INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection and methadone monitoring inspection conducted on November 14, 2019 through November 15, 2019 by staff from the Department of Drug and Alcohol Programs, Bureau of Quality Assurance for Prevention and Treatment. Based on the findings of the on-site inspection, Habit OPCO, Inc. 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 records during the onsite licensing inspection on November 14, 2019 through November 15, 2019, it was determined that the project failed to complete individual training plans for 2 out of 10 employees reviewed.
Employee #3 was hired on June 2, 2014 and was a current employee at the time of the inspection. A written individual training plan was not completed for this employee for the 2019 training year
Employee #8 was hired on January 1, 2019 and was a current employee at the time of the inspection. A written individual training plan was not completed for this employee for the 2019 training year.
These findings were reviewed with project staff during the licensing process.
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Plan of Correction
Pursuant to 704.11, the two staff members in question will have completed Individual training plans in place on 12/30/2019. Both staff in question were direct reports to the previous Clinic Director who resigned their position in October.
As Acadia Healthcare moves to a 'common' Annual Performance review date, all such individual training plans will coincide with this common review date, thereby ensuring on-going and continued compliance consistently. |
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
The Staffing Requirements Facility Summary Report was completed and reviewed on November 14, 2019. Employee #3 was hired as a counselor on June 2, 2014 and was still acting in that position. Employee #3 was reported to have 13 hours per week devoted to their 13 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 37.5. 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: 13/35 = .346(FTE); 13/.346 = 37.5, which equals to a client/counselor ratio of 38:1. The FTE counselor caseload for counseling in outpatient programs may not exceed 35 active clients.
These findings were reviewed with project staff during the licensing process.
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Plan of Correction
In concert with 704.12 additional staffing pattern adjustments have been identified and will take effect on January 1, 2020 which include the reassignment of the CS solely to the Pottstown CTC location as well as the hiring of an additional counselor; the latter to commences their employment on January 6, 2020. A reassignment of caseloads will occur, once this new staff member is on site, which will more accurately reflect regulation expectations for all clinical personnel.
The Clinical Supervisor will review ratios weekly when assigning new admissions to counselors. The Clinic Director will review on a monthly or as needed basis to ensure compliance is maintained.
Additionally, a thorough review of the existing staffing patterns that are in place at HOI-Pottstown CTC will be conducted by the Regional Director and the Clinic Director who commences their employment on January 2, 2020.
Based on the current census and those who meet the criteria of licensing alert 01-14, the facility will meet the 35:1 requrirement.
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705.22 (2) LICENSURE Building exterior and grounds.
705.22. Building exterior and grounds.
The nonresidential facility shall:
(2) Keep the grounds of the facility clean, safe, sanitary and in good repair at all times for the safety and well being of clients, employees and visitors. The exterior of the building and the building grounds or yard shall be free of hazards.
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Observations
During an onsite licensing inspection conducted on November 14, 2019 through November 15, 2019, it was determined that the facility failed to keep the grounds of the facility in good repair at all times for the safety and wellbeing of clients, employees and visitors as evidence by the following:
1) The lower molding was removed throughout the building.
2) The drywall was peeling in multiple places throughout the building.
3) There were holes in the wall.
4) Tile was missing, chipped and/or peeling in multiple places throughout the building.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Regional Director, upon commencing interim coverage of this location, has engaged the landlord in an effort to correct this matter.
This author has met with the contract vendor chosen by the landlord and work is slated to begin beginning of February 2020.
Discussions around the scope of work and a work schedule that will not disrupt center operations has been completed. The established date will provide enough lead time so that any necessary notifications and adjustments to schedule(s) may be made to ensure no disruption to patient care or staff schedules. |
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
During a licensing inspection conducted on November 14, 2019 through November 15, 2019, it was determined that the facility failed to conduct unannounced fire drills monthly. The facility failed to conduct unannounced fire drills for the months of November 2018, December 2018, January 2019, February 2019, March 2019, April 2019, May 2019, June 2019, July 2019, August 2019, September 2019 and October 2019.
These findings were reviewed with facility staff during the licensing process.
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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. The CTC Director will monitor compliance in this area by inspecting the extinguishers and reviewing the Health and Safety documentation quarterly. |
709.26 (b) (3) LICENSURE Personnel management.
§ 709.26. Personnel management.
(b) The personnel records must include, but are not limited to:
(3) Annual written individual staff performance evaluations, copies of which shall be reviewed and signed by the employee.
