INITIAL COMMENTS
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Based on the concerns arising from COVID-19, The Department of Drug and Alcohol Programs, Bureau of Program Licensure, has implemented temporary procedures for conducting an annual renewal inspection.
The inspection will be divided into two parts.
1, an abbreviated off-site inspection, will be conducted off site, and will require the submission of administrative information via email to a Licensing Specialist.
2, an abbreviated on-site inspection, will be conducted on-site at a later date and will include a review of client/patient records, and a physical plant inspection.
This report is a result of Part 2, an abbreviated on-site inspection, conducted on February 4, 2021 by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Not all regulations were reviewed, the remainder of the regulations were reviewed during Part 1.
Based on the findings of Part 2, an abbreviated on-site inspection, Freedom Healthcare Services 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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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 patient records, the facility failed to document a random monthly drug-screening urinalysis in five of five patient records reviewed February 4, 2021.
Patient # 4 was admitted October 1, 2019 and discharged September 10, 2020. No drugs screens were documented for the following months: February through August 2020.
Patient # 5 was admitted April 7, 2020 and discharged August 5, 2020. No drugs screens were documented for the following months: May and July 2020.
Patient # 6 was admitted July 20, 2020. No drugs screens were documented for the following months: August, October and December 2020 and January 2021.
Patient # 7 was admitted November 24, 2020. No drugs screens were documented for December 2020.
Patient # 8 was admitted July 17, 2019. No drugs screens were documented for the following months: April, May, June, November and December 2020 and January 2021.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
715.14 (a) - Due to COVID-19 and the implementation of telehealth, F.H.S. did not have patients come into the building for face to face appointments for most of 2020. This decision was made in an effort to protect both staff and patients from exposure to COVID- 19 and attempt to reduce the spread. Patients will be asked to return for in person medical appointments at least once a month, where they will be required to submit a urine screen. Nursing will develop a monthly rotation schedule for patients to come in for their monthly medical appointment and urine screen. This process will begin by March 29, 2021, the Clinical Director will be responsible for implementation of this process. The Clinical Director will also be responsible for maintaining this process once implemented to assure that a drug screen is obtained at least monthly. |
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 document each patient was provided an average of 2.5 hours of psychotherapy per month in one of five patient records reviewed on February 4, 2021.
Patient # 4 was admitted October 1, 2019 and discharged September 10, 2020. No psychotherapy hours were provided from February 2020 through August 2020.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
715.19(1)- Many of our staff were voluntarily furloughed as a result of COVID- 19 due to lack of childcare, caring for an elderly individual or the staff's physician recommending they quarantine due to health issues. As a result, F.H.S. was short staffed throughout 2020, this led to not all patients receiving 2.5 hours of counseling per month. F.H.S. became fully staffed in Ellwood City as of January 2021, allowing for all patients in their first two years of treatment to receive an average of 2.5 hours per month of counseling. Maintaining that all patients are receiving an average of 2.5 hours of counseling per month will be the responsibility of the Clinical Director. |
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 client records, the facility failed to document a review and update of treatment and rehabilitation plans at least every 60 days in three of seven client records reviewed on February 4, 2021.
Client # 1 was admitted December 31, 2019 and discharged June 8, 2020. The treatment plan was documented February 3, 2020. Treatment plan updates were due April 3 and June 3, 2020 but were not documented until June 16 and June 29, 2020.
Client # 3 was admitted October 9, 2019 and discharged June 8, 2020. The treatment plan was documented October 31, 2020. The only treatment plan updates were documented December 12, 2020 and February 10, 2020. The next update was due April 10, 2020 but was not documented until June 16, 2020.
Client # 4 was admitted October 1, 2019 and discharged September 10, 2020. The treatment plan was documented October 24, 2019. The only treatment plan updates were documented December 18, 2019 and September 10, 2020. Treatment plan updates were due February 18, April 18, June 18 and August 18, 2020 but were not documented.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
709.92(b)- F.H.S. shall review and update all treatment plans at least every 60 days. Clinical staff will check their documents due every Monday, per the list provided in F.H.S.'s electronic medical record. Supervisors will send out reminders via email to assure that this document list is checked weekly. This procedure will be implemented by March 29, 2021, implementation and follow up to assure that all treatment plans are reviewed and updated at least every 60 days will be the responsibility of the Clinical Director. |
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
The facility failed to document follow-up information within ninety days of discharge, as per facility policy, in four of four client records reviewed on February 4, 2021.
No follow-up information was documented in the following client records:
Client # 1 was admitted December 31, 2019 and discharged June 8, 2020.
Client # 3 was admitted October 9, 2019 and discharged June 8, 2020.
Client # 4 was admitted October 1, 2019 and discharged September 10, 2020.
Client # 5 was admitted April 7, 2020 and discharged August 5, 2020.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
709.93(a)(11)- Follow- up information will be obtained from all discharged patients within 90 days of discharge, per F.H.S.'s policy. A report will be generated at least monthly with a list of the patients needing to be contacted for follow up calls. This will be implemented by March 22, 2021. It will be the responsibility of the Front Office Manager to implement and maintain this procedure, assuring that all patients are contacted for follow-up information within 90 days. |