INITIAL COMMENTS
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This report is a result of an on-site licensure renewal and methadone monitoring inspection conducted on November 3-5, 2021 by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, Habit OPCO, Inc. - Pottstown 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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704.7(b) LICENSURE Counselor Qualifications
704.7. Qualifications for the position of counselor.
(a) Drug and alcohol treatment projects shall be staffed by counselors proportionate to the staff/client and counselor/client ratios listed in 704.12 (relating to full-time equivalent (FTE) maximum client/staff and client/counselor ratios).
(b) Each counselor shall meet at least one of the following groups of qualifications:
(1) Current licensure in this Commonwealth as a physician.
(2) A Master's Degree or above from an accredited college with a major in chemical dependency, psychology, social work, counseling, nursing (with a clinical specialty in the human services) or other related field which includes a practicum in a health or human service agency, preferably in a drug and alcohol setting. If the practicum did not take place in a drug and alcohol setting, the individual's written training plan shall specifically address a plan to achieve counseling competency in chemical dependency issues.
(3) A Bachelor's Degree from an accredited college with a major in chemical dependency, psychology, social work, counseling, nursing (with a clinical specialty in the human services) or other related field and 1 year of clinical experience (a minimum of 1,820 hours) in a health or human service agency, preferably in a drug and alcohol setting. If a person's experience did not take place in a drug and alcohol setting, the individual's written training plan shall specifically address a plan to achieve counseling competency in chemical dependency issues.
(4) An Associate Degree from an accredited college with a major in chemical dependency, psychology, social work, counseling, nursing (with a clinical specialty in the human services) or other related field and 2 years of clinical experience (a minimum of 3,640 hours) in a health or human service agency, preferably in a drug and alcohol setting. If a person's experience was not in a drug and alcohol setting, the individual's written training plan shall specifically address a plan to achieve counseling competency in chemical dependency issues.
(5) Current licensure in this Commonwealth as a registered nurse and a degree from an accredited school of nursing and 1 year of counseling experience (a minimum of 1,820 hours) in a health or human service agency, preferably in a drug and alcohol setting. If a person's experience was not in a drug and alcohol setting, the individual's written training plan shall specifically address a plan to achieve counseling competency in chemical dependency issues.
(6) Full certification as an addictions counselor by a statewide certification body which is a member of a National certification body or certification by another state government's substance abuse counseling certification board.
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Observations
Based on a review of personnel records, the facility failed to document that each counselor met both the education and experiential qualifications for the position.Employee #8, who was hired as a counselor on September 20, 2021, did not meet the experience requirements to be a counselor. At the time of the hire, the employee did not have one year of clinical experience required to be a counselor with a bachelor's degree. The findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
Pottstown CTC will ensure that all Counselor staffing additions meet the necessary educational and experience requirements to hold the counselor position. Pottstown CTC will also ensure that prior to hire date, all resumes are reviewed thoroughly to ensure the accurate representation of experience and competency in chemical dependency treatment for regulatory bodies is indicated. Any and all future new hires for clinical staff members will require the presentation of all necessary data and supporting documentation to the Clinic Director and or their designee to ensure all areas of 704.7 are met prior to the hire date. |
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 the Staffing Requirements Facility Summary Report and personnel records, the facility failed to document the completion of 24 clock hours of annual training required for counselors.Employee #4 was hired as a counselor on July 6, 2010 and was still in the position as of the date of the onsite inspection. The facility's training year that was reviewed was from January 1, 2020 through December 31, 2020. Employee # 4's record only document 14 hours and 14 minutes of annual training for the training year reviewed.The findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
Pottstown CTC Clinical Management team will ensure that each and every clinical staff member completes the required number of annual trainings expected during a calendar year. 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 12, 2021. Also discussed was that the staff ensure that certificates of completion of trainings are provided to the Clinical Supervisor so that it may be accurately represented in ones' personnel file. This effort will remain ongoing, and monitored monthly by Clinical Supervisor to ensure this is not a repeat deficiency for Pottstown CTC. |
704.12(a)(6) LICENSURE OutPatient Caseload
704.12. Full-time equivalent (FTE) maximum client/staff and client/counselor ratios.
(a) General requirements. Projects shall be required to comply with the client/staff and client/counselor ratios in paragraphs (1)-(6) during primary care hours. These ratios refer to the total number of clients being treated including clients with diagnoses other than drug and alcohol addiction served in other facets of the project. Family units may be counted as one client.
