INITIAL COMMENTS
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This report is a result of an on-site licensure renewal and methadone monitoring inspection conducted on October 10-11, 2023, by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, Allentown 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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704.7(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 one of six applicable employees reviewed, the facility failed to provide documentation of the qualifications for one applicable counselor.
Employee # 5 was hired as a counselor on February 20, 2023 and was still in this position at the time of the inspection. Based on a review of employee # 5's personal record and resume, there was no documentation of at least one year of clinical experience for a qualifying bachelor's degree.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The CD completed a review with all hiring Mgmt. personnel and reviewed necessary protocols under the §704 regulations on October 23, 2023. PDF copies of these regulations were also provided to each hiring manager for their use when considering candidates. Each hiring manager will review their short list during Supervisory group sessions with the CD to ensure candidates meet any and all such requirements. Any and all future recommendations 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 actual hire. |
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 one of nine personnel records reviewed, the facility failed to provide a written individual training plan to include documentation of input from both the employee and the supervisor in employee record # 1.
Employee # 1 was hired as the 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.
These findings were reviewed with facility staff during the licensing process.
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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. |
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
Based on a review of personnel records and the facility's Staffing Requirement Facility Summary Report (SRFSR) form, the facility failed to ensure that employee # 10 received the minimum of 6 hours of HIV/AIDS training and at least 4 hours of TB/STD and other health related topics within the regulatory timeframe.
Employee # 10 was hired as a support staff on September 20, 2021 and was still in this position at the time of the inspection. Employee # 10 was due to have the communicable disease trainings no later than September 20, 2023. There was no documentation in the personnel file of the completion of the HIV/AIDS training and the TB/STD training as of the date of the inspection.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Allentown Clinical Management team will ensure that each and every 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 October 23, 2023. Also discussed was that the staff ensure that certificates of completion of trainings are provided to the Clinic Director so that it may be accurately represented in ones' personnel file. Management team will meet bi-annually to ensure their team members have their trainings completed. |
704.11(e)(2) LICENSURE Annual Trng Req-Clin Sup
704.11. Staff development program.
(e) Training requirements for clinical supervisors.
(2) Each clinical supervisor shall complete at least 12 clock hours of training annually in areas such as:
(i) Supervision and evaluation.
(ii) Counseling techniques.
(iii) Substance abuse trends and treatment methodologies in the field of addiction.
(iv) Confidentiality.
(v) Codependency/Adult Children of Alcoholics (ACOA) issues.
(vi) Ethics.
(vii) Interaction of addiction and mental illness.
(viii) Cultural awareness.
(ix) Sexual harassment.
(x) Developmental psychology.
(xi) Relapse prevention.
(xii) Disease of addiction.
(xiii) Principles of Alcoholics Anonymous and Narcotics Anonymous.
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Observations
Based one of one applicable employee personnel records reviewed, the facility failed to provide documentation of at least 12 clock hours of annual training required for a clinical supervisor for the training year January-December 2022 in employee record # 3.
Employee # 3 was hired as a clinical supervisor on August 2, 2020 and was still in this position at the time of the inspection. After a review of employee # 3 ' s personnel record, there was only 11.11 training hours documented.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Allentown 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 October 23, 2023. Also discussed was that the staff ensure that certificates of completion of trainings are provided to the Clinic Director so that it may be accurately represented in ones' personnel file. The CD will also review each manager's training hours on a bi-annual basis. |
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 two of two applicable employee personnel records reviewed, the facility failed to provide documentation of at least 25 clock hours of annual training required for a counselor for the training year January-December 2022 in employee records # 8 and # 9.
Employee # 8 was hired as a counselor on July 12, 2021 and was still in this position at the time of the inspection. After a review of employee # 3 ' s personnel record, there was only 19.67 training hours documented.
Employee # 9 was hired as a counselor on November 23, 2020 and was still in this position at the time of the inspection. After a review of employee # 9 ' s personnel record, there was only 7.02 training hours documented.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Allentown 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 October 23, 2023. Also discussed was that the staff ensure that certificates of completion of trainings are provided to the Clinic Director so that it may be accurately represented in ones' personnel file. Management team will meet bi-annually to ensure their team members have their trainings completed. |
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 review of The Staffing Requirements Facility Summary Report, the FTE counselor caseload for employee # 3 in the outpatient program exceeded 35 active clients.
Employee # 3 was hired as a Clinical Supervisor on August 2, 2020 and was still in this position at the time of the inspection. Employee #3 was reported to have 19 hours per week devoted to their 20 clients on their caseload.
The FTE counselor ' s caseload calculation is as follows: 19/37.5 = .506(FTE); 20/.506 = 39.52, which equals to a client/counselor ratio of 39:1.
