INITIAL COMMENTS
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This report is a result of an on-site licensure renewal, provisional follow-up and methadone monitoring inspection conducted on November 29-30, 2023 by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, Pottstown 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(b)(1) LICENSURE Individual training plan.
704.11. Staff development program.
(b) Individual training plan.
(1) A written individual training plan for each employee, appropriate to that employee's skill level, shall be developed annually with input from both the employee and the supervisor.
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Observations
Based on the review of personnel files, the facility failed to provide a written individual training plan to include documentation of input from both the employee and the supervisor in one out of three applicable files reviewed.Employee # 1 was promoted to project director on April 22, 2018 and was still in this position at the time of the inspection. A training plan was acknowledged by the employee on January 4, 2023; however, there was no documentation of input from both the employee and the supervisor.The finding was reviewed with facility staff during the licensing inspection.
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Plan of Correction
This citation has been presented to the Project Director via the RD. The Individual Training Plan will be revised as per 704.11(b)(1) to include documented input from the Employee as well as their Supervisor and will included the additional signature line for both parties to sign and date accordingly. Such will be put into effect immediately. |
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 an initial drug-screening urinalysis for prospective patients in one out of ten applicable records. Patient #15 was admitted on November 21, 2022 and discharged on July 10, 2023.This is a repeat citation from the October 14, 2022 and May 5, 2023 licensing inspection.The finding was 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. Pottstown CTC will ensure there is documented evidence of an initial drug-screening urinalysis for all patients on day of admission. Compliance to this regulation was reviewed with all nursing staff on December 15, 2023.
Pottstown CTC Charge Nurse and CTC Director will monitor compliance in this area. |
715.16(a)(4) LICENSURE Take-home privileges
(a) A narcotic treatment program shall determine whether a patient may be provided take-home medications.
(4) A narcotic treatment physician may rescind take-home medication privileges.
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Observations
Based on a review of patient records, the facility failed to manage take-home medications by a physician in two applicable records. Patient #12 was admitted on November 29, 2021 and was still active at the time of the inspection. A May 5, 2023 verbal order to rescind take homes was given by a certified registered nurse practitioner.Patient #17 was admitted on June 18, 2021 and was still active at the time of the inspection. Documentation for a October 4, 2023 take home order showed a non-medical personnel gave the order.These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
All Take-home medication orders will be managed by CTC Physician, as evidenced in patient records. Review of this regulation was conducted by CTC Director during nursing staff meeting on December 15, 2023, and reviewed with Pottstown CTC medical providers on December 15 and December 18, 2023. Compliance to this regulation will be montiored by CTC Charge Nurse. |
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 the review of patient records, the facility failed to provide 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, in one out of six applicable records. Patient #10 was admitted on February 22, 2023 and was still active at the time of the inspection. There were no individual sessions in August 2023.This is a repeat citation from the November 15, 2019, December 30, 2020, November 5, 2021, April 21, 2022, October 14, 2022 and May 5, 2023 licensing inspection.The finding was 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 December 6,2023 and December 13, 2023 during clinical supervision. 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. |
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 review of patient records, the facility failed to conduct an annual physical examination in one out of four applicable records.Patient #9 was admitted on July 3, 2019 and discharged on September 28, 2023. There was no documentation of an annual physical in 2023. This is a repeat citation from the November 5, 2021, April 21, 2022, October 14, 2022 and May 5, 2023 licensing inspection.The finding was 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.
Pottstown CTC Medical staff will ensure all patient records reflect annual physical examination as per regulatory guidelines. CTC Charge Nurse will review the services due report in the EHR for the upcoming month and schedule annual physicals with the physicians and patients. Holds will be placed on patients to not only remind them of upcoming appointments, but also on the day of their appointment. CTC Charge Nurse will monitor compliance weekly. CTC Clinic Director will monitor monthly for compliance. Adherence to this policy was reviewed during Nursing staff meeting on December 13, 2023.
