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 3, 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 six of six patient records reviewed February 3, 2021.
Patient # 1 was admitted December 9, 2019 and discharged July 24, 2020. No drugs screens were documented for the following months: April, May and June 2020.
Patient # 2 was admitted March 2, 2020 and discharged June 30, 2020. No drugs screens were documented for the following months: April and May 2020.
Patient # 4 was admitted October 8, 2020 and discharged June 10, 2020. No drugs screens were documented for the following months: April and May 2020.
Patient # 5 was admitted September 9, 2020. No drugs screens were documented for the following months: October, November and December 2020 and January 2021.
Patient # 6 was admitted July 2, 2019. No drugs screens were documented for the following months: March 2020 through December 2020 and January 2021.
Patient # 7 was admitted September 23, 2020. No drugs screens were documented for the following months: October, 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 four of six patient records reviewed on February 3, 2021.
Patient # 2 was admitted March 2, 2020 and discharged June 30, 2020. No psychotherapy hours were provided during April 2020.
Patient # 4 was admitted October 8, 2020 and discharged June 10, 2020. No psychotherapy hours were provided during April and May 2020.
Patient # 6 was admitted July 2, 2019. The following psychotherapy hours were provided: November 2020 - 1.25 hours, December 2020 - .75 hours and January 2021 - 0 hours.
Patient # 7 was admitted September 23, 2020. No psychotherapy hours were provided during January 2021.
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. has been short staffed throughout 2020, this led to not all patients receiving 2.5 hours of counseling per month. F.H.S. is in the process of hiring two full time counselors, this will help to assure that all patients are receiving 2.5 hours of counseling per month as required. Hiring of new staff to allow for full coverage will be completed by April 10, 2021. Hiring of new staff and maintaining that all patients are receiving an average of 2.5 hours of counseling per month will be the responsibility of the Clinical Director. |