The counselor Full Time Equivalent (FTE) is determined by dividing the total number of hours the counselor devotes to their clients by the facilities hours of operation 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 findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Due to recent staff transitions the Management Team has been actively seeking and interviewing candidates to fill vacant positions. This process continues to present as an arduous task, yet the Management Team will continue this effort and will hire qualified candidates to correct these ratios. On the date of this audit, a new clinician began working on site in Allentown. |
705.27 (3) LICENSURE General safety and emergency procedures.
705.27. General safety and emergency procedures.
The nonresidential facility shall:
(3) Limit smoking to designated smoking areas.
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Observations
Based on a physical plant inspection, the facility failed to limit smoking to designated smoking areas. Patients were observed smoking in the front of the building and on the porch away from the designated smoking area.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Beginning immediately the Allentown CTC will increase Pt. education and monitoring with Mgmt. and counseling staff members to ensure Pt. adherence to the use of the designated smoking area; identified by the Property Owner (LLC). |
705.28 (d) (2) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(2) Conduct fire drills during normal staffing conditions.
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Observations
Based on a review of the facility fire drill log for the months of January 2023 through September 2023, the facility failed to conduct fire drills during normal staffing conditions. All documented fire drills occurred after dosing hours ended at 11:00 am when less staff members were at the facility.
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 a quarterly fire drill during dosing hours 530a-1130a and document appropriately. The CTC Clinic Director will monitor compliance in this area by inspecting and reviewing the Health and Safety documentation monthly. |
705.28 (d) (3) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(3) Ensure that all personnel on all shifts are trained to perform assigned tasks during emergencies.
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Observations
Based on two of three applicable personnel records reviewed, the facility failed to ensure that all personnel on all shifts are trained to perform assigned tasks during emergencies upon employment.
Employee # 4 was hired as a counselor on November 7, 2022 and was still in this position at the time of the inspection. Training to perform assigned tasks during emergencies was not documented to have occurred until March 3, 2023.
Employee # 5 was hired as a counselor on February 20, 2023 and was still in this position at the time of the inspection. Training to perform assigned tasks during emergencies was not documented to have occurred until May 10, 2023.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Health and Safety Liaison will provide new staff with fire safety and emergency procedures training within the first 7 days of hire and document appropriately. The CTC Clinic Director will monitor compliance in this area by inspecting and reviewing the Health and Safety documentation monthly. |
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 facility fire drill log for the months of January 2023 through September 2023, the facility failed to maintain a written fire drill record including documentation of any problems encountered during the fire drill for the months of March, May, June, July, August, and September 2023.
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, 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. Management team will meet bi-annually to ensure compliance to Health & Safety requirements. |
705.28 (d) (6) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(6) Conduct fire drills on different days of the week, at different times of the day and on different staffing shifts.
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Observations
Based on a review of the facility fire drill log for the months of January 2023 through September 2023, the facility failed to conduct fire drills on different days of the week, at different times of the day and on different staffing shifts. Eight of the nine months reviewed documented time of drill to be between the hours of 12pm and 1pm.
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 on different days, times of day, 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 reviewing the Health and Safety documentation monthly. Management team will meet bi-annually to ensure compliance to Health & Safety requirements. |
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 one of twelve client records reviewed, the facility failed to obtain an informed and voluntary consent from the client for the disclosure of information to include the specific information disclosed.
Client # 12 was admitted on February 10, 2023 and discharged on July 10, 2023. An informed and voluntary consent from the client for the disclosure of information dated January 27, 2023 to a treatment facility allowed for the release of presence in treatment and nature of project. The information released to the facility included intake data sheet, dosing history, and urinalysis report.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Allentown CTC Clinic Director and Clinical Supervisor will ensure that all release of information forms will indicate a specific purpose of the disclosure to named parties within the ROI prior to any release of information is given. All releases of information will be reviewed for accuracy and that these releases of information are completed in its entirety on a quarterly basis. This information will be presented during the October 23, 2023 all staff meeting to ensure compliance to this regulation. On March 8, 2022 the Regional Director, along with Management team conducted a training on confidentiality and release of information and a second training will be scheduled on December 7, 2023 to ensure all staff are up to date on this information. |
715.13(b) LICENSURE Patient identification
(b) A narcotic treatment program shall maintain onsite a photograph of each patient which includes the patient 's name and birth date. The narcotic treatment program shall update the photograph every 3 years.
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Observations
Based on one of twelve patient records reviewed, the facility failed to maintain onsite a photograph of each patient which includes the patient 's name and birth date and update the photograph every 3 years.