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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 a review of patient records, the facility failed to include financial management information in the patient's annual evaluation in seven out of seven applicable records. Patient #9 was admitted on July 3, 2019 and discharged on September 28, 2023. The annual evaluation was completed on February 2, 2023.Patient #11 was admitted on January 11, 2021 and was still active at the time of the inspection. The annual evaluation was completed on December 28, 2022.Patient #12 was admitted on November 29, 2021 and was still active at the time of the inspection. The annual evaluations were completed on November 3, 2022 and November 15, 2023.Patient #13 was admitted on July 5, 2017 and was still active at the time of the inspection. The annual evaluation was completed on July 21, 2023.Patient #17 was admitted on July 18, 2021 and was still active at the time of the inspection. The annual evaluation was completed on June 15, 2023.Patient #18 was admitted on July 26, 2016 and discharged on August 15, 2023. The annual evaluation was completed on July 11, 2023.Patient #19 was admitted on February 24, 2020 and was still active at the time of the inspection. The annual evaluation was completed on February 13, 2023. 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, per state regulation, including financial management information, required for patients files will be present in annual clinincal evaluation. EHR template has been updated, and inclusion of such was also reviewed with clinicians during supervison on December 6, 2023. Compliance to this regulation will be reviewed by the Clinical Supervisor. 5% of patient charts will be internally audited for completion on a monthly basis. The CTC Director will monitor compliance in this area.
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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 the review of client records, the facility failed to document follow-up information according to their policy and procedures manual, in two out of six applicable records. The policy and procedures manual states follow-up will be done at 30 and 90 days post discharge.Client #1 was admitted on October 6, 2013 and discharged on July 17, 2023. There was no documentation of follow-up in the client's record.Client #9 was admitted on July 3, 2019 and discharged on September 28, 2023. Follow-up occurred on October 31, 2023. 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 due, including that of post treatment documentation such as discharge summaries and follow-up contacts on both successful and unsuccessful discharges. Follow up contacts will be assigned by the Clinical Supervisor to either the primary clinician and/or the Admissions team and these contacts will be documented within the EMR in order to meet this regulation. Review of this regulation was conducted by Clinical Supervisor with Admissions/Case Management team on December 13, 2023. Compliance to this regualtion will be monitored monthly by Clinic Director. |
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 client records, the facility failed to comply with plans of correction that were approved by the Department.A plan of correction for patients to receive an average of 2.5 hours of psychotherapy per month during the patient's first two years were submitted and approved by the Department for the November 15, 2019, December 30, 2020, November 5, 2021, April 21, 2022, October 14, 2022 and May 5, 2023.A plan of correction for failure to conduct an annual physical examination in the regulatory timeframe were submitted and approved by the Department for the November 5, 2021, April 21, 2022, October 14, 2022 and May 5, 2023. A plan of correction for failure to complete initial drug-screening urinalysis for each prospective patient and random urinalysis at least monthly thereafter were submitted and approved by the Department for the October 14, 2022 and May 5, 2023 licensing inspections.This is a repeat citation from the November 5, 2021, April 21, 2022, October 14, 2022 and May 5, 2023 licensing inspection.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Any and all repeat deficiencies identified are presented and reviewed with Regional Director, as have these. During Pottstown CTC All-staff meeting held on December 15, 2023, Clinic Director reviewed findings and POC, to address and ensure sustained corrective measures. 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. Annual Physical Examination: CTC Charge Nurse will pull "Services Due" report in the EHR for the upcoming month and schedule annual physical exam appointments with CTC physicians for each pt. due. CTC Clinic Director will also monitor for compliance weekly and address non-compliance with Charge Nurse/Physician as needed. Patients who miss their scheduled appointments will have "holds" placed for pt. to meet with Clinic Director to address non-compliance. Counseling Requirements: If a patient does not meet the minimum counseling requirement during the month, the reason for such will be documented using a General Note providing such information along with using Tx Plan updates and, as needed Treatment Compliance Agreements to support Pt. compliance and success in the patient file. Counselors will continue to contact patients who are not meeting the minimum monthly counseling requirement immediately following a missed appointment and placed on a Hard Hold to identify the rational for the missed session and set to reschedule. Patients who continue to demonstrate counseling non-compliance are placed on a hard hold to review the issues/barriers to compliance and placed on a Treatment Compliance Agreement in an effort to support corrective measures to their Personal Recovery and Journey. A treatment team meeting is be held to review therapeutic interventions and strategies to increase session attendance. Approved interventions are incorporated into a Treatment Compliance Agreement 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 repeat and continued counseling non-compliance and failure to adhere to TCA's provided and continued non-compliance to Tx plan expectations. Alternate Tx modalities are discussed and presented to the Pt. Such requiring various levels of non-compliance and Management agreement to same. 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. |