INITIAL COMMENTS
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This report is a result of an on-site licensure renewal and methadone monitoring inspection conducted on October 10, 2024 through October 11, 2024, by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, Allentown Comprehensive Treatment Center 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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704.11(c)(1) LICENSURE Mandatory Communicable Disease Training
704.11. Staff development program.
(c) General training requirements.
(1) Staff persons and volunteers shall receive a minimum of 6 hours of HIV/AIDS and at least 4 hours of tuberculosis, sexually transmitted diseases and other health related topics training using a Department approved curriculum. Counselors and counselor assistants shall complete the training within the first year of employment. All other staff shall complete the training within the first 2 years of employment.
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Observations
Based on a review of personnel records, the facility failed to ensure that one of seven employees received a minimum of 6 hours of HIV/AIDS and 4 hours of TB/STD training using a Department approved curriculum within the regulatory timeframe.
Employee # 4 has been in the position of counselor since February 20, 2023 and was due to have the communicable disease trainings no later than February 20, 2024. However, the HIV/AIDS training was not completed until September 11, 2024 and the personnel record contained no documentation of the completion of the TB/STD training as of the date of the inspection.
This is a repeat citation from the October 11, 2023 annual licensing renewal inspection.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Allentown Clinical Management team will add quarterly reviews of counseling staffs' adherence to annual training expectations utilizing an Excel spreadsheet to be maintained to ensure regular contact and review of staff adherence to ensure each and every staff member completes the required number of annual trainings expected during a calendar year. Employee #$ is scheduled for TB/STD training on November 20, 2024. A review of the staff members adherence to the appropriate amount of trainings each year was presented and reviewed during the full staff monthly meeting held on November 7, 2024. Also to be discussed is staff ensuring certificates of completion for trainings are provided to their immediate supervisor quarterly so training completions are accurately represented in ones' personnel file. Clinic Director and Management team will meet bi-annually to ensure each department team members are compliant to trainings completed via the use of a spreadsheet for accurate tracking. |
704.11(f)(2) LICENSURE Trng Hours Req-Coun
704.11. Staff development program.
(f) Training requirements for counselors.
(2) Each counselor shall complete at least 25 clock hours of training annually in areas such as:
(i) Client recordkeeping.
(ii) Confidentiality.
(iii) Pharmacology.
(iv) Treatment planning.
(v) Counseling techniques.
(vi) Drug and alcohol assessment.
(vii) Codependency.
(viii) Adult Children of Alcoholics (ACOA) issues.
(ix) Disease of addiction.
(x) Aftercare planning.
(xi) Principles of Alcoholics Anonymous and Narcotics Anonymous.
(xii) Ethics.
(xiii) Substance abuse trends.
(xiv) Interaction of addiction and mental illness.
(xv) Cultural awareness.
(xvi) Sexual harassment.
(xvii) Developmental psychology.
(xviii) Relapse prevention.
(3) If a counselor has been designated as lead counselor supervising other counselors, the training shall include courses appropriate to the functions of this position and a Department approved core curriculum or comparable training in supervision.
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Observations
Based on a review of personnel records, the facility failed to ensure that each counselor completed at least 25 clock hours of training annually during the facility's January 1, 2023 through December 31, 2023 training year, in two of two applicable personnel records reviewed.
Employee # 3 has been in the position of counselor since October 24, 2019. The personnel record documented only 18.66 hours of annual training during the training year reviewed.
Employee # 5 has been in the position of counselor since November 7, 2022. The personnel record documented only 15 hours of annual training during the training year reviewed.
This is a repeat citation from the October 11, 2023 annual licensing renewal inspection.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
Allentown Clinical Management team will ensure that each and every staff member completes the required number of annual trainings expected during a calendar year. A review of the staff members adherence to the appropriate number of trainings each year was presented and reviewed during the full staff monthly meeting held on November 7, 2024. Also to be discussed is that the staff ensure that certificates of completion of trainings are provided to the Clinic Director so that it may be accurately represented in ones' personnel file. Management team will meet bi-annually to ensure their team members have their trainings completed; they will utilize a spreadsheet for accurate monitoring/tracking. |
705.24 (2) LICENSURE Bathrooms.
705.24. Bathrooms.
The nonresidential facility shall:
(2) Provide a sink, a wall mirror, an operable soap dispenser, and either individual paper towels or a mechanical dryer in each bathroom.