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Observations
During a licensing inspection conducted on November 14, 2019 through November 15, 2019, the project failed to ensure that personnel records included annual written individual staff performance evaluations for two out of ten personnel records reviewed.
Employee #3 was hire June 2, 2014 and was a current employee at the time of licensing. An annual written individual staff performance evaluation was completed for this employee on March 12, 2018. The next annual written individual staff performance evaluation was to be complete no later than March 12, 2019; however, it was not documented as of the date of the inspection.
Employee #8 was hire January 10, 2009 and was a current employee at the time of licensing. An annual written individual staff performance evaluation was completed for this employee on March 13, 2018. The next annual written individual staff performance evaluation was to be complete no later than March 13, 2019; however, it was not documented as of the date of the inspection.
These findings were reviewed with project staff during the licensing process.
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Plan of Correction
A review of the staff members in question will be conducted by this author and the newly hired Clinic Director. Reviews will be completed and filed accordingly for any past due in concert with the manager responsible for the completion of said review(s).
During the week of January 6, 2020 a training will be afforded to the new Clinic Director and all of the management personnel on site as to the annual performance review completion and the 'common review' date, paper review completion and signing by both staff and supervisor and electronic upload to the electronic personnel record to ensure recorded accountability and future access to such records. |
709.30 (3) 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.
(3) Clients have the right to inspect their own records. The project, facility or clinical director may temporarily remove portions of the records prior to the inspection by the client if the director determines that the information may be detrimental if presented to the client. Reasons for removing sections shall be documented in the record.
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Observations
During a licensing inspection conducted on November 14, 2019 through November 15, 2019, the project failed to inform clients that the project, facility or clinical director may temporarily remove portions of the records prior to the inspection by the client if the director determines that the information may be detrimental if presented to the client. Those reasons for removing sections shall be documented in the record.
These findings were reviewed with project staff during the licensing process.
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Plan of Correction
The Regional Director will work with the Clinic Director, Quality & Compliance Department staff as well as with the Clinical Support and Compliance staff members to review the notifications offered to patients with regards to patient rights and generate an appropriate revision to the existing that includes the language of the Directors ability to temporarily remove portions of the records prior to patient inspection if such a temporary removal is deemed appropriate for the benefit of the patient at the moment.
Such a review will commence with the new clinic director commencing their employment and training; offering a new revision for all Project locations. |
709.34 (a) (1) LICENSURE Reporting of unusual incidents
§ 709.34. Reporting of unusual incidents.
(a) The project shall develop and implement policies and procedures to respond to the following unusual incidents:
(1) Physical assault or sexual assault by staff or a client.
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Observations
During a licensing inspection conducted on November 14, 2019 through November 15, 2019, the project failed to develop and implement policies and procedures to respond to an unusual incident involving physical or sexual assault by staff or a client.
These findings were reviewed with project staff during the licensing process
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Plan of Correction
The Regional Director will work with the Clinic Director, Quality & Compliance Department staff as well as with the Clinical Support and Compliance staff members to review the existing 7.1.18 and ensure that there exists appropriate language exists to address incidents of physical or sexual assault by staff or a patient.
Such revisions will be prepared, along with any other policy revisions, for regional director approval and be disseminated by January 31, 2020. |
709.34 (a) (2) LICENSURE Reporting of unusual incidents
§ 709.34. Reporting of unusual incidents.
(a) The project shall develop and implement policies and procedures to respond to the following unusual incidents:
(2) Selling or use of illicit drugs on the premises.
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Observations
During a licensing inspection conducted on November 14, 2019 through November 15, 2019, the project failed to develop and implement policies and procedures for responding to an unusual incident involving selling or use of illicit drugs on the premises.
These findings were reviewed with project staff during the licensing process.
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Plan of Correction
The Regional Director will work with the Clinic Director, Quality & Compliance Department staff as well as with the Clinical Support and Compliance staff members to review the existing 7.1.18 policies and ensure that language is in place to address unusual incidents involving selling or use of illicit drugs on CTC premises.
As with other policy related reviews and re-drafts, such will be prepared for review and approval by the regional director by January 31, 2020. |
709.34 (a) (3) LICENSURE Reporting of unusual incidents
§ 709.34. Reporting of unusual incidents.
(a) The project shall develop and implement policies and procedures to respond to the following unusual incidents:
(3) Death or serious injury due to trauma, suicide, medication error or unusual circumstances while in residential treatment or, when known by facility, for ambulatory services.