(6) Outpatients. FTE counselor caseload for counseling in outpatient programs may not exceed 35 active clients.
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Observations
Based on the review of the Staffing Requirements Facility Summary Report, the facility failed to keep client/staff ratios at or below the regulation limit of 35/1.The counselor Full Time Equivalent (FTE) is determined by dividing the total number of hours the counselor devotes to their clients by facility ' s work week. Then, in order to obtain the counselor ' s ratio, the total number of clients on the counselor ' s caseload is divided by the FTE.Employee # 3 was hired as a clinical supervisor on November 1, 2021 and was still acting in that position. Employee #3 was reported to have 13 hours per week devoted to their 15 clients on their caseload. The FTE caseload calculation is as follows: 13/37.5 = .34 (FTE); 15/.34 = 44.1, which equals to a client/counselor ratio of 44:1.Employee #7 was hired as a counselor on May 24, 2021 and was still acting in that position. Employee #7 was reported to have 38 hours per week devoted to their 41 clients on their caseload.The FTE caseload calculation is as follows: 38/37.5 = 1.01 (FTE), 41/1.01 = 40.5, which equals to a client/counselor ratio of 40:1.Employee #8 was hired as a counselor on September 20, 2021 and was still acting in that position. Employee #8 was reported to have 38 hours per week devoted to their 37 clients on their caseload.The FTE caseload calculation is as follows: 38/37.5 = 1.01 (FTE); 37/1.01 = 36.6, which equals to a client/counselor ratio of 36:1.These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
Plan of Correction: By January 2022, the Clinic Director will hire two additional staff to correct the issue of ratio compliance. Based on the current census and those who meet the criteria of licensure alert 01-14, the facility will meet the 35:1 requirement with the addition of (2) clinical staff members. The Clinical Supervisor will monitor the ratio weekly when assigning new admissions to counselors. The CTC Director will monitor census weekly to ensure compliance with this regulation and hire additional staff as needed. To be noted, Pottstown CTC has had a very difficult time hiring new employees during the pandemic. During this audit period, the Clinic Director and Clinical Supervisor were actively engaged in the process of scheduling and completing interviews to replace staff who resigned.
Subsequent to the date of this audit, a new clinician has been identified and offered the position on site in Pottstown with a start date of December 7, 2021. Pottstown CTC is still recruiting for another additional staff member - once identified, this hire will place Pottstown CTC back into compliance with this regulation.
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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 fire drill logs from January 2021 - October 2021, the facility failed to conduct unannounced fire drills at least once a month. There was no documentation of a fire drill occurring during the months of March, June and July 2021.This is a repeat citation from November 15, 2019 and December 30, 2020 annual licensing inspections. These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
The Health and Safety Liaison will conduct at minimum, one fire drill per month and document the drill using the designated Emergency drill form, which notes the time the fire drill took place, the time it took to evacuate, the exit route used, the number of people in the facility at the time of the fire drill, and any problems that may have been encountered during the drill. The CTC Director will monitor compliance in this area by inspecting the extinguishers and reviewing the Health and Safety documentation monthly. |
705.28 (d) (5) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(5) Prepare alternate exit routes to be used during fire drills.
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Observations
Based on a review of fire drill logs from January 2021 - October 2021, the facility failed to prepare alternative exit route to be used during fire drills, as all drills utilized the same exit routes. The findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
The Health and Safety Liaison will conduct at a minimum, one fire drill per month and document the drill indicating the exit route used, ensuring that alternate exit routes be used during the drills. The CTC Director will monitor compliance in this area by inspecting the extinguishers and reviewing the Health and Safety documentation monthly. |
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 the review of patient records, the facility failed to document an informed and voluntary consent to release information form prior to the disclosure of information in one out of ten patient records reviewed.Patient #5 was admitted on September 20, 2021 and was still active at the time of the inspection. The patient's record did not have a release form for the funding source. Contact was made with the funding source on September 20, 2021. The findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
Pottstown CTC Clinic Director and Office Manager will ensure that all release of information forms are obtained for all patients. All releases of information will be reviewed for accuracy and that these releases of information are completed in its entirety on a monthly basis. This information was presented during the November 12, 2021 staff meeting to ensure compliance to this regulation. The CTC Director will monitor compliance in this area. |
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 the review of patient records, the facility failed to obtain a complete informed and voluntary consent which includes specific information to be disclosed in one out of ten patient records.Patient #1 was admitted on November 13, 2020 and was still active at the time of the inspection. A release form dated July 22, 2021 to a government agency did not list what information could be released. These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
Pottstown CTC Clinic Director and Office Manager will ensure that all release of information forms are obtained with specific information disclosed. All releases of information will be reviewed for accuracy and that these releases of information are completed in its entirety on a monthly basis. This information was presented during the November 12, 2021 staff meeting to ensure compliance to this regulation. The CTC Director will monitor compliance in this area. |
709.33 (a) LICENSURE Notification of termination.