Patient # 5 was admitted on October 18, 2016 and was still active at the time of the inspection. The patient photograph was uploaded on October 18, 2016 and expired February 20, 2019. The photograph was not updated.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Allentown CTC administrative staff will review patient EMR records at time of contact data updates (monthly) by utilizing the quality record review process, to ensure photo ID provided is valid. The CTC Director will monitor compliance in this area by reviewing the quality record review documentation quarterly and bi-annually via the Chart to Charge method. |
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 one of twelve patient records reviewed, the facility failed to document an initial drug-screening urinalysis for each prospective patient and a random urinalysis at least monthly thereafter.
Patient # 7 was admitted on June 4, 2020 and was discharged on August 21, 2023. A random drug-screening urinalysis was not completed for the months of June and July 2023.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Patients provide random monthly drug screening samples as per 715.14(a). Allentown CTC uses an EMR to randomly generate a monthly urinalysis screening for all patients. The Charge Nurse reviews SMART records the final week of the month and place hard holds on all patients who require a DSA for the last day of month. The Charge Nurse will add to this process reviewing all suspended status patients and ensure to document an Unable to Obtain (UTO) notification in the Pt. record to support compliance to 715.14(a) and noting suspended Pt.'s non-presence at the time, and inability to obtain a random urinalysis sample. |
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 four of eight applicable patient records reviewed, the narcotic treatment program 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 patient records # 1, 2, 9, and 10.
Patient # 1 was admitted on June 20, 2023 and was still active at the time of the inspection. There was not at least 2.5 hours of psychotherapy documented the months of July and August 2023.
Patient # 2 was admitted on October 4, 2021 and was still active at the time of the inspection. There was not at least 2.5 hours of psychotherapy documented the months of June and September 2023.
Patient # 9 was admitted on March 7, 2023 and was discharged July 17, 2023. There was not at least 2.5 hours of psychotherapy documented the month of April 2023.
Patient # 10 was admitted on July 1, 2021 and was discharged August 8, 2023. There was not at least 2.5 hours of psychotherapy documented the month of April 2023.
These findings were reviewed with facility staff during the licensing process.
This is a repeat citation from the October 27, 2022 annual licensing inspection.
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Plan of Correction
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 October 23, 2023 during the All-Staff meeting. Each counselor is responsible to 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. Documentation will be added to the Pt. record noting the Pt.'s inability to maintain clinical compliance with updated treatment planning to assist in correcting such and progressive measures to be used as needed to ensure Pt. compliance.
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. |
715.20(3) 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.
(3) The transferring narcotic treatment program shall document what materials were sent to the receiving narcotic treatment program.
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Observations
Based on two of two applicable patient records reviewed, the facility failed to document what materials were sent to the receiving narcotic treatment program.
Patient # 9 was admitted on March 7, 2023 and was transferred on July 17, 2023. Transfer paperwork was not documented in the patient record.
Patient # 10 was admitted on July 1, 2021 and was transferred on August 8, 2023. Transfer paperwork was not documented in the patient record.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Clinic Director, Clinical Supervisor, and Charge Nurse will ensure that any and all documents required for a patient transfer are sent to the receiving facility and then uploaded into patient chart within 7 days. This will be reviewed with clinicians at next All staff meeting October 23, 2023. CD, CS, or CN will initial transfer paperwork to ensure compliance and will monitor while completing monthly Discharge Chart reviews. |
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 one of five applicable patient records reviewed, the facility failed to document an annual evaluation of each patient 's status completed by the patient 's counselor and reviewed, dated and signed by the medical director in patient record # 7.
Patient # 7 was admitted on June 4, 2020 and was discharged August 21, 2023. An annual evaluation was last completed on July 1, 2022; the next evaluation was due to be completed no later than July 1, 2023. The annual evaluation was not documented in the patient record.
These findings were reviewed with facility staff during the licensing process.
This is a repeat citation from the October 27, 2022 and the November 2, 2021 annual licensing inspection.
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Plan of Correction
Clinic director and Clinical Supervisor reviewed 715.23(c)(1-7) and failure to be in compliance with this regulation on October 13, 2023. Allentown 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.
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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 two of six applicable client records reviewed, the facility failed to provide documentation of an individual treatment and rehabilitation plan being developed within 30 days in accordance with the facility policy and procedure manual.
Client # 1 was admitted on June 20, 2023 and was still active at the time of the inspection. The comprehensive treatment and rehabilitation plan was due no later than July 20, 2023. There was not a treatment and rehabilitation plan documented in the client record.