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Observations
During a licensing inspection conducted on November 14, 2019 through November 15, 2019, the project failed to develop and implement policies and procedures for responding to an unusual incident involving death or serious injury due to trauma, suicide, medication error or unusual circumstances while in residential treatment or, when known by facility, for ambulatory services.
These findings were reviewed with project staff during the licensing process.
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Plan of Correction
The Regional Director will work with the Clinic Director, Quality & Compliance Department staff as well as with the Clinical Support and Compliance staff members to review the existing policies and procedures and ensure that language is in place to address unusual incidents involving death or serious injury along with various subsets of origin while actively engaged in an Outpatient treatment setting.
As with other policy related reviews and re-drafts, such will be prepared for review and approval by the regional director by January 31, 2020.
Additionally, such will be followed up with a full staff meeting and training to review the re-drafted policies and procedures. |
709.34 (a) (6) LICENSURE Reporting of unusual incidents
§ 709.34. Reporting of unusual incidents.
(a) The project shall develop and implement policies and procedures to respond to the following unusual incidents:
(6) Event at the facility requiring the presence of police, fire or ambulance personnel.
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Observations
During a licensing inspection conducted on November 14, 2019 through November 15, 2019, the project failed to develop and implement policies and procedures for responding to an unusual incident involving an event at the facility requiring the presence of police, fire or ambulance personnel.
These findings were reviewed with project staff during the licensing process.
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Plan of Correction
The Regional Director will work with the Clinic Director, Quality & Compliance Department staff as well as with the Clinical Support and Compliance staff members to review the existing policies and procedures and ensure that language is in place to address unusual incidents involving an event at the facility requiring the presence of police, fire, or ambulance personnel.
As with other policy related reviews and re-drafts, such will be prepared for review and approval by the regional director by January 31, 2020.
Additionally, such will be followed up with a full staff meeting and training to review the re-drafted policies and procedures. |
709.34 (a) (7) LICENSURE Reporting of unusual incidents
§ 709.34. Reporting of unusual incidents.
(a) The project shall develop and implement policies and procedures to respond to the following unusual incidents:
(7) Fire or structural damage to the facility.
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Observations
During a licensing inspection conducted on November 14, 2019 through November 15, 2019 the project failed to develop and implement procedures in responding to fire or structural damage to the facility.
These findings were reviewed with project staff during the licensing process.
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Plan of Correction
Do not recall being provided with any supporting evidence of this Observation nor discussion to the same; and would welcome such.
To that end, The Regional Director will work with the Clinic Director, Quality & Compliance Department staff as well as with the Clinical Support and Compliance staff members to review the existing procedures and ensure that language is in place to respond to fire or structural damage to the facility. As with other procedure related reviews and re-drafts, such will be prepared for review and approval by the regional director by January 31, 2020.
Additionally, such will be followed up with a full staff meeting and training to review the re-drafted procedures.
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709.34 (a) (8) LICENSURE Reporting of unusual incidents
§ 709.34. Reporting of unusual incidents.
(a) The project shall develop and implement policies and procedures to respond to the following unusual incidents:
(8) Outbreak of a contagious disease requiring Centers for Disease Control (CDC) notification.
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Observations
During a licensing inspection conducted November 14, 2019 through November 15, the project failed to develop and implement procedures in responding to an outbreak of a contagious disease requiring Centers for Disease Control (CDC) notification.
These findings were reviewed with project staff during the licensing process.
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Plan of Correction
Do not recall being provided with any supporting evidence of this Observation nor discussion to the same; and would welcome such.
To that end, The Regional Director will work with the Clinic Director, Quality & Compliance Department staff as well as with the Clinical Support and Compliance staff members to review the existing procedures and ensure that language is in place to respond to an outbreak of a contagious disease requiring Centers for Disease Control (CDC) notification.
As with other procedure related reviews and re-drafts, such will be prepared for review and approval by the regional director by January 31, 2020.
Additionally, such will be followed up with a full staff meeting and training to review the re-drafted procedures. |
709.34 (b) (2) LICENSURE Reporting of unusual incidents
§ 709.34. Reporting of unusual incidents.
(b) Policies and procedures must include the following:
(2) Prompt review and identification of the causes directly or indirectly responsible for the unusual incident.
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Observations
During a licensing inspection conducted on November 14, 2019 through November 15, 2019, the project ' s policy and procedure manual did not provide a procedure on the prompt review and identification of the cause directly or indirectly responsible unusual incidents.
These findings were reviewed with project staff during the licensing process.
