INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection and methadone and buprenorphine monitoring inspection conducted on March 18, 2019 through March 20, 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, 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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704.11(c)(1) LICENSURE Mandatory Communicable Disease Training
704.11. Staff development program.
(c) General training requirements.
(1) Staff persons and volunteers shall receive a minimum of 6 hours of HIV/AIDS and at least 4 hours of tuberculosis, sexually transmitted diseases and other health related topics training using a Department approved curriculum. Counselors and counselor assistants shall complete the training within the first year of employment. All other staff shall complete the training within the first 2 years of employment.
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Observations
The facility failed to ensure that all employees completed the mandatory 6 hours of HIV/AIDS and 4 hours of TB/STD training within regulatory time frame based off a review of the facilities Staffing Requirement Facility Summary Report. Employee # 9 was hired as security on January 1, 2017 and both trainings were due no later than January 1, 2019. There was no record of completion in the employee file.Employee # 10 was hired as security on January 1, 2017 and both trainings were due no later than January 1, 2019. There was no record of completion in the employee file. These findings were discussed with facility staff during the licensing process.
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Plan of Correction
Due to scheduling constraints, it is difficult for our guards to go to outside trainings. They are required to complete internal web based trainings each month that are required for all staff companywide. The trainings cover various topics including infectious disease and safety. Clinic Director will see if the internal training meets the curriculum requirement for the License Alert 6-97 and 1-97. If not, an exception request will be submit by 4/12/2019 to exempt the security staff from HIV and TB/STD training. If the request is not approved, the FT guard will be scheduled for the training on his scheduled day to work. The PT guard will be asked if he can request a vacation day from his FT job.
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709.26 (a) (4) LICENSURE Personnel management.
§ 709.26. Personnel management.
(a) The governing body shall adopt and have implemented written project personnel policies and procedures in compliance with State and Federal employment laws. In addition, the written policies and procedures must specifically include, but are not limited to:
(4) Orientation of new employees.
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Observations
The facility failed to adopt and implement written policies and procedures that included the orientation of new employees, based on a review of the facility's policy and procedure manual.The findings were discussed with facility staff during the licensing process.
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Plan of Correction
Acadia Healthcare has a new orientation for new employees through the Onboarding Process. The facility staff did not realize that the location of the policy changed and the Clinic Director was not present during the Exit Survey. The last updates occurred 12/2018. Going forward, the Clinic Director or designee will be provide this information to the auditors during the next monitoring visit to be included in the presubmission documents. The new updates have been in place since 12/2018. The policy will be available for review during the next scheduled monitoring visit in 4/2020. |
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
The facility failed to ensure all employees receive written annual staff performance evaluations.Employee # 2 was hired on February 12, 2007. The previous evaluation was completed March 12, 2018.Employee # 3 was hired on April 2, 2001. The previous evaluation was completed March 13, 2018The findings were discussed with facility staff during the licensing process.
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Plan of Correction
Employee #2 and #3 report directly to Clinic Director who was on maternity leave from 12/9/2018-3/11/2019. Both of the staff had reviews due that same week of return. The reviews were completed on 3/25/2019. The Regional Director covered for the Clinic Director. To give a fair assessment of both employees performance over the last year, the reviews were completed after the Clinic Director's return. If the Clinic Director is on leave, the Regional Director or other designee will ensure that all direct reports are provided with a performance review. |
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
The facility failed to obtain an informed and voluntary consent to release information form prior to the disclosure of information in 4 of 14 client records reviewed. Client #4 was admitted on January 16, 2018 and was discharged on May 30, 2018. There was documentation that contact was made with a funding source; however, there was no consent to release information form documented to the funding source in the record prior to the disclosure.Client #8 was admitted on March 27, 2018 and was active at the time of inspection. There was documentation that contact was made with a funding source; however, there was no consent to release information form documented to the funding source in the record prior to the disclosure.Client #9 was admitted on March 6, 2018 and was active at the time of inspection. There was documentation that contact was made with a funding source; however, there was no consent to release information form documented to the funding source in the record prior to the disclosure.Client #13 was admitted on February 27, 2018 and was discharged on February 13, 2019. There was documentation that contact was made with a funding source; however, there was no consent to release information documented to the funding source in the record prior to the disclosure.The findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
Clinical Supervisor will complete random monthly chart audits to ensure required clinical documentation is not missed. Clinic Staff will complete chart audits for all staff once per quarter and all needed corrections will be submitted to Clinical Supervisor for approval. A training review was completed on 4/1 on required timeframes for clinical documentation including consent to release. Clinical Team was reminded that consent to release need to be completed for funding sources. |
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
The facility failed to provide at least one hour of on-site physician services for every ten patients during every week of the reviewed October 1, 2018 through February 28, 2019 timeframe.The findings were discussed with facility staff during the licensing process.
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Plan of Correction
Clinic Director will work with Regional Director on a plan to increase physician hours by 5/6. A contracted physician will be contacted by the Clinic Director to set up a business affiliation agreement. The contract will be review with the legal department. If a contractor is not secured, Clinic Director will contract the corporate recruiting department that works specifically with finding qualified physicians. Until one is secured, Clinic Director will utilize other physicians in the region to make up the missing hours. |
715.6(e) LICENSURE Physician Staffing
(e) A physician assistant or certified registered nurse practitioner may perform functions of a narcotic treatment physician in a narcotic treatment program if authorized by Federal, State and local laws and regulations, and if these functions are delegated to the physician assistant or certified registered nurse practitioner by the medical director, and records are properly countersigned by the medical director or a narcotic treatment physician. One-third of all required narcotic treatment physician time shall be provided by a narcotic treatment physician. Time provided by a physician assistant or certified registered nurse practitioner may not exceed two-thirds of the required narcotic treatment physician time.
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Observations
The facility failed to ensure that a narcotic treatment physician provided at least one third of the required physician time for two separate weeks within the reviewed period. Based on this review, it was discovered that for the week of December 23- December 29, 2018, the weekly census was 535 and the number of physician hours worked was 8 and for the week of December 30, 2018 - January 5, 2019, the weekly census was 537 and the number of physician hours worked was 0.The findings were discussed with facility staff during the licensing process.
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Plan of Correction
The Clinic Director and Regional Director will be responsible for ensuring additional physician coverage as needed to avoid in shortage in hours based on the MD to patient ratio. A PRN physician will be utilized effective immediately as needed. |