INITIAL COMMENTS
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This report is a result of an on-site licensure renewal and methadone monitoring inspection conducted on March 30 - 31, 2023 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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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. Employee #4 was hired as a counselor on September 14, 2015 and was still acting in that position. Employee #4 was reported to have 40 hours per week devoted to their 40 clients on their caseload.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.The FTE counselor ' s caseload calculation is as follows: 40/40 = 1 (FTE); 40/1= 40, which equals to a client/counselor ratio of 40:1.These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
To address staff ratio requirements, Coatesville CTC is engaged in aggressive hiring activities, including attending Career Link Job fair dated April 5, 2023. We have open positions posted on electronic job boards as well. CTC has a new hire scheduled to start during the month of April 2023. As we continue to address staffing issues during this unique period, CD and CS will review caseloads periodically to ensure patients receive the appropriate standard care level. We will continue these recruitment tactics until which time we are fully staffed. The CD is working closely with our HR business partner on recruitment activities. |
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 May 2022 through March 2023, the facility failed to conduct unannounced fire drills at least once a month. There was no documentation of a fire drill occurring in June 2022.The finding was reviewed with facility staff during the licensing inspection.
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Plan of Correction
On April 26, 2023, we will facilitate a Mandatory staff meeting where the Health and Safety committee will meet to present the need for various Health and Safety reviews, including monthly fire drills. The CD will ensure that all monthly unannounced fire drills are conducted and documented accordingly. The CD and the Facility Health and Safety Committee officers will conduct routine reviews of the Health and Safety binder to ensure compliance in all areas, including monthly fire drills, and during such, the reviews of the point of egress and operational integrity of the smoke detectors ensuring appropriate documentation of same. |
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 May 2022 through March 2023 fire drill logs, the facility failed to document whether the fire alarm or smoke detector was operative during the May 2022, October 2022, November 2022 and December 2022 fire drills.This finding was reviewed with facility staff during the licensing inspection.
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Plan of Correction
During the April 26, 2023, Mandatory staff meeting the Health and Safety Committee will meet to present the need for various Health and Safety reviews, including monthly fire drills. The CD will ensure that all monthly unannounced fire drills are conducted and documented accordingly. The Facility Health and Safety Committee officers will conduct routine reviews of the Health and Safety binder to ensure compliance in all areas, including monthly fire drills, and during such, the reviews of the point of egress and operational integrity of the smoke detectors ensuring appropriate documentation of same. |
709.28 (c) LICENSURE Confidentiality
§ 709.28. Confidentiality.
(c) The project shall obtain an informed and voluntary consent from the client for the disclosure of information contained in the client record.
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Observations
Based on a review of patient records, the facility failed to obtain a consent to release information form prior to releasing information in one out of eight records reviewed. There was no consent to release information form for the funding source. Facility staff confirmed billing had occurred. Patient #5 was originally admitted on December 20, 2018 and discharged on August 30, 2022. The patient was readmitted on December 1, 2022 and was still active at the time of the inspection.The finding was reviewed with facility staff during the licensing inspection.
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Plan of Correction
n April 12, 2023, all counselors were provided with training on how to ensure that an appropriate Release of Information (ROI) is completed during admission, readmission, and annual updates as required. CS will monitor this practice during weekly chart audits with a focus on admission charts. CD will spot-check this practice during the Chart to Charge Audit Process. Deficiencies will be reviewed with the CS and returned to the counselor to ensure there is fluid communication to correct such practices. |
715.6(d) LICENSURE Physician Staffing
(d) A narcotic treatment program shall provide narcotic treatment physician services at least 1 hour per week onsite for every ten patients
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Observations
Based on the review of physician timesheets from November 6, 2022 through February 25, 2023, the facility failed to provide at least one hour of physician time a week onsite for every ten patients in two out of the sixteen weeks reviewed.During the week of November 20 - 26, 2022, the patient census was 443. The facility was required to provide at least 44.3 physician hours. There were 41.75 physician hours documented.During the week of December 11-17, 2022, the patient census was 441. The facility was required to provide at least 44.1 physician hours. There were 39 physician hours documented. These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
Effective April 3, 2023, the CD and MD will plan accordingly to ensure appropriate medical coverage is in place during any/all vacation and/or missed MD time due to illness during the week in question.
Additional Physician service personnel such as Physician's Assistant/CRNP will be added to ensure compliance is readily available, to which CD and MD will continue to monitor and plan accordingly for sustained MD coverage on site. CD will send weekly reports to the Regional Director to monitor and ensure physician/mid-level coverage and full adherence to §715.6(e). We will utilize a physician/practitioner, or mid-level to cover needed hours. If/when needed, the medical hour exception for vacation or other such will be utilized. |
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 a review of patient records, the facility failed to document monthly random urinalysis with results in one out of eight applicable records reviewed.Patient #1 was admitted on February 14, 2019 and was still active at the time of the inspection. There were no documented results for the March 16, 2023 urinalysis. The finding was reviewed with facility staff during the licensing inspection.
