INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on April 9-11, 2018 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Coatesville Treatment Center, was found to be not 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(d)(2) LICENSURE Annual Training Requirements
704.11. Staff development program.
(d) Training requirements for project directors and facility directors.
(2) A project director and facility director shall complete at least 12 clock hours of training annually in areas such as:
(i) Fiscal policy.
(ii) Administration.
(iii) Program planning.
(iv) Quality assurance.
(v) Grantsmanship.
(vi) Program licensure.
(vii) Personnel management.
(viii) Confidentiality.
(ix) Ethics.
(x) Substance abuse trends.
(xi) Developmental psychology.
(xii) Interaction of addiction and mental illness.
(xiii) Cultural awareness.
(xiv) Sexual harassment.
(xv) Relapse prevention.
(xvi) Disease of addiction.
(xvii) Principles of Alcoholics Anonymous and Narcotics Anonymous.
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Observations
Based on a review of employee training files conducted on April 9, 2018, the facility failed to document that the project director completed the required number of training hours.Employee #1 was hired as the Projected Director on 11/1/16. Training certificates were reviewed for the period from January 1, 2017 through December 31, 2017; Employee #1 had documented only 6.28 hours of trainings at the time of the licensing inspection.This information was reviewed with the facility staff during the licensing inspection.
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Plan of Correction
Employee #1, Project Director last day with the organization was 3/23/2018. His replacement started 4/22/2018. Based on his current role, the new Project Director will have 12 hours of required training hours each year through the organizations Healthstream trainings. These trainings are tracked electronically and copies of his completion will be accessed through the HR Department as his file is maintained at the corporate level. His required training hours will be completed by the end of the year, 12/31/2018. |
705.28 (d) (1) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(1) Conduct unannounced fire drills at least once a month.
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Observations
Based on a review of the fire drill record, conducted on April 9, 2018, the facility failed to document a fire drill for December 2017. This information was reviewed with the facility staff during the licensing inspection.
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Plan of Correction
Clinical Supervisor is the appointed Health & Safety Liaison. Due to inclement weather, one of the drills were missed; two fire drills were conducted in January 2018 to address the miss. The Clinical Supervisor has created a new tracking system to ensure that there are no drills missed even during inclement weather. It is now being tracked on a monthly calendar. |
705.28 (d) (4) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(4) Maintain a written fire drill record including the date, time, the amount of time it took for evacuation, the exit route used, the number of persons in the facility at the time of the drill, problems encountered and whether the fire alarm or smoke detector was operative.
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Observations
Based on a review of the fire drill record, conducted on April 9, 2018, the facility failed to document the number of persons in the facility on a fire drill record dated October 31, 2017, and whether the fire alarm or smoke detector was operative on a fire drill record dated January 23, 2017. This information was reviewed with the facility staff during the licensing inspection.
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Plan of Correction
The Health and Safety Liaison has developed a new tracking system and checklist to ensure that nothing gets missed including the number of the persons in the facility during the drill as well as whether or not the fire alarm and detector were operative. The new tracking system and checklist was implanted on 4/23/2018 and will be maintained and reviewed by the Health Safety Liaison for accuracy. |
709.26 (b) (3) LICENSURE Personnel management.
§ 709.26. Personnel management.
(b) The personnel records must include, but are not limited to:
(3) Annual written individual staff performance evaluations, copies of which shall be reviewed and signed by the employee.
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Observations
Based on a review of employee files conducted on April 9, 2018, the facility failed to ensure that each employee was given an annual work performance evaluation.Employee #1 was hired as the Projected Director on 11/1/16. An annual work performance evaluation was last documented on 5/10/16; another annual performance evaluation was due to be completed by 5/10/17 but was not documented.This information was reviewed with the facility staff during the licensing inspection.
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Plan of Correction
Employee #1, Project Director had an evaluation that was completed but HR was unable to locate the signed copy. As of 3/23/2018, Employee #1 is no longer with the organization. His new replacement started on 4/22/2018. All employee reviews are tracked electronic through the new Ultipro System as every employee is required to have an annual evaluation completed along with their salary review. Based on his hire date, the new Project Director will have an annual review completed by 4/22/2019 and it will be completed by the CTC Division President. |
709.30 (1) LICENSURE Client rights
§ 709.30. Client rights.
The project shall develop written policies and procedures on client rights and document written acknowledgement by clients that they have been notified of those rights.
(1) A client receiving care or treatment under section 7 of the act (71 P. S. § 1690.107) shall retain civil rights and liberties except as provided by statute. No client may be deprived of a civil right solely by reason of treatment.