§ 709.33. Notification of termination.
(a) Project staff shall notify the client, in writing, of a decision to involuntarily terminate the client ' s treatment at the project. The notice shall include the reason for termination.
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Observations
Based on the review of patient records, the facility failed to notify the client, in writing, of a decision to involuntarily terminate the client's treatment at the project in one out of one applicable patient record.Patient #7 was admitted on February 3, 2021 and discharged on July 8, 2021. The findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
Clinical Supervisor will provide, upon the decision of involuntarily termination, all patients with written notification of such decision with the reason identified. CTC Director will ensure compliance with this regulatory requirement is maintained.
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715.7(b) LICENSURE Dispensing or Administering Staffing
(b) Dispensing time shall be prorated for patient census. There shall be sufficient dispensing staff to ensure that all patients are medicated within 15 minutes of arrival at the dispensing area.
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Observations
Based on direct observation and interviews with patients and staff, the facility failed to ensure all patients are medicated within 15 minutes of arrival at the dispensing area. Through direct observation by Department staff, the wait time was observed to be approximately 45 minutes. Patient and staff interviews revealed that a wait time of 45 minutes to two hours occurs on a regular basis, with the wait time being as long as three hours occasionally. This is a repeat citation from the December 30, 2020 annual licensing inspection. The findings were reviewed with facility staff at the time of the licensing inspection.
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Plan of Correction
On December 7, 2021 an additional staff member was hired and on-boarded as part of the nursing dispensing team at Pottstown CTC.
Pottstown CTC is presently in compliance to the regulation and will ensure continued compliance with the ability to maintain a competent staff schedule to same. Additional per diem Nursing staff will be hired/utilized when full-time nursing staff are absent.
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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 verify the individual's identity or obtain an emergency contact in two out of four applicable records reviewed.Patient #4 was admitted on July 23, 2021 and was still active at the time of the inspection. No ID was documented in the client's record. Patient #6 was admitted on August 31, 2020 and was still active at the time of the inspection. There was no emergency contact in the patient's recordThese findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
Pottstown CTC will obtain a copy of each patient's identity in the form of a state issued photo ID, driver's license, and/or birth certificate and social security card prior to the initial administration of medication. The office manager will monitor each patients chart on a weekly basis to ensure that patient identification is present. This information was presented during an all staff meeting on November 12, 2021. |
715.12(1-5) LICENSURE Informed patient consent
A narcotic treatment program shall obtain an informed, voluntary, written consent before an agent may be administered to the patient for either maintenance or detoxification treatment. The following shall appear on the patient consent form:
(1) That methadone and LAAM are narcotic drugs which can be harmful if taken without medical supervision.
(2) That methadone and LAAM are addictive medications and may, like other drugs used in medical practices, produce adverse results.
(3) That alternative methods of treatment exist.
(4) That the possible risks and complications of treatment have been explained to the patient.
(5) That methadone is transmitted to the unborn child and will cause physical dependence.
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Observations
Based on a review of patient records, the facility failed to obtain an informed written consent prior to administering an agent in one out of four applicable records.Patient #7 was admitted on February 3, 2021 and discharged on July 8, 2021. The findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
Pottstown CTC Medical Director and Clinical Supervisor will ensure that each patient record reflects informed written consent upon admission, prior to administration of medication. This information was reviewed with Clinical Supervisor and Medical Director during managers meeting on November 10, 2021 to ensure compliance to this regulation. Pottstown CTC Clinic Director will monitor during patient record review monthly for compliance. |
715.13(a) LICENSURE Patient identification
(a) A narcotic treatment program shall use a system for patient identification for the purpose of verifying the correct identity of a patient prior to administration of an agent.