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Plan of Correction
The CTC Director will work with the Director of Quality and Compliance to revise the Unusual incident policy (3.4) to clarify the procedure for prompt review and identification of the causes directly or indirectly responsible for the unusual incident. The revision will be completed by 1/31/2020. The CTC Director will review all policy revisions during the February 2020 All Staff Meeting. |
709.34 (b) (3) LICENSURE Reporting of unusual incidents
§ 709.34. Reporting of unusual incidents.
(b) Policies and procedures must include the following:
(3) Implementation of a timely and appropriate corrective action plan, when indicated.
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Observations
During a licensing inspection conducted on November 14, 2019 through November 15, 2019, the project ' s policy and procedure manual did not provide a procedure on the implementation of a timely and appropriate corrective action plan for an unusual incident, when indicated.
These findings were reviewed with project staff during the licensing process.
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Plan of Correction
The CTC Director will work with the Director of Quality and Compliance to revise the Unusual incident policy (3.4) to clarify the procedure on the implementation of a timely and appropriate corrective action plan for an unusual incident, when indicated. The revision will be completed by 1/31/2020. The CTC Director will review all policy revisions during the February 2020 All Staff Meeting. |
709.34 (b) (4) LICENSURE Reporting of unusual incidents
§ 709.34. Reporting of unusual incidents.
(b) Policies and procedures must include the following:
(4) Ongoing monitoring of the corrective action plan.
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Observations
During a licensing inspection conducted on November 14, 2019 through November 15, 2019, the project ' s policy and procedure manual did not provide a procedure on the ongoing monitoring of the corrective action plan for an unusual incident.
These findings were reviewed with project staff during the licensing process.
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Plan of Correction
The CTC Director will work with the Director of Quality and Compliance to revise the Unusual incident policy (3.4) to clarify the procedure for ongoing monitoring of the corrective action plan for an unusual incident. The revision will be completed by 1/31/2020. The CTC Director will review all policy revisions during the February 2020 All Staff Meeting. |
709.34 (b) (5) LICENSURE Reporting of unusual incidents
§ 709.34. Reporting of unusual incidents.
(b) Policies and procedures must include the following:
(5) Reporting mechanism to ensure that reporting of an unusual incident to an entity is in compliance with State and Federal confidentiality laws.
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Observations
During a licensing inspection conducted on November 14, 2019 through November 15, 2019, the project ' s policy and procedure manual did not provide a procedure on the reporting mechanism to ensure that reporting of an unusual incident to an entity is in compliance with State and Federal confidentiality laws.
These findings were reviewed with project staff during the licensing process.
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Plan of Correction
The CTC Director will work with the Director of Quality and Compliance to revise the Unusual incident policy (3.4) to clarify that reporting of unusual incidents to external agencies is to be in compliance with State and Federal confidentiality laws. The revision will be completed by 1/31/2020. The CTC Director will review all policy revisions during the February 2020 All Staff Meeting. |
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
During a licensing inspection conducted on November 14, 2019 through November 15, 2019, the program failed to ensure that a narcotic treatment physician provide narcotic treatment physician services at least 1 hour per week onsite for every ten patients.
Based on the weekly census report for the week of July 14, 2019 through July 20, 2019, the program was to have 24.9 narcotic treatment physician service hours. Fifteen of these hours were covered by a Certified Registered Nurse Practitioner. The program failed to provide documentation for coverage of 9.9 of the 24.9 narcotic treatment physician hours required.
Based on the weekly census report for the week of July 21, 2019 through July 27, 2019, the program was to have 24.8 narcotic treatment physician service hours. Fifteen of these hours were covered by a Certified Registered Nurse Practitioner. The program failed to provide documentation for coverage of 9.8 of the 24.8 narcotic treatment physician hours required.
Based on the weekly census report for the week of July 28, 2019 through August 3, 2019, the program was to have 24.5 narcotic treatment physician service hours. Fifteen of these hours were covered by a Certified Registered Nurse Practitioner. The program failed to provide documentation for coverage of 9.5 of the 24.5 narcotic treatment physician hours required.
Based on the weekly census report for the week of September 29, 2019 through October 5, 2019, the program was to have 23.3 narcotic treatment physician service hours. A narcotic treatment physician provided 14.25 hours and Certified Registered Nurse Practitioner provided 8.5 hours. The program failed to provide documentation for coverage of .55 of the 23.3 narcotic treatment physician hours required.
Based on the weekly census report for the week of October 6, 2019 through October 12, 2019, the program was to have 23.6 narcotic treatment physician service hours. A narcotic treatment physician provided 14.25 hours and Certified Registered Nurse Practitioner provided 6.5 hours. The program failed to provide documentation for coverage of 2.6 of the 23.6 narcotic treatment physician hours.