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Observations
Facility policy and procedure manual was reviewed on April 9, 2018. The facility policy failed to include the following elements with regard to client rights:(3) Clients have the right to inspect their own records. The project, facility or clinical director may temporarily remove portions of the records prior to the inspection by the client if the director determines that the information may be detrimental if presented to the client. Reasons for removing sections shall be documented in the record. (4) Clients have the right to appeal a decision limiting access to their records to the director. (5) Clients have the right to request the correction of inaccurate, irrelevant, outdated or incomplete information in their records. (6) Clients have the right to submit rebuttal data or memoranda to their own records.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
As the facility has transitioned into a new electronic medical record as of 10/12/2017, the new patient rights form that was uploaded by the technical team will need to be updated with the previous version that covers the following:
(3) Clients have the right to inspect their own records. The project, facility or clinical director may temporarily remove portions of the records prior to the inspection by the client if the director determines that the information may be detrimental if presented to the client. Reasons for removing sections shall be documented in the record.
(4) Clients have the right to appeal a decision limiting access to their records to the director.
(5) Clients have the right to request the correction of inaccurate, irrelevant, outdated or incomplete information in their records.
(6) Clients have the right to submit rebuttal data or memoranda to their own records.
On 4/24/2018, Clinic Director will notify the Clinical Care Coordinator to submit a request for the form to be updated. The correction will be completed by 7/2/2018. |
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 a review of the physician and physician assistant schedules conducted on April 10, 2018, the facility failed to provide narcotic treatment physician services at least 1 hour per week onsite for every ten patients.A schedule was submitted that indicated the hours worked for the physician and the physician extender staff, as well as the patient census, for the period from October 29, 2017 through March 31, 2018. The facility was not in compliance for the following weeks:November 12-November 18, 2017: census 503, coverage 49.75 hrsNovember 19-November 25, 2017: census 522, coverage 28 hrsNovember 26-December 2, 2017: census 519, coverage 49.58 hrsDecember 10, 2017- December 16, 2017: census 524, coverage 49.25 hrsDecember 17, 2017- December 23, 2017: census 527, coverage 50.75 hrsDecember 24, 2017- December 30, 2017: census 524, coverage 17 hrsDecember 31, 2017- January 6, 2018: census 522, coverage 49.5 hrsJanuary 7, 2018-January 13, 2018: census 522, coverage 49.5 hrsJanuary 14, 2018-January 20, 2018: census 523, coverage 50.25 hrsJanuary 21, 2018-January 27, 2018: census 522, coverage 50 hrsJanuary 28, 2018-February 3, 2018: census 522, coverage 49.25 hrsFebruary 4, 2018-February 10, 2018: census 521, coverage 49.75 hrsFebruary 11, 2018-February 17, 2018: census 519, coverage 50.25 hrsFebruary 18, 2018-February 24, 2018: census 511, coverage 50.5 hrsFebruary 25, 2018-March 3, 2018: census 510, coverage 49.5 hrsMarch 4, 2018-March 10, 2018: census 513, coverage 49.5 hrsMarch 11, 2018-March 17, 2018: census 515, coverage 49.25 hrsMarch 18, 2018-March 24, 2018: census 515, coverage 50 hrsMarch 25, 2018-March 31, 2018: census 516, coverage 24 hrsThis information was reviewed with the facility staff during the licensing inspection.
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Plan of Correction
Clinic Director will reach out to Medical Directors at other Acadia run CTC facilities to obtain onsite support during scheduled PTO time. Medical Director will work additional hours as needed to ensure that there is at least 1 hour per week onsite for every ten patients or another contracted physician will be utilized. This will be the responsibility of the Clinic Director and Regional Director and will be implemented starting 4/30/2018. |
715.6(e) LICENSURE Physician Staffing
(e) A physician assistant or certified registered nurse practitioner may perform functions of a narcotic treatment physician in a narcotic treatment program if authorized by Federal, State and local laws and regulations, and if these functions are delegated to the physician assistant or certified registered nurse practitioner by the medical director, and records are properly countersigned by the medical director or a narcotic treatment physician. One-third of all required narcotic treatment physician time shall be provided by a narcotic treatment physician. Time provided by a physician assistant or certified registered nurse practitioner may not exceed two-thirds of the required narcotic treatment physician time.
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Observations
Based on a review of the physician and physician assistant schedules conducted on April 10, 2018, the facility failed to ensure that a narcotic treatment physician provided at least one third of the required physician time.A schedule was submitted that indicated the hours worked for the physician and the physician extender staff, as well as the patient census, for the period from October 29, 2017 through March 31, 2018. The facility was not in compliance for the following weeks:December 24, 2017- December 30, 2017: census 524, coverage 17 hrsall conducted by physician assistant.This information was reviewed with the facility staff during the licensing inspection.
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Plan of Correction
The Clinic Director will reach out to other Medical Directors within the CTC Division to provide onsite support as needed during scheduled vacation, training, or other time off requested by the facility medical Director to ensure that the Physician Extender is not onsite without face-to-face physician support more than 2/3 of the required hours based on current census. The Clinic Director and Regional Director will be responsible for this item and the process will be implanted by 4/30/2018. |
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
Six methadone client records were reviewed on April 11, 2018, the facility failed to conduct an annual physical examination on time for client #3.Client #3 was admitted on 10/9/16 and was an active client at the time of the licensing inspection. An annual physical exam was conducted on 2/21/17; the annual physical exam was due to be completed by 2/21/18 but had not been completed at the time of the licensing inspection.This information was reviewed with the facility staff during the licensing inspection.