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Observations
Based on direct observation of medication administration, the facility failed to verify the correct identity of the patient prior to administration of an agent in one observed patient. The facility's policy and procedures manual, section 6.1.1 states the dispensing nurse will verify the patient's identity by asking for their patient ID number and current dose level. The dispensing nurse did not verify the current dose level in one observed dosing. In addition, nine patients were not asked to remove their hats prior to being dosed, which is outlined in the policy and procedures manual in section 6.1.1. The findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
Dispensing nurses will ensure the patient verifies current dose and Patient ID # prior to medication administration. Additionally, dispensing nurses will ensure that every patient removes hats and/or sunglasses in order to verify identity prior to medication administration. Clinic Director reviewed this process with dispensing nurse staff for consistency with dispensing nurse staff presented this information during the staff meeting on November 12, 2021. The Charge Nurse and CTC Director will monitor compliance in this area. |
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 the review of patient records, the facility failed to complete random urinalysis at least monthly in two out of ten patient records. Patient # 1 was admitted on November 13, 2020 and was still active at the time of the inspection. There was no documentation of a urinalysis done in August 2021.Patient #9 was admitted on February 22, 2018 and discharged on June 30, 2021. There was no documentation of a urinalysis done in March 2021. These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
All methadone and buprenorphine patients are to provide drug screening analysis samples based on state regulations, at minimum, monthly. Pottstown CTC uses an EMR to randomly generate a monthly urinalysis screening for all patients. Non-compliance with Urinalysis screenings will be addressed individually during Multi-disciplinary Team Meetings. The Charge Nurse and CTC Director will monitor compliance in this area.
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715.14(b) LICENSURE Urine testing
(b) A narcotic treatment program shall develop and implement policies and procedures to ensure that urine collected from patients is unadulterated. These policies and procedures shall include random observation which shall be conducted professionally, ethically and in a manner which respects patient privacy.
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Observations
Based on direct observation, the facility failed to follow their policy and procedures manual to ensure the urine collection from patients is unadulterated in one observed patient. The facility's policy and procedures manual, section 5.12.1 states "a designated staff member will observe the patient entering and exiting the testing area." During direct observation, the staff member did not observe the patient entering or exiting the testing area as they did not look at the monitor while the urine collection took place.The findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
To ensure urine collected from patients is unadulterated, nursing staff will watch monitor while patients are in pt. bathroom during urine collection, as well as when entering and exiting the patient bathroom. Pottstown CTC Clinic Director reviewed this process with nursing staff for during the monthly nursing meeting on November 12, 2021. The Charge Nurse and CTC Director will monitor compliance in this area. |
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 provide each patient with an average of 2.5 hours of psychotherapy per month during the patient's first two years in two out of six applicable patient records. Patient #1 was admitted on November 13, 2020 and was still active at the time of the inspection. The patient received two hours of counseling in August and September 2021 and one hour of counseling in October 2021.Patient #7 was admitted on February 3, 2021 and discharged on July 8, 2021. The patient received 2.5 hours of counseling in March and May 2021, 1.5 hours in April 2021 and one hour with a 30 minute no show appointment in June 2021.This is a repeat citation from the November 15, 2019 and December 30, 2020 annual licensing inspection.These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
Pottstown CTC Clinic Director and Clinical Supervisor are responsible for ensuring compliance with psychotherapy services for all patients within this narcotic treatment program. The Clinical Supervisor reviewed the requirements for counseling services with all counselors on November 22, 2021. As of November 23, 2021, each counselor will run their Direct Services Analysis reports in the EMR and turn into the Clinical Supervisor for verification of patient compliance to psychotherapy. The Clinical Supervisor will review the reports in individual and group supervision.
Patients that missed counseling will be held to meet with a member of the clinical team prior to medicating to address issues of counseling non-compliance. Continued issues of counseling non-compliance after multiple intervention attempts will be brought to the team for consideration of an Administrative Medically Supervised Withdrawal.
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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 a review of patient records, the facility failed to document the notification of the previous narcotic treatment program of the admission and initial dose of the patient in one out of one applicable record.Patient #4 was admitted on July 23, 2021 and was still active at the time of the inspection. The findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
Upon successful transfer of a patient admittance to Pottstown CTC, Administrative Asst or "other designated staff" will send written notification of the previous narcotic treatment program of the admission and initial dose of the patient. Clinic Director reviewed this process with staff during Staff meeting on November 12, 2021. The CTC Director will monitor compliance in this area.