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Observations
Based on a physical plant inspection on October 11, 2024, the facility failed to provide a wall mirror and an operable soap dispenser in each bathroom. The first floor women's bathroom, across from the dosing area, did not have soap. A second floor staff restroom did not have a mirror.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
CD will purchase and install a mirror for the said bathroom on or before November 15, 2024, as well as discuss with cleaning company that soap dispensers are filled on a regular basis. CD will monitor soap dispensers by spot checking at least 1-2x per week. |
709.28 (c) LICENSURE Confidentiality
§ 709.28. Confidentiality.
(c) The project shall obtain an informed and voluntary consent from the client for the disclosure of information contained in the client record.
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Observations
Based on a review of ten client records, the facility failed to obtain an informed and voluntary consent from the client for the disclosure of information in ten records reviewed.
Client # 1 was admitted on September 10, 2024 and was active at the time of the inspection. Per a discussion with the Facility Director, information such as the client's diagnosis was disclosed to the funding source; however, the consent to release information form to the funding source signed by the client on September 10, 2024, did not allow for the release of that information.
Client # 2 was admitted on February 28, 2023 and was active at the time of the inspection. Per a discussion with the Facility Director, information such as the client's diagnosis was disclosed to the funding source; however, the consent to release information form to the funding source signed by the client on March 6, 2024, did not allow for the release of that information.
Client # 3 was admitted on October 10, 2022 and was discharged on May 3, 2024. Per a discussion with the Facility Director, information such as the client's diagnosis was disclosed to the funding source; however, the consent to release information form to the funding source signed by the client on October 4, 2023, did not allow for the release of that information.
Client # 4 was admitted on November 4, 2022 and was discharged on May 24, 2024. Per a discussion with the Facility Director, information such as the client's diagnosis was disclosed to the funding source; however, the consent to release information form to the funding source signed by the client on November 8, 2023, did not allow for the release of that information.
Client # 5 was admitted on February 7, 2014 and was discharged on April 22, 2024. Per a discussion with the Facility Director, information such as the client's diagnosis was disclosed to the funding source; however, the consent to release information form to the funding source signed by the client on March 8, 2024, did not allow for the release of that information. Additionally, there was a release of information form to the funding source that was signed and dated by the client on February 20, 2023 and expired on April 23, 2023. Another release of information form to the funding source was signed on March 8, 2024. There was evidence of disclosures to the funding source after the first release form expired on April 23, 2023 and prior to the new form being signed on March 8, 2024.
Client # 6 was admitted on January 2, 2023 and was active at the time of the inspection. Per a discussion with the Facility Director, information such as the client's diagnosis was disclosed to the funding source; however, the consent to release information form to the funding source signed by the client on January 25, 2024, did not allow for the release of that information. Additionally, there was a release of information form to the funding source that was signed and dated by the client on January 2, 2023 and expired on January 2, 2024. Another release of information form to the funding source was signed on January 25, 2024. There was evidence of disclosures to the funding source after the first release form expired on January 2, 2024 and prior to the new form being signed on January 25, 2024.
Client # 7 was admitted on September 17, 2019 and was discharged on October 2, 2024. The record contained documentation that the psychosocial evaluation, annual physical, and dosing history were sent to another treatment provider on September 9, 2024, however, the consent to release information form to the treatment provider signed by the client on July 9, 2024, did not allow for the release of that information.
Client # 8 was admitted on January 17, 2024 and was active at the time of the inspection. Per a discussion with the Facility Director, information such as the client's diagnosis was disclosed to the funding source; however, the consent to release information form to the funding source signed by the client on January 19, 2024, did not allow for the release of that information.
Client # 9 was admitted on February 14, 2024 and was active at the time of the inspection. Per a discussion with the Facility Director, information such as the client's diagnosis was disclosed to the funding source; however, the consent to release information form to the funding source signed by the client on February 14, 2024, did not allow for the release of that information.
Client # 10 was admitted on July 12, 2018 and was active at the time of the inspection. The record contained a release of information form to the funding source that was signed and dated by the client on April 21, 2023 and expired on April 21, 2024. Another release of information form to the funding source was signed on July 26, 2024. There was evidence of disclosures to the funding source after the first release form expired on April 21, 2024 and prior to the new form being signed on July 26, 2024.