Client # 12 was admitted on February 10, 2023 and was discharged July 10, 2023. The comprehensive treatment and rehabilitation plan was due no later than March 10, 2023. The comprehensive treatment and rehabilitation plan was not developed until March 29, 2023.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Clinic Director met with the Clinical Supervisor to review regulation 709.92(b) on October 13, 2023. From this meeting the CD and CS developed a more thorough review of patient files to 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 October 23, 2023 All 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. Continued quality record reviews will assist with monitoring and ensuring compliance. |
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 six of eleven applicable client records reviewed, the facility failed to assure that counseling services are provided according to the individual treatment and rehabilitation plan in client records # 2, 4, 5, 8, 10, and 12.
Client # 2 was admitted on October 4, 2021 and was still active at the time of the inspection. A treatment and rehabilitation plan update developed on June 2, August 7, and October 4, 2023, indicates a thirty-minute individual session to occur weekly and three sixty-minute group sessions occur monthly. A review of progress notes and record of service did not document individual sessions weekly the months of June, July, August, and September 2023 or three sixty-minute groups the month of July 2023.
Client # 4 was admitted on December 19, 2019 and was still active at the time of the inspection. A treatment and rehabilitation plan update developed on June 16, 2023, indicates a thirty-minute individual session to occur biweekly and sixty-minute group sessions occur weekly. A treatment and rehabilitation plan update on August 23, 2023, indicates a thirty-minute individual session occur two times monthly and a sixty-minute group session occur two times monthly. A review of progress notes and record of service did not document sixty-minute groups weekly the months of June and July 2023 and sixty-minute groups two times monthly the month of September 2023.
Client # 5 was admitted on October 18, 2016 and was still active at the time of the inspection. A treatment and rehabilitation plan update developed on February 15 and June 23, 2023, indicates a thirty-minute individual session to occur biweekly and a sixty-minute group session occur biweekly. A review of progress notes and record of service did not document individual sessions biweekly the months of June, July, August, and September 2023. Also, an individual session on September 29, 2023 was not completed by the counselor but was completed by the certified recovery specialist.
Client # 8 was admitted on August 15, 2022 and was discharged May 11, 2023. A treatment and rehabilitation plan update developed on October 21 and December 13, 2022, and February 15, and April 6, 2023, indicates a thirty-minute individual session to occur weekly and a sixty-minute group session occur weekly. A review of progress notes and record of service did not document thirty-minute individual sessions weekly the months of January, February, March, and April 2023 or sixty-minute groups weekly the months of February, March, and April 2023.
Client # 10 was admitted on July 1, 2021 and was discharged August 8, 2023. A treatment and rehabilitation plan update developed on March 9, May 5, and July 7, 2023, indicates a thirty-minute individual session to occur weekly and a sixty-minute group session occur weekly. A review of progress notes and record of service did not document thirty-minute individual sessions weekly the months of April and May 2023 or sixty-minute groups weekly the months of April, May, and June 2023.
Client # 12 was admitted on February 10, 2023 and was discharged July 10, 2023. A treatment and rehabilitation plan update developed on March 29 and May 26, 2023, indicates a thirty-minute individual session to occur weekly and a sixty-minute group session occur weekly. A review of progress notes and record of service did not document thirty-minute individual sessions weekly the months of March and April 2023 or sixty-minute groups weekly the months of March and April 2023.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Clinic Director met with the Clinical Supervisor to review regulation 709.92(b) on October 13, 2023. 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 October 23, 2023 All 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. CS will also provide additional training to new staff to ensure correct documentation to treatment counseling expectations in treatment plan. |
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 patient records, the facility failed to comply with plans of correction that were approved by the Department.
Plans of correction for an annual evaluation of each patient 's status completed by the patient's counselor and reviewed, dated and signed by the medical director were submitted and approved by the Department for the October 27, 2022 and November 21, 2021 annual licensing inspections. Annual evaluations were again found to be a deficiency in the October 11, 2023 licensing inspection.
Plans of correction for providing 2.5 hours of psychotherapy per month during the patient ' s first 2 years was submitted and approved by the Department for the October 27, 2022 annual licensing inspection. Providing 2.5 hours of psychotherapy per month during the patient ' s first 2 years was again found to be a deficiency in the October 11, 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 that are identified are presented and reviewed with the Regional Director, as these will be. From there the Regional Director brings these issues to the pre-scheduled monthly Director calls for the Region. Upon approval, these items will follow the plan of action already in place by the RD. The RD and the CD's will review the identified item(s) and collaboratively prepare a sustainable corrective measure; all in concert with Licensing regulations and input working to ensure a sustained corrective measure. An Annual Evaluation is expected for all patients, including those that are suspended. CS will conduct a weekly review to identify any and all Annual Evaluations or other such services that populate for all suspended patients and review with counseling staff during supervision to ensure task completion. 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. |