INITIAL COMMENTS
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This report is a result of an on-site licensure renewal methadone or buprenorphine monitoring inspection conducted on April 20-22, 2021 by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, Coatesville 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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705.24 (3) LICENSURE Bathrooms.
705.24. Bathrooms.
The nonresidential facility shall:
(3) Have hot and cold water under pressure. Hot water temperature may not exceed 120F.
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Observations
Based on a physical plant inspection, the facility failed to ensure hot water temperatures not exceed 120 degrees farenheit. A bathroom in the dosing building had a sink with hot water temperatures reading 130 degrees farenheit.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The thermostat was turned down so that the water temperature no longer exceeds 120F. The Health & Safety Officer will check the temperature during monthly inspections to ensure that it does not exceed 120F. |
705.24 (7) LICENSURE Bathrooms.
705.24. Bathrooms.
The nonresidential facility shall:
(7) Maintain each bathroom in a functional, clean and sanitary manner at all times.
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Observations
Based on a physical plant inspection, the facility failed to maintain each bathroom in a functional, clean and sanitary manner at all times. During an observation of dosing, a patient reported that urine had been spilled and staff failed to inspect or clean the bathroom before another patient used it.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The bathroom will be checked periodically throughout the dispensing day for cleanliness. If a spill is reported or observed in the bathroom, it will be cleaned immediately. In addition, sanitizing wipes and disinfectant spray will be available at the bathroom window. A handicap rail was also installed in the bathroom if a patient requires such assistance. |
705.28 (a) (1) (i) LICENSURE Fire safety.
705.28. Fire safety.
(a) Exits.
(1) The nonresidential facility shall:
(i) Ensure that stairways, hallways and exits from rooms and from the nonresidential facility are unobstructed.
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Observations
Based on a physical plant inspection, the facility failed to ensure that stairways, hallways and exits from rooms and from the nonresidential facility are unobstructed. An emergency exit in the dosing building was obstructed by a patient sitting in a chair in front of the door. These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The area mentioned will no longer be a place where patients can wait for transportation. Going forward, only two people will be allowed in this area at a time. Patients who are waiting for their suboxone to dissolve will now wait outside of the Director of Nursing's office. |
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 facility fire drill log, the facility failed to conduct unannounced fire drills at least once a month. There was no December 2020 fire drill in a review of fire drills from April 2020 through March 2021. These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Health & Safety Officer will train another staff member to fill in as needed for vacation and time off to ensure that no monthly drills are missed. The Clinic Director will sign the fire drill log immediately. |
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 facility fire drill log, there was no documentation of the exit route used during the fire drill. The fire drill log was reviewed from April 2020 through March 2021.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The evacuation exits are placed on the Emergency Drill report, and the exit routes used during the fire drills will now be circled by the Health & Safety Liaison and signed by the Clinic Director. |
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 two of twelve client records reviewed, the facility failed to obtain an informed and voluntary consent from the client for the disclosure of information in client records # 6 and #9.Client # 6 was admitted on February 26, 2020 and was discharged on July 29, 2020. There was not an informed and voluntary consent from the client for the disclosure of information to a funding source. Authorizations occurred March 1 through July 25 and July 26 through July 29.Client # 9 was admitted on December 16, 2020 and was still active at the time of the inspection. A letter dated March 1, 2021 and March 17, 2021 to "To whom it may concern" and did not have an informed and voluntary consent from the client for the disclosure of information. These findings were reviewed with facility staff during the licensing process.This is a repeat citation from September 18, 2020 and March 20, 2019 inspection.
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Plan of Correction
Going forward all readmissions will have to sign new releases of information. The Primary Counselor and Clinical Supervisor will complete an intake chart review within seven days to ensure that all necessary releases of information are on file. |
709.28 (c) (2) 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. The consent must be in writing and include, but not be limited to:
(2) Specific information disclosed.
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Observations
Based on one of twelve client records reviewed, the facility failed to obtain an informed and voluntary consent from the client for the disclosure of information to include the specific information disclosed to not exceed 255.5 (b).Client # 6 was admitted on February 26, 2020 and was discharged on July 29, 2020. A case note dated August 19, 2020 to a government agency allowed verbally "an explanation of the situation" in regards to the clients reason for discharge. These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Clinical Supervisors conducted a training on confidentiality in group supervision. In addition, Confidentiality training will now be required on each clinical staff member's annual training plan. |
709.30 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.