This is a repeat citation from the October 11, 2023 annual licensing renewal inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Allentown CD will work with RD and Quality team to have all necessary information for payor releases populated on to the ROI. Prior to signing, all necessary information will be discussed with the patient. All clinical staff will receive a training with the CS on December 4, 2024 to review ROI purposes and limitations. During the training, it will be highlighted that only the information listed on the release can be released. CTC Clinic Director and Clinical Supervisor will ensure that all release of information forms will indicate a specific purpose of the disclosure to named parties within the ROI prior to any release of information is given. All releases of information will be reviewed for accuracy and that these releases of information are completed in its entirety on a quarterly basis. Progress on this plan will be monitored by the CS monthly via the Quality Record Review Process, as well as addressed in individual and group supervision. ROI trainings to be offered, as needed. CMS with CS assistance will ensure ROI's are current and will update as needed. |
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 17 weeks of physician and certified registered nurse practitioner timesheets, the facility failed to provide at least one hour of physician time a week on site for every ten patients in one week reviewed.
During the week of May 25, 2024 through June 1, 2024, the patient census was 444. The facility was required to provide at least 44.4 physician hours. There were 40.75 hours documented.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The CTC Director will ensure that the Program Physician(s) provide at least 1 hour per week onsite for every ten patients. The CTC Director, along with the CN, will monitor the monthly calendar weekly to ensure there is adequate coverage and if/when needed will file an exception for the week in question, preferably in advance. |
715.9(a)(2) LICENSURE Intake
(a) Prior to administration of an agent, a narcotic treatment program shall screen each individual to determine eligibility for admission. The narcotic treatment program shall:
(2) Verify the individual 's identity, including name, address, date of birth, emergency contact and other identifying data.
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Observations
Based on a review of patient records, the facility failed to ensure that emergency contact information was obtained during the intake process in one of three records reviewed.
Patient # 1 was admitted on September 10, 2024 and was active at the time of the inspection. Emergency contact information was not obtained as of the date of the inspection, and the record contained no documentation showing that the patient declined to provide it during the intake process or that there was a lapse in attendance preventing the information from being gathered.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
CMS and CD at next team meeting, November 7, 2024, will review requirements for admissions including emergency contact ROI. CTC will obtain emergency contacts for all patients upon admission. If patient refuses- this will be documented in case management note at admission. CTC Case Managers will add the ROI at admission and complete with the patient. CD, CS, and CMS will review with case managers. New staff will be trained on proper policy and reviewed in team meetings and supervision upon hire. Ongoing noncompliance will be addressed by the Case Management Supervisor and Clinic Director individually utilizing the Employee Improvement Planning process. Compliance will be monitored monthly via the quality record review process. |
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 an observation of medication administration on October 11, 2024, the nurse in the first medication window was observed to be preparing take-home medications or looking at a computer monitor, instead of observing the patient when ingesting the agent at 08:29 a.m. and 08:34 a.m.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Charge Nurse will review policy with staff on a monthly basis in nursing supervision. New staff will be trained on proper policy and reviewed in team meetings and supervision. The charge nurse did present this information during the monthly nursing meeting on October 31, 2024. Clinic Director will observe dosing periodically for compliance. Ongoing noncompliance will be addressed by the Nurse Manager and Clinic Director individually utilizing the Employee Improvement Plan process. |
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 a review of patient records, the facility failed to ensure an annual physical reevaluation in one of six applicable records reviewed.
Patient # 6 was admitted on January 2, 2023 and was active at the time of the inspection. The most recent annual physical evaluation was due no later than January 2, 2024; however, it was not documented in the patient record until August 19, 2024.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Charge Nurse will pull the services due report in the EHR for the upcoming month and schedule annual physicals with the physicians by placing holds on patients to schedule when they appear at the dosing window. CTC director will also monitor compliance weekly and address non-compliance with the Physician as needed. |
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 a completed annual evaluation signed by the medical director in one of six applicable records.
Patient # 6 was admitted on January 2, 2023 and was active at the time of the inspection. The annual evaluation was due to be completed by January 2, 2024; however, an annual evaluation was not completed as of the date of the inspection.
This is a repeat citation from the October 11, 2023, October 27, 2022, and November 2, 2021 annual licensing renewal inspections.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The CTC Director and Clinical Supervisor are responsible for ensuring compliance with psychotherapy services, including Annual Clinical Evaluations. The CTC Director & Clinical Supervisor will re-review the requirements for counseling services with all counselors on October 22, 2024, in group supervision, as well as, in weekly individual supervision. Immediately following this meeting, each counselor will run their Direct Services Analysis reports in SMART and place HOLDs in EHR for Clinical Evaluations that are due. Additionally, the Clinical Supervisor will run the report monthly and send results to the CTC Director and the Director of Quality and Compliance with a plan of action for overall results below the benchmark of 96%. The Clinical Supervisor will review the reports in individual and group supervision. Progress on this plan will be monitored by the CS monthly via the Quality Record Review Process. Ongoing noncompliance in meeting the Direct Services requirement will be addressed by the Clinical Supervisor individually utilizing the Employee Improvement Plan process. |
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 treatment plan updates within the regulatory timeframe in eight of nine applicable records reviewed. The facility has a Department approved exception indicating that treatment plans may be updated every 120 days for long-term patients who are stable and receiving counseling less than twice per month.