Based on the weekly census report for the week of October 13, 2019 through October 19, 2019, the program was to have 23.7 narcotic treatment physician service hours. A narcotic treatment physician provided 14.25 hours and Certified Registered Nurse Practitioner provided 7.75 hours. The program failed to provide documentation for coverage of 1.7 of the 23.7 narcotic treatment physician hours required.
Based on the weekly census report for the week of October 20, 2019 through October 26, 2019, the program was to have 23.9 narcotic treatment physician service hours. A narcotic treatment physician provided 14.25 hours and Certified Registered Nurse Practitioner provided 8.25 hours. The program failed to provide documentation for coverage of 1.4 of the 23.9 narcotic treatment physician hours required.
These findings were reviewed with program staff during the licensing process.
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Plan of Correction
The CTC Director will ensure that the Program Physician(s) provide at least 1 hour per week onsite for every ten patients. A Physician schedule has been developed as of 12/18/2019 and will be submitted to the medical staff monthly to ensure there is adequate coverage. The CTC Director will monitor the monthly calendar to ensure there is adequate coverage. |
715.9(a)(4) 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:
(4) Have a narcotic treatment physician make a face-to-face determination of whether an individual is currently physiologically dependent upon a narcotic drug and has been physiologically dependent for at least 1 year prior to admission for maintenance treatment. The narcotic treatment physician shall document in the patient 's record the basis for the determination of current dependency and evidence of a 1 year history of addiction.
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Observations
During a licensing inspection conducted on November 14, 2019 through November 15, 2019, it was determined that the program failed to ensure that a narcotic treatment physician make a face-to-face determination of whether an individual is currently physiologically dependent upon a narcotic drug and has been physiologically dependent for at least 1 year prior to admission for maintenance treatment in 2 out of 14 patient records reviewed.
Patient # 9 was admitted on March 27, 2019 and was a current client at the time of the inspection. There was no documentation that a narcotic treatment physician made a face-to-face determination of whether the patient was currently physiologically dependent upon a narcotic drug and had been physiologically dependent for at least 1 year prior to admission.
Patient # 11 was admitted on March 26, 2019 and was discharged on September 11, 2019. There was no documentation that a narcotic treatment physician made a face-to-face determination of whether the patient was currently physiologically dependent upon a narcotic drug and had been physiologically dependent for at least 1 year prior to admission.
These findings were reviewed with program staff during the licensing process.
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Plan of Correction
The CTC Director will review the admission documentation requirements with the CTC Physician. The Nursing Supervisor will review every admission chart to ensure that all required documentation is in the EHR. The CTC director will also monitor compliance weekly and address non-compliance with the Physician as needed. |
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
During a licensing inspection conducted on November 14, 2019 through November 15, 2019, it was determined that the program failed to document that an informed, voluntary, written consent was obtained prior to an agent being administered in 2 out of 14 patient records reviewed.
Patient #8 was admitted on March 13, 2019 and was a current client at the time of licensing. There was no documentation that informed, voluntary, written consent was obtained prior to an agent being administered.
Patient # 9 was admitted on March 27, 2019 and was a current client at the time of the inspection. There was no documentation that informed, voluntary, written consent was obtained prior to an agent being administered.
These findings were reviewed with program staff during the licensing process.
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Plan of Correction
The admitting prescriber will review the appropriate Informed Consent with the patient and answer any questions. Patient and prescriber will sign the consent. The Nurse Supervisor will review each chart for compliance prior to admission. |
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
During a licensing inspection conducted on November 14, 2019 through November 15, 2019, it was determined that the program failed to provide documentation that 1 out of 14 patients reviewed had received an average of 2.5 hours of psychotherapy per month during the patient's first 2 years, 1 hour of which should be individual psychotherapy.
Patient #3 was admitted on May 3, 2019 and was discharged on November 14, 2019. This patient was missing .5 hours of individual therapy for the month of August 2019. There was no documentation of client no shows or cancellations during those time periods.
These findings were reviewed with program staff during the licensing process.