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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 conduct annual physical examination in the regulatory timeframe in four out of five applicable records reviewed.Patient #3 was admitted on February 20, 2018 and discharged on October 8, 2021. An annual physical was due on February 20, 2021. There was no documentation of the exam being completed. Patient #6 was admitted on August 31, 2020 and was still active at the time of the inspection. An annual physical was due on August 31, 2021; however, it was completed on September 20, 2021.Patient # 9 was admitted on February 22, 2018 and discharged on June 30, 2021. An annual physical was due on February 22, 2021; however, it was completed on March 12, 2021. Patient #10 was admitted on March 15, 2019 and discharged on June 4, 2021. An annual physical was due on March 15, 2021. The patient was a no show for an appointment on April 20, 2021 and the exam was completed on April 29, 2021. These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
Pottstown CTC Medical staff will ensure all patient records reflect annual physical examination as per regulatory guidelines. Medical staff and CTC Clinic Director will monitor monthly for compliance. |
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 complete an annual evaluation by the counselor which included a dated signature by the medical director within the regulatory timeframe in three out of five applicable records reviewed.Patient #3 was admitted on February 20, 2018 and discharged on October 8, 2021. An annual clinical evaluation was completed on February 8, 2021; however, it did not have a dated signature of the medical director. Patient #6 was admitted on August 31, 2020 and was still active at the time of the inspection. There was no documentation of a clinical evaluation being completed.Patient #10 was admitted on March 15, 2019 and discharged on June 4, 2021. An annual evaluation was due on March 15, 2021; however, it was completed on May 11, 2021 and did not contain a dated signature of the medical director. These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
Pottstown CTC will ensure that all documentation required for patients files will be completed in a timely manner and will be reviewed by the Clinical Supervisor. 5% of patient charts will be internally audited for completion on a monthly basis.
The clinic director will meet with the Medical Director in order to review the necessity for the Medical Director to review and sign off on all clinical annual evaluations completed by the primary clinicians.
The CTC Director will monitor compliance in this area.
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709.91(b)(7) LICENSURE Intake and admission
709.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(7) Preliminary treatment and rehabilitation plan.
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Observations
Based on a review of patient records, the facility failed to document a preliminary treatment plan within the regulatory timeframe in two out of four records reviewed. The facility's policy and procedures manual states in section 7.1.4 that the preliminary treatment plan must be completed by day seven following admission.Patient #5 was admitted on September 20, 2021 and was still active at the time of the inspection. There was no documentation of a preliminary treatment plan at the time of the inspection.Patient #7 was admitted on February 3, 2021 and discharged on July 8, 2021. The preliminary treatment plan was due on February 10, 2021; however, it was not completed until March 4, 2021.These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
Clinic director and Clinical Supervisor reviewed regulatory guidelines and policy. Preliminary treatment plans will be completed within 7 days of admission to Pottstown CTC. A thorough review of patient treatment plans will be conducted to ensure that counseling staff are completing preliminary treatment plans timely, as per regulation. All treatment plans are reviewed by the Clinical Supervisor for accuracy on a monthly basis. The Clinical Supervisor discussed this regulation on November 22, 2021 with all clinical staff members. The Clinical Supervisor will monitor compliance in this area. |
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 the review of patient records, the facility failed to develop an individual treatment plan within the regulatory timeframe in three out of four applicable records. The facility's policy procedure manual states in section 7.1.4 that the comprehensive treatment plan must be completed between days 8-30. Patient #4 was admitted on July 23, 2021 and was still active at the time of the inspection. There was no documentation of a comprehensive treatment plan at the time of the inspection.Patient #5 was admitted on September 20, 2021 and was still active at the time of the inspection. There was no documentation of a comprehensive treatment plan at the time of the inspection.Patient #8 was admitted on March 24, 2021 and was still active at the time of the inspection. A comprehensive treatment plan was due on April 24, 2021; however, it was not completed until June 11, 2021. These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
The Clinic Director met with the Clinical Supervisor to review regulation 709.92(a). A more thorough review of patient files will be conducted to ensure that counseling staff are completing necessary paperwork and documentation in a timely manner. The continued utilization of the EMR will ensure that all documentation is met within allotted time frames necessary to meet this regulation.
During the November 22, 2021 clinical staff meeting, the clinical supervisor reviewed this regulation and required that all counseling staff complete internal audits of patient electronic records on a weekly basis. The Clinical Supervisor will monitor compliance in this area.
