5 was transferred to another facility and the facility did not provide documentation of the transfer files.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Effective 9/5/2023 program will ensure adherence to the Patient Transfer policy regarding all clients seeking transfer to an external narcotic treatment program. A checklist is being developed to assist counselors in ensuring that all required information is included in the fax sent to the receiving facility. Executive director/clinical supervisor will ensure that all requested documentation is submitted to the transferring facility within 7 days of reception. In order to ensure compliance with the 7-day requirement, the program will fax all information and retain of copy of the fax transmittal with proper date and time of submission. All shared information, including received fax transmittal, will be saved in the client's clinical record for potential reference at a later time.
Clinical supervisor will review transfer discharges weekly and monitor to ensure that all transfer documentation was submitted and uploaded.
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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 one of two applicable patient record reviewed, the facility failed to provide documentation to 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 in patient record # 3.Patient # 3 was admitted on June May 16, 2023 and was still active at the time of the inspection. There was no documentation of admission and dosage being provided to the transferring narcotic treatment program.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
On 8/8/23, executive director and the nursing staff reviewed the process for communicating the admission and dosage information to the transferring program. It was further reviewed that the admission and dosage information provided to the transferring narcotic treatment program must be documented in the Nursing Progress Note and filed in the client's medical chart.
Executive director will monitor for transfers in weekly and review patients' medical chart to ensure that the admission and dosage information provided to the transferring narcotic treatment program is documented in the Nursing Progress Note. and filed in the client's medical chart.
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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 two of five applicable outpatient client records reviewed, the facility failed to review and update the treatment and rehabilitation plan at least every sixty days in client records # 1 and # 4.Client # 1 was admitted on September 13, 2022 and was still active at the time of the inspection. A treatment and rehabilitation plan was developed on November 22, 2022. A treatment and rehabilitation plan update occured on February 28, 2023. A treatment plan update was due no later than April 28, 2023. A treatment and rehabilitation plan update did not occur until May 4, 2023.Client # 4 was admitted on December 27, 2022 and was still active at the time of the inspection. A treatment and rehabilitation plan was developed on January 11, 2023. A treatment and rehabilitation plan update was due no later than March 11, 2023. A treatment and rehabilitation plan update did not occur until May 5, 2023.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Clinical supervisor reviewed regulations/time frames for treatment plan reviews per level of care during treatment team meeting on 8/24/23. Clinical supervisor will keep an excel database to record all treatment plans. This will include the patient's start date, date the initial treatment plan was created and date the treatment plan reviews are due.
Clinical supervisor will email counselors monthly with treatment plan reviews that are coming due. Counselor will inform clinical supervisor when treatment plan has been completed and signed by all parties. Clinical supervisor will review patient chart to ensure the treatment plan review was completed.
Clinical supervisor and lead counselors will monitor for completion of treatment plan reviews according to regulation during monthly supervision.
In addition, the Quality Team reviews quality and compliance indicators on a monthly basis and reviews during monthly key performance indicator meetings with site leadership. A random sample of charts is monitored each month. The Quality team monitors the following indicator each month with a benchmark goal of 80%. Site leadership will work with the quality team to address any indicator below the benchmark score and will provide additional training and resources as needed.
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709.93(a)(8) 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:
(8) Case consultation notes.
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Observations
Based on three of seven applicable outpatient client records reviewed, the facility failed to provide case consultations in accordance with the facility policy and procedure manual. The facility policy and procedure manual indicates case consultations occur at least once every three months during the first year of treatment. For patients in treatment longer than 1 year, case consults need to be documented at least once annually. Provisions should be made for more frequent case consultation if dictated by patient response to treatment. Client # 1 was admitted on September 13, 2022 and was still active at the time of the inspection. A case consultation was due to occur no later than December 13, 2022. A case consultation did not occur until January 9, 2023. Another case consultation was due no later than April 9, 2023. No other case consultations were documented in the client record. Client # 4 was admitted on December 27, 2022 and was still active at the time of the inspection. A case consultation was due to occur no later than March 27, 2023. No case consultations were documented in the client record. Client # 7 was admitted on September 27, 2022 and was discharged June 9, 2023. A case consultation was due to occur no later than December 27, 2023. No case consultations were documented in the client record. These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Clinical supervisor reviewed regulations/time frames for completion of case consultations during treatment team meeting on 8/24/23. Clinical supervisor will keep an excel database to record the due date for all case consultations during the first year in treatment. This will include the patient's start date and the quarterly due date.
Clinical supervisor will email counselors monthly with case consultation that are coming due. Counselors will review case consultations during weekly treatment meetings. Clinical supervisor will review patient chart to ensure the case consultation review was completed.
Clinical supervisor and lead counselors will monitor for completion of case consultation reviews according to regulation during monthly supervision.
In addition, the Quality Team reviews quality and compliance indicators on a monthly basis and reviews during monthly key performance indicator meetings with site leadership. A random sample of charts is monitored each month. The Quality team monitors the following indicator each month with a benchmark goal of 80%. Site leadership will work with the quality team to address any indicator below the benchmark score and will provide additional training and resources as needed.
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