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Plan of Correction
As the facility switched to a new electronic record, some of the original admission dates did not transfer over correctly from the previous system. This issue was resolved by or IT Department on 4/13/2018. As a back-up, the Director of Nursing will be responsible for maintaining a tracking sheet with all admission dates to ensure that all annual physicals are completed prior to the due date, which is the anniversary of the admission date. Client #3 was provided with an annual physical. As of today's date, all required physicals have been completed and the system all physicals listed at 100% complete. |
715.28(a)(1-10) LICENSURE Unusual incidents
(a) A narcotic treatment program shall develop and implement policies and procedures to respond to the following unusual incidents:
(1) Physical assault by a patient.
(2) Inappropriate behavior by a patient causing disruption to the narcotic treatment program.
(3) Selling of drugs on the premises.
(4) Complaints of patient abuse (physical, verbal, sexual and emotional).
(5) Death or serious injury due to trauma, suicide, medication error or unusual circumstances.
(6) Significant disruption of services due to disaster such as fire, storm, flood or other occurrence.
(7) Incident with potential for negative community reaction or which the facility director believes may lead to community concern.
(8) Theft, burglary, break-in or similar incident at the facility.
(9) Drug related hospitalization of a patient.
(10) Other unusual incidents the narcotic treatment program believes should be documented.
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Observations
The facility's policy and procedure manual was reviewed on April 9, 2018. The policy failed to include the following elements with regard to the reporting of unusual incidents: (9) Drug related hospitalization of a patient. (10) Other unusual incidents the narcotic treatment program believes should be documented.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Clinic Director will meet with Clinical Care Coordinator for the CTC Region to review the POC on 4/26/2018. Clinical Care Coordinator will be responsible for ensuring the policy related to unusual incident reporting includes the following:
(9) Drug related hospitalization of a patient.
(10) Other unusual incidents the narcotic treatment program believes should be documented.
These findings were reviewed with facility staff during the licensing process.
As there is an approval process to make any updates to policies and procedures, this will be completed by 6/29/2018. |
709.92(a) LICENSURE Treatment and rehabilitation services
709.92. Treatment and rehabilitation services.
(a) An individual treatment and rehabilitation plan shall be developed with a client. This plan shall include, but not be limited to, written documentation of:
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Observations
Seven client records were reviewed on April 11, 2018, the facility failed to document a comprehensive treatment plan or that the plan was developed with the client in records, #2 & 5.Client #2 was admitted on 11/14/17 and was an active client at the time of the licensing inspection. The comprehensive treatment plan was not documented at the time of the licensing inspection. Client #5 was admitted on 10/24/17 and discharged on 1/25/18. The comprehensive treatment plan was listed as having a due date of 11/24/17 in the electronic records system but was not documented until 1/2/18; additionally this document was not signed by the client and no other documentation was found in the record to indicate that the plan was developed with the client.This information was reviewed with the facility staff during the licensing inspection.
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Plan of Correction
The new electronic record was not deleting upcoming to do items from the system if the patient was discharged. This issue was fixed by the IT Department on 4/13/2018. The new electronic record has a report that will now allow Clinic Supervisors and Counselors to track treatment plans to ensure they are completed prior to the due date. Clinic Directors will be responsible for reviewing this report weekly to ensure no treatment plans are missed or submitted late. This was implemented on 4/13/2018. Client #2 missed counseling sessions but has now completed the required counseling and there was a treatment plan completed in April and another will be completed by June 14, 2018. |
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
Seven client records were reviewed on April 11, 2018, the facility failed to update the treatment plan every 60 days in client records, #1, 4, 6 & 7.Client #1 was admitted on 8/1/11 and was an active client at the time of the licensing inspection. A treatment plan update was documented on 5/1/17; a treatment plan update was due by 9/1/17 but was not documented until 9/5/17.Client #4 was admitted on 11/22/16 and discharged on 3/6/18. A treatment plan update was documented on 11/21/17; a treatment plan update was due by 1/21/18 but was not documented until 1/23/18.Client #6 was admitted on 9/6/16 and discharged on 3/27/18. A treatment plan update was documented on 8/18/17; a treatment plan update was due by 10/18/17 but was not documented until 11/7/17; additionally, another treatment plan update was due by 1/7/18 but was not documented until 1/23/18.Client #7 was admitted on 4/19/17 and discharged on 8/16/17. A comprehensive treatment plan was documented on 8/24/17; a treatment plan update was due by 10/24/17 but was not documented until 10/31/17.This information was reviewed with the facility staff during the licensing inspection.
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Plan of Correction
The new electronic record has a report that will now allow Clinic Supervisors and Counselors to track treatment plans to ensure they are completed prior to the due date. Clinic Directors will be responsible for reviewing this report weekly to ensure no treatment plans are missed or submitted late. This was implemented on 4/13/2018. CLinical Supervisors will also review the productivity logs weekly to review all clinical documentation to ensure nothing is missed. |