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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 the review of patient records, the facility failed to review and update the patient's treatment plan at least every 60 days in five out of nine records reviewed. Patient #1 was admitted on November 13, 2020 and was still active at the time of the inspection. A treatment plan update was completed on July 15, 2021 with the next one due on September 15, 2021; however, it was not completed until September 23, 2021.Patient #3 was admitted on February 20, 2018 and discharged on October 8, 2021. A treatment plan was completed on March 9, 2021 with the next one due on May 9, 2021; however, it was not done until June 24, 2021. In addition, the patient's record did not have any further treatment plan updates documented. Patient #4 was admitted on July 23, 2021 and was still active at the time of the inspection. There was no documentation of a treatment plan update in the patient's record.Patient #6 was admitted on August 31, 2020 and was still active at the time of the inspection. A treatment plan update was completed on June 7, 2021 with the next one due on August 7, 2021; however, it was not done until September 1, 2021.Patient #8 was admitted on March 24, 2021 and was still active at the time of the inspection. A treatment plan update was completed on July 14, 2021 with the next one due on September 14, 2021; however, it was not done until October 11, 2021.These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
The Clinic Director met with the Clinical Supervisor to review regulation 709.92(b). A more thorough review of patient files will be conducted to ensure that counseling staff are completing necessary paperwork and documentation in a timely manner. The continued utilization of the EMR will ensure that all documentation is met within allotted time frames necessary to meet this regulation.
During the November 22, 2021 clinical staff meeting, the clinical supervisor reviewed this regulation and required that all counseling staff complete internal audits of patient electronic records on a weekly basis. . The Clinical Supervisor will monitor compliance in this area.
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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 patient records, the facility failed to ensure that the patients received counseling services according to their individual treatment plans in seven out of seven applicable records. Patient #1 was admitted on November 13, 2020 and was still active at the time of the inspection. A comprehensive treatment plan dated December 20, 2021 indicated individual weekly sessions and 1.5 hours per week of group sessions. There was no documentation of individual sessions between January 27 - February 8, February 10-21, March 3-22, March 24 - May 10, May 12 - 26, June 3-21, June 24-July 13, August 4-25, August 27 - September 13 and October 1-25, 2021. In addition, there were zero documented group hours during the weeks of April 4-10, April 11-17, one hour documented the week of May 2-8, and two hours documented the weeks of April 18-24 and April 25-May 1, 2021.jPatient #2 was admitted on April 18, 2013 and was still active at the time of the inspection. A treatment plan dated March 24, 2021 indicated monthly individual sessions and group sessions two times per month. There were no documented individual sessions during the month of October 2021. Patient #6 was admitted on August 31, 2021 and was still active at the time of the inspection. A treatment plan update dated June 7, 2021 indicated weekly individual and group sessions. There were no documented individual sessions between June 15- July 29, and July 31-August 29, 2021. In addition, there were no documented group sessions between June 10-22, June 24- July 6, and July 8-18, 2021. Patient #7 was admitted on February 3, 2021 and discharged on July 8, 2021. A comprehensive treatment plan dated March 4, 2021 indicated weekly individual sessions and group sessions two times per month. There were no documented individual sessions between March 5-April 26, April 28 - May 10, May 12 through a documented no show by client on May 26, and May 27 through another no show by the client on June 8, 2021. In addition, there was one documented group session in the patient's record, which occurred on April 23, 2021. Patient #8 was admitted on March 24, 2021 and was still active at the time of the inspection. A comprehensive treatment plan dated June 11, 2021 indicated biweekly individual sessions and 60 minutes of group sessions per week. There were no documented individual sessions between June 26 - July 15, August 13 - 29, and September 24 - October 21, 2021. In addition, there were no documented group sessions between June 26-July 15, July 17-28, July 30 - August 11, August 13 - 29, August 31- September 15, September 17 - October 13, and October 15-27, 2021. Patient #9 was admitted on February 22, 2018 and discharged on June 30, 2021. A treatment plan updated dated March 9, 2021 indicated biweekly individual and group sessions. There were no documented individual sessions after March 9, 2021. Patient #10 was admitted on March 15, 2019 and discharged on June 4, 2021. A treatment plan updated dated March 30, 2021 indicated individual sessions two times per month and group sessions of 90 minutes per week. There was a group session documented on March 12, 2021 with no further sessions documented in the patient's record. These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
The Clinic Director met with the Clinical Supervisor to review regulation 709.92(c). A more thorough review of patient files will be conducted to ensure that counseling staff are completing necessary paperwork and documentation in a timely manner. The continued utilization of the EMR will ensure that all documentation is met within allotted time frames necessary to meet this regulation.