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Plan of Correction
The CTC Director and Clinical Supervisor are responsible for ensuring compliance with psychotherapy services. The CTC Director & Clinical Supervisor will re-review the requirements for counseling services with all counselors on 1/10/2020. Immediately following this meeting, each counselor will run their Direct Services Analysis reports in SMART and turn into the Clinical Supervisor weekly. Additionally the Clinical Supervisor will run the report monthly and send results to the CTC Director and the Director of Quality and Compliance with a plan of action for overall results below the benchmark of 96%. The Clinical Supervisor will review the reports in individual and group supervision. Ongoing non-compliance in meeting the Direct Services requirement will be addressed by the Clinical Supervisor individually utilizing the Employee Improvement Plan process.
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. |
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
During a licensing inspection conducted on November 14, 2019 through November 15, 2019, it was determined that the program failed to provide documentation that 2 out of 14 patients reviewed had annual physical examinations given by the narcotic treatment program which includes an annual reevaluation by the narcotic treatment physician.
Patient # 2 was admitted on March 24, 2017 and was a current patient at the time of the inspection. An annual physical examination was to be completed no later than March 24, 2019; however, it was not documented as of the date of the inspection.
Patient #5 was admitted on December 16, 2011 and was discharged on November 9, 2019. An annual physical examination was to be completed no later than December 16, 2018; however, it was not documented as of the date of the inspection.
These findings were reviewed with program staff during the licensing process.
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Plan of Correction
The Nursing Supervisor will pull the services due report in the EHR for the upcoming month and schedule annual physicals with the physicians. CTC director will also monitor compliance weekly and address non-compliance with the Physician as needed. |
715.28(a)(1-10) LICENSURE Unusual incidents
(a) A narcotic treatment program shall develop and implement policies and procedures to respond to the following unusual incidents:
(1) Physical assault by a patient.
(2) Inappropriate behavior by a patient causing disruption to the narcotic treatment program.
(3) Selling of drugs on the premises.
(4) Complaints of patient abuse (physical, verbal, sexual and emotional).
(5) Death or serious injury due to trauma, suicide, medication error or unusual circumstances.
(6) Significant disruption of services due to disaster such as fire, storm, flood or other occurrence.
(7) Incident with potential for negative community reaction or which the facility director believes may lead to community concern.
(8) Theft, burglary, break-in or similar incident at the facility.
(9) Drug related hospitalization of a patient.
(10) Other unusual incidents the narcotic treatment program believes should be documented.
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Observations
During a review of the policy and procedure manual on November 14-15, 2019, the program failed to develop and implement policies and procedures to respond to the following unusual incidents:
-Inappropriate behavior by a patient causing disruption to the narcotic treatment program
-Incident with potential for negative community reaction or which the facility director believes may lead to community concern.
-Drug related hospitalization of a patient.
These findings were reviewed with program staff during the licensing process.
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Plan of Correction
The CTC Director will work with the Director of Quality and Compliance to develop a policy to address how the facility will respond to the following: 1.) inappropriate behavior by a patient causing disruption to the narcotic treatment program, 2.) Incident with potential for negative community reaction or which the facility director believes may lead to community concern. 3.) Drug related hospitalization of a patient. The policy will be developed by 1/31/2020. The CTC Director will review all policy revisions during the February 2020 All Staff Meeting. |
715.28(c)(1-5) LICENSURE Unusual incidents
(c) A narcotic treatment program shall file a written Unusual Incident Report with the Department within 48 hours following an unusual incident including the following:
(1) Complaints of patient abuse (physical, verbal, sexual and emotional).
(2) Death or serious injury due to trauma, suicide, medication error or unusual circumstances.
(3) Significant disruption of services due to a disaster such as a fire, storm, flood or other occurrence.
(4) Incidents with potential for negative community reaction or which the facility director believes may lead to community concern.
(5) Drug related hospitalization of a patient.
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Observations
During a licensing inspection conducted on November 14, 2019 through November 15, 2019, the project ' s policy and procedure manual did not address that a narcotic treatment program shall file a written Unusual Incident Report with the Department within 48 hours following the occurrence of the specific unusual incidents including the following:
-Complaints of patient abuse (physical, verbal, sexual and emotional).
-Death or serious injury due to trauma, suicide, medication error or unusual circumstances.
-Significant disruption of services due to a disaster such as a fire, storm, flood or other occurrence.
-Incidents with potential for negative community reaction or which the facility director believes may lead to community concern.
-Drug related hospitalization of a patient.
These findings were reviewed with program staff during the licensing process.
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Plan of Correction
The CTC Director will work with the Director of Quality and Compliance to revise the Sentinel Event policy (3.4.1) in the PA Operations manual to meet the requirements of the regulation. The revision will be completed by 1/31/2020. The CTC Director will review all policy revisions during the February 2020 All Staff Meeting. |