Client # 2 was admitted on February 28, 2023 and was active at the time of the inspection. A treatment plan update was completed on October 24, 2023, and the next update was due no later than December 22, 2023; however, the next treatment plan update was not completed until December 27, 2023. The next treatment plan update was due to be completed by February 24, 2024, however, the next update was not completed until February 28, 2024. A treatment plan update was completed on June 26, 2024 and the next treatment plan update was due to be completed by August 24, 2024; however, the treatment plan update was not completed until August 27, 2024.
Client # 3 was admitted on October 10, 2022 and was discharged on May 3, 2024. A treatment plan update was completed on December 9, 2023, and the next update was due no later than February 7, 2024; however, the next treatment plan update was not completed until February 12, 2024.
Client # 4 was admitted on November 4, 2022 and was discharged on May 24, 2024. A treatment plan update was completed on September 29, 2023, and the next update was due no later than January 27, 2024; however, the next treatment plan update was not completed until February 1, 2024.
Client # 6 was admitted on January 2, 2023 and was active at the time of the inspection. A treatment plan update was completed on September 2, 2023, and the next update was due no later than December 31, 2023; however, the next treatment plan update was not completed until May 3, 2024. The next treatment plan update was due to be completed by July 2, 2024, however, the next update was not completed until July 5, 2024.
Client # 7 was admitted on September 17, 2019 and was discharged on October 2, 2024. A treatment plan update was completed on January 17, 2024, and the next update was due no later than May 15, 2024; however, the next treatment plan update was not completed until May 23, 2024.
Client # 8 was admitted on January 17, 2024 and was active at the time of the inspection. A treatment plan update was completed on March 15, 2024, and the next update was due no later than May 13, 2024; however, the next treatment plan update was not completed until May 17, 2024.
Client # 9 was admitted on February 14, 2024 and was active at the time of the inspection. A treatment plan update was completed on June 11, 2024, and the next update was due no later than August 9, 2024; however, the next treatment plan update was not completed until August 14, 2024.
Client # 10 was admitted on July 12, 2018 and was active at the time of the inspection. A treatment plan update was completed on March 8, 2024, and the next update was due no later than July 5, 2024; however, the next treatment plan update was not completed until July 10, 2024.
These findings were discussed with facility staff during the licensing process.
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Plan of Correction
The CTC Director and Clinical Supervisor are responsible for ensuring compliance with psychotherapy services. The CTC Director & Clinical Supervisor will re-review the requirements for counseling services with all counselors on October 22, 2024. As the EHR schedules treatment plans on a 60-day cycle, clinician is required to add the next plan 30, 60, or 120 days from the author date. Immediately following this meeting, each counselor will run their Direct Services Analysis reports in SMART and turn into the Clinical Supervisor weekly. Additionally, the Clinical Supervisor will run the report monthly and send results to the CTC Director and the Director of Quality and Compliance with a plan of action for overall results below the benchmark of 96%. The Clinical Supervisor will review the reports in individual and group supervision. Progress on this plan will be monitored by the CS monthly via the Quality Record Review Process. Ongoing noncompliance in meeting the Direct Services requirement will be addressed by the Clinical Supervisor individually utilizing the Employee Improvement Plan process. |
709.92(c) LICENSURE Treatment and rehabilitation services
709.92. Treatment and rehabilitation services.
(c) The project shall assure that counseling services are provided according to the individual treatment and rehabilitation plan.
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Observations
Based on a review of client records, the facility failed to ensure that counseling services were provided according to the individual treatment and rehabilitation plans in four of ten applicable records reviewed.
Client # 3 was admitted on October 10, 2022 and was discharged on May 3, 2024. Treatment plans completed on December 9, 2023 and February 12, 2024, indicated that the client was to receive one hour of individual counseling sessions per month; however, the record did not contain documentation of any individual sessions during the month of February 2024.
Client # 4 was admitted on November 4, 2022 and was discharged on May 24, 2024. The treatment plan completed on September 29, 2023, indicated that the client was to receive 1 hour individual counseling sessions per month; however, the record contained documentation that only 30 minutes of individual counseling were documented during November 2023 and January 2024.