During the November 22, 2021 clinical staff meeting, the clinical supervisor reviewed this regulation and required that all counseling staff complete internal audits of patient electronic records on a weekly basis. . The Clinical Supervisor will monitor compliance in this area.
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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 the review of patient records, the facility failed to document case consultations within the regulatory timeframe in six out of nine applicable patient records. The facility's policy and procedures manual, section 7.3.2 states "all patients will have their treatment reviewed at a minimum, quarterly for the first year and annually thereafter". Patient #1 was admitted on November 13, 2020 and was still active at the time of the inspection. There was one case consultation documented in the patient record on May 13, 2021.Patient #2 was admitted on April 18, 2013 and was still active at the time of the inspection. The last documented case consultation was on November 18, 2019.Patient #4 was admitted on July 23, 2021 and was still active at the time of the inspection. There were no case consultations documented in the patient's record.Patient #6 was admitted on August 31, 2020 and was still active at the time of the inspection. The last case consultation was documented on November 30, 2020. Patient #7 was admitted on admitted on February 3, 2021 and discharged on July 8, 2021. A case consultation was due on May 3, 2021; however, it was not completed until June 14, 2021. Patient #8 was admitted on March 24, 2021 and was still active at the time of the inspection. A case consultation was due on June 24, 2021; however, it was not completed until November 4, 2021.These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
The Clinical Supervisor will continue to conduct weekly and monthly reviews of all services necessary, including that of Case Consultation notes due. The review of this regulation was addressed during clinical staff meeting on November 22, 2021. As of November 22, 2021, each counselor will run their Direct Services Analysis reports in the EMR Case Consults will be documented within the EMR in order to meet this regulation. . The Clinical Supervisor will monitor compliance in this area. |
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 fire drill logs, patient records, direct observation and client/staff interviews, the facility failed to comply with three plans of correction approved by the Department. A plan of correction was submitted to the Department for an inspection occurring on December 30, 2020, addressing the requirement to administer patient's dose within 15 minutes of arrival to the dosing area. Two plans of correction were submitted for inspections occurring on November 14, 2019 and December 30, 2020, addressing the requirement to conduct monthly unannounced fire drills. In addition, two plans of correction were submitted for inspections occurring on November 15, 2019 and December 30, 2020, addressing the requirement to provide 2.5 hours of counseling each month for patients in their first two years of treatment. These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
: Pottstown 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 current plans of correction for this audit period are believed to be attained and maintained with current staffing and policies in place.
Patient Wait Time: Pottstown CTC has experienced nursing staffing difficulties throughout the COVID pandemic. To minimize patient wait times and meet regulatory guidelines, as of November 8, 2021, within 3 days of this audit period, additional nursing staff was brought in from other CTC clinics to assist with dispensing medication. New nursing staff member was hired on December 7, 2021, and recruiting for an additional staff member has occurred to address the need to meet this regulation.
Fire Drills: The Health and Safety Liaison at Pottstown CTC received additional training and a thorough review of the expectations of fire drill procedures and fire drill logs has occurred on November 16, 2021.
Counseling Requirements: If a patient does not meet the minimum counseling requirement during the month, the reason for such will be documented in the patient file. Counselors will continue to attempt to contact patients who are not meeting the minimum monthly counseling requirement immediately following a missed appointment, or after 4 weeks have passed without a clinical session. Patients who continue to refuse to meet minimum counseling requirements are placed on a Treatment Contract. A treatment team meeting is be held to review therapeutic interventions and strategies to increase session attendance. Approved interventions are incorporated into a Treatment Contract that is presented to and signed by the patient. CTC staff will determine, when a non-compliant patient may be eligible for Administrative Discharge due to counseling non-compliance. This decision will be made at a treatment team meeting, with agreement of the CTC physician, and the patient must be placed on an appropriate administrative detoxification schedule. Patient/Staff Ratios: Dunmore CTC has experienced clinical staffing difficulties throughout the COVID pandemic. Within 30 days of this audit period, a new clinical staff member was hired and recruiting for an additional staff member has occurred to address the need to meet this regulation.
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