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Observations
Based on three of ten applicable client records reviewed, the facility failed to provide documentation of written acknowledgement by clients that they have been notified of those rights in client records # 1, 4, and 10. Client # 1 was admitted on February 17, 2021 and was still active at the time of the inspection. An orientation group occurred on March 24, 2021 explaining the orientation process however, there was no acknowledgement by the client that they were notified of their rights. Client # 4 was admitted on March 9, 2021 and was still active at the time of the inspection. There was no written acknowledgement the client was notified of their rights documented in client record. Client # 10 was admitted on August 6, 2020 and was still active at the time of the inspection. The client is a readmit and all client record forms are from previous episode in 2019.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
All admission documentation will be completed again for readmissions. This includes patient rights which are part of the admission forms. The assigned Counselor and Clinical Supervisor will monitor to ensure that the necessary forms are completed upon admission by completing an intake chart review within seven days of admission. |
715.15(a) LICENSURE Medication Dosage
(a) The narcotic treatment physician shall review the dosage levels at least twice a year, with each review occurring at least 2 months apart, to determine a patient 's therapeutic dosage.
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Observations
Based on two of three applicable patient records reviewed, the facility failed to have a narcotic treatment physician perform the semi-annual dose review to determine the patient's therapeutic dosage in patient records # 3 and 5.Patient # 3 was admitted on April 12, 2005 and was still active at the time of the inspection. A dose review conducted on April 6, 2021 was completed by the physician assistant.Patient # 5 was admitted on May 30, 2019 and was discharged on November 9, 2020. A dose review conducted on May 26, 2020 was completed by the physician assistant.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Medical Director will ensure to complete all dose reviews going forward. |
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 two of two applicable patient records reviewed, the facility failed to 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 in patient records # 2 and 7.Patient # 2 was admitted on November 3, 2020 and was still active at the time of the inspection. There was no documentation of the admission of the patient and the date of the initial dose given to the patient by the receiving narcotic treatment program.Patient # 7 was admitted on July 16, 2020 and was discharged on November 25, 2020. There was no documentation of the admission of the patient and the date of the initial dose given to the patient by the receiving narcotic treatment program.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Clinical Supervisors will train another Counselor to be responsible for transfers in/out of the program. The Case Manager will be responsible for confirming transfers in writing to the referring clinic. The confirmation documentation will be uploaded in Stored Documents in the electronic chart. |
709.91(b)(4) LICENSURE Intake and admission
709.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(4) Consent to treatment.
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Observations
Based on two of two applicable client records reviewed, the facility failed to provide intake documentation to include consent to treatment forms in client records # 10 and 12.Client # 10 was admitted on August 6, 2020 and was still active at the time of the inspection. There was not a consent to treatment form documented in the client record for the activity of drug-free treatment or an informed consent to treatment prior to the administration of an agent. . Client # 12 was admitted on June 16, 2020 and was discharged on October 29, 2020. There was not a consent to treatment form documented in the client record. These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
All readmissions will have to sign a new consent to treatment. The Clinical Supervisor and Primary Counselor will complete an intake chart review within seven days to ensure that the consent to treatment was signed. In addition, an IT Ticket will be submitted so that a drug-free consent to treatment will now populate for all drug-free patients. |
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
Based on one of two applicable client records reviewed, the facility failed to provide an individual treatment and rehabilitation plan developed with the client within 30 days of admission per the facility policy and procedure manual.Client # 12 was admitted on June 16, 2020 and was discharged on October 29, 2020. There was not an individual treatment and rehabilitation plan developed with the client documented in the client record. These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
An IT ticket was submitted and resolved so that now treatment plans generate at the required intervals for drug-free patients. In addition, we have the ability to create a treatment plan if the system fails to generate one. The Clinical Supervisors will conduct a record review within 30 days to ensure that the comprehensive treatment plan has been completed in the appropriate time frame. In addition, the Primary Counselor will continue to monitor their electronic charts on a monthly basis and will review treatment plans in particular. Monthly peer reviews will be conducted by the clinical staff to ensure that treatment plans are within compliance. |