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Plan of Correction
Effective April 3, 2023, medical staff will review all urine drug screens at the end of the day, on a daily basis. The review will focus on any "force tests" to ensure that the urine is collected. Should the review discover there was no urine drawn, medical can reconcile the data for accuracy. Charge Nurse and their team will complete a review of urinalysis testing on the last week of each month to ensure any and all necessary NFTs are in place. |
715.20(1) 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.
(1) The transferring narcotic treatment program shall transfer patient files which include admission date, medical and psychosocial summaries, dosage level, urinalysis reports or summary, exception requests, and current status of the patient, and shall contain the written consent of the patient.
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Observations
Based on a review of patient records, the facility failed to document that it transferred patient files the narcotic treatment program to which the patient was transferring to in one out of one applicable record reviewed.Patient # 5 was admitted on December 20, 2018 and discharged on August 30, 2022. The finding was reviewed with facility staff during the licensing inspection.
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Plan of Correction
During the mandatory staff meeting held on April 12, 2023, a review of the Pt. Transfer Policies were reinforced and a 'checklist' was provided to all staff to be used for all Pt transfers. CS and CN will assign all staff to complete the training on patient transfer to reinforce this discussion. CD, CS, and CN will actively monitor each such Pt transfer to ensure the process is followed. |
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 that it notified a patient's previous facility of the patient's admission including the date of initial dose in one out of two applicable records reviewed.Patient #5 was admitted on December 1, 2022 and was still active at the time of the inspection.The finding was reviewed with facility staff during the licensing inspection.
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Plan of Correction
During the mandatory staff meeting held on April 12, 2023, a review of the Pt. Transfer Policies were reinforced and a 'checklist' was provided to all staff to be used for all Pt. transfers. CS and CN will assign all staff to complete the training on patient transfer to reinforce this discussion. CS and CN will actively monitor each such transfer and approve paperwork to be sent prior to the initial send and will review policy/procedures during weekly supervision. Beginning immediately, CD will add this to chart reviews and weekly management meetings. |
715.22(b) LICENSURE Patient grievance procedures
(b) The procedure shall permit aggrieved patients a full and fair opportunity to be heard, to question and confront persons and evidence used against them and to have a fair review of their grievances by the narcotic treatment program director. If the grievance is filed against the narcotic treatment program director, the review of the case shall be conducted by either a multi-representative group of the narcotic treatment program or a subcommittee of the governing body instituted for the express purposes of grievance adjudication.
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Observations
Based on the review of grievances submitted by patients and the facility's policy and procedures manual, the facility failed to document whether the client was given a grievance hearing, if a resolution was found and results of the grievance. The policy and procedures manual states with a grievance, the clinical director must meet with the patient within three working days and respond within 48 hours of the meeting. The two grievances without documentation were filed by patient # 9 and 10.Patient #9 was admitted on June 22, 2021 and was still active at the time of the inspection.Patient #10 was admitted on March 8, 2017 and was still active at the time of the inspection. These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
During the mandatory staff meeting held on April 3, 2023, a review of the Pt. Grievance Policies were reinforced and a 'checklist' was provided to all staff to be used for all Pt. grievances. CN and CS will assign all staff to complete the training on patient grievances to reinforce this discussion. CD, CS, and CN will actively monitor each such Pt grievances to ensure that the aggrieved Pt has a full and fair opportunity to be heard. Beginning immediately, CD will add this to chart reviews and weekly management meetings |
715.23(c)(1-7) LICENSURE Patient records
(c) An annual evaluation of each patient 's status shall be completed by the patient 's counselor and shall be reviewed, dated and signed by the medical director. The annual evaluation period shall start on the date of the patient 's admission to a narcotic treatment program and shall address the following areas:
(1) Employment, education and training.
(2) Legal standing.
(3) Substance abuse.
(4) Financial management abilities.
(5) Physical and emotional health.
(6) Fulfillment of treatment objectives.
(7) Family and community supports.
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Observations
Based on the review of patient records, the facility failed to document an annual clinical evaluation within the regulatory timeframe in one out of two applicable records reviewed.Patient #1 was admitted on February 14, 2019 and was still active at the time of the inspection. The annual clinical evaluation was due on February 14, 2023; however, it was not completed until February 22, 2023.The finding was reviewed with facility staff during the licensing inspection.
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Plan of Correction
To ensure all Annual evaluations are completed thoroughly and timely, staff will continue to be provided with their 'Services Due' list printout each day and such will be reviewed with the Counselor End of Day Checklist that is to be presented, in person to the CS daily. Weekly reviews for content and thoroughness will be conducted during regular supervision. |