Client # 5 was admitted on February 7, 2014 and was discharged on April 22, 2024. The treatment plan completed on October 9, 2023, indicated that the client was to receive one hour of individual counseling per month; however, the record contained documentation that only 30 minutes of individual counseling were documented during November 2023.
Client # 9 was admitted on February 14, 2024 and was active at the time of the inspection. Treatment plans completed on June 11, 2024 and August 14, 2024, indicated that the client was to receive one hour of individual counseling and 2.5 hours of group therapy per month; however, the record did not contain documentation of any individual sessions during the month of September 2024 or group sessions during September or August 2024.
This is a repeat citation from the October 11, 2023 annual licensing renewal inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The CTC Director and Clinical Supervisor are responsible for ensuring compliance with psychotherapy services. The CTC Director & Clinical Supervisor will re-review the requirements for counseling services with all counselors on October 22, 2024. During regular Individual and Group supervision sessions, CS will review with each Counselor all recent Tx Plans completed in that week to review Pt. engagement and frequency to ensure Pt. is adherent to same or if an alteration is required to the Pt.'s treatment plan while ensuring documentation to Pt. non-compliance is noted within the Pt. record. The Clinical Supervisor will review the reports in individual and group supervision. Ongoing noncompliance in meeting the Direct Services requirement will be addressed by the Clinical Supervisor individually utilizing the Employee Improvement Plan process. |
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 a review of client records and the facility's policy and procedure manual, the facility failed to ensure a complete client record included information relative to the client's involvement with the project to include case consultation notes every three months for the first year of treatment and annually thereafter, per the facility's policy, in three of eight applicable records reviewed.
Client # 4 was admitted on November 4, 2022 and was discharged on May 24, 2024. A case consultation note was due to be completed by November 4, 2023; however, the next case consultation was not documented until December 14, 2023.
Client # 7 was admitted on September 17, 2019 and was discharged on October 2, 2024. A case consultation note was due to be completed by September 26, 2024; however, the next case consultation was not documented until September 30, 2024.
Client # 9 was admitted on February 14, 2024 and was active at the time of the inspection. The first case consultation note was due to be completed by May 14, 2024; however, it was not completed until August 13, 2024.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Beginning immediately Clinical Supervisor will monitor Case Consults due on a weekly basis in supervision with staff. This will be accomplished by utilizing the Services Due report via the EMR for respective staff. Weekly review of evaluations will be completed by the CS to ensure completion. Additionally, the CS will monitor via the quality record review process. |
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 ensure a complete client record included information relative to the client's involvement with the project to include follow-up information at 30 days post discharge, per facility policy, in two of three applicable records reviewed.
Client # 3 was admitted on October 10, 2022 and was discharged on May 3, 2024. The client record did not contain documentation of follow-up information.
Client # 5 was admitted on February 7, 2014 and was discharged on April 22, 2024. The client record did not contain documentation of follow-up information.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Beginning immediately Clinical Supervisor will monitor Follow-up for discharged patients due on a weekly basis in supervision with staff. This will be accomplished by utilizing the Services Due report via the EMR for respective staff. Weekly review of evaluations will be completed by the CS to ensure completion. Additionally, the CS will monitor via the quality record review process. Documented completion in EHR. |
709.17(a)(3) LICENSURE Subchapter B.Licensing Procedures.Refusal/rev
709.17. Refusal or revocation of license.
(a) The Department may revoke or refuse to issue a license for any of the following reasons:
(3) Failure to comply with a plan of correction approved by the Department, unless the Department approves an extension or modification of the plan of correction.
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Observations
Based on a review of patient records, the facility failed to comply with plans of correction that were approved by the Department.
A plan of correction for completing an annual evaluation was submitted and approved by the Department for the October 11, 2023, October 27, 2022, and November 2, 2021 annual licensing inspections. Completing annual clinical evaluations was again found to be a deficiency in the October 11, 2024 licensing inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Allentown CTC will identify issues with proposed plans of correction as they present and formulate protocols to ensure that repeat citations are avoided in the future. The RD and the CD's will review the identified item(s) and collaboratively prepare a sustainable corrective measure; all in concert with Licensing regulations and input working to ensure a sustained corrective measure. CS and CN will conduct a weekly review to identify any and all annual documentations or other such services that populate for all Pts and review with counseling staff during supervision to ensure task completion. The CS and CN will monitor compliance on annual documentation as well via the quality record review process. |