INITIAL COMMENTS
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This report is a result of an on-site licensure renewal and methadone and buprenorphine monitoring inspection conducted on March 28, 2024 through March 29, 2024 by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, Coatesville Treatment Center was found not to be in compliance with the applicable chapters of 28 PA Code which pertain to the facility. The following deficiencies were identified during this inspection:
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Plan of Correction
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704.7(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 a review of eight personnel records, qualifications for one employee hired as a counselor could not be determined to meet the regulatory requirements for the position at the time of the inspection.Employee # 4 was hired as a counselor on May 22, 2023 and was current in that position at the time of the inspection. Based on documentation provided by the facility, it could not be determined if the employee had a major in a qualifying field. These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
During the interview portion of our hiring process, prospective counselors are required to present proof of a degree in Human Services or a related field, either through a transcript or degree certificate. Commencing April 1, 2024, these documents will be stored electronically in the employee's personnel file. The Clinical Director (CD) will ensure that these documents are obtained from the new employee within the first 30 days of hire by instructing the Clinical Supervisor (CS) to collect the documents from the new counselor. The CD will monitor this process to ensure it is done and will be the back-up if/when the CS is out. The CS will upload the documents into the electronic personnel file (UltiPro). A duplicate transcript was requested by employee #4 on April 1, 2024. As of the date of this POC, the transcript has not arrived. Once it arrives, we will submit a copy via email to this auditor. Oversight of this process will be jointly managed by the CS and CD to ensure availability of such documents on-site.
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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
Based on a review of eight personnel records, the facility failed to ensure that one employee received the minimum of 6 hours of HIV/AIDS training and 4 hours of TB/STD training within the regulatory timeframe.Employee # 7 was hired as a counselor on February 7, 2023 and was due to have the HIV/AIDS and TB/STD trainings no later than February 7, 2024. However, the communicable disease trainings were not completed prior to the inspection. The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Clinical Supervisor (CS) will ensure all new hires secure a DDAP (Department of Drug and Alcohol Programs) account within their three-month probationary period. They will undergo training on HIV/AIDS and TB/STD, to be completed within the first six months of hire. The CS will oversee this process by reviewing training needs monthly and providing guidance and direction with scheduling and completion of said trainings in accordance with regulation § 704.11(c)(1). Employee #7 completed HIV/AIDS training on April 11, 2024, and is scheduled for TB/STD training on May 11, 2024. |
704.11(d)(2) LICENSURE Annual Training Requirements
704.11. Staff development program.
(d) Training requirements for project directors and facility directors.
(2) A project director and facility director shall complete at least 12 clock hours of training annually in areas such as:
(i) Fiscal policy.
(ii) Administration.
(iii) Program planning.
(iv) Quality assurance.
(v) Grantsmanship.
(vi) Program licensure.
(vii) Personnel management.
(viii) Confidentiality.
(ix) Ethics.
(x) Substance abuse trends.
(xi) Developmental psychology.
(xii) Interaction of addiction and mental illness.
(xiii) Cultural awareness.
(xiv) Sexual harassment.
(xv) Relapse prevention.
(xvi) Disease of addiction.
(xvii) Principles of Alcoholics Anonymous and Narcotics Anonymous.
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Observations
Based on a review of eight personnel records, the facility failed to document the completion of 12 clock hours of annual training required for the project director.Employee # 1 has been in the position of Project Director since April 22, 2018. The facility's training year that was reviewed was from January 1, 2023 through December 31, 2023. Employee # 1's employee record only documented 2 hours of training for the period reviewed.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The project director is aware of training hour shortage. The project director will enroll in several trainings throughout the year and provide certificates/registration info. upon completion as needed to ensure ample training hours. |
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 on a review of eight personnel records, the facility failed to document the completion of 12 clock hours of annual training required for the clinical supervisor.Employee # 3 has been in the position of Clinical Supervisor since September 11, 2006. The facility's training year that was reviewed was from January 1, 2023 through December 31, 2023. Employee # 3's employee record only documented 10.5 hours of training for the period reviewed.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The CD will monitor the CS's training progress during weekly supervision to ensure all obligations are met in accordance with regulation 704.11(d)(s). Presently, the CS has completed 45 hours of training in 2024. He is on track to meet this regulatory compliance measure for the coming audit and will remain on track moving forward. |
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 April 2023 through February 2024 fire drill logs, the facility failed to document whether the fire alarm or smoke detector was operative during the August 2023, September 2023, October 2023, November 2023, December 2023, January 2024, and February 2024 fire drills.This is a repeat citation from the March 31, 2023 annual licensing renewal inspection. This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
On April 9, 2024, a designated backup person was assigned to oversee fire drills. This person will conduct drills in the absence of the Health and Safety Officer and will review all health and safety records and forms. The Health and Safety Officer or the designee will submit completed fire drill reports to the CD for review before filing. Post-drill, the Health and Safety Office or Designee will verify the alarm system is functioning properly and ensure alternate exit routes are used. CD will review and sign off on all Fire Drills effective April 2024. |
709.28 (c) LICENSURE Confidentiality
§ 709.28. Confidentiality.
(c) The project shall obtain an informed and voluntary consent from the client for the disclosure of information contained in the client record.
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Observations
Based on a review of nine client records, the facility failed to obtain an informed and voluntary consent to release information form from the client for the disclosure of information contained in three records reviewed. Client # 1 was admitted on December 5, 2023 and was active at the time of the inspection. The record did not contain an informed and voluntary consent form to the funding source; however, there was evidence of billing. Additionally, the record contained documentation of a release of information to a treatment provider on January 22, 2024; however, the consent to release information form to the treatment provider was not signed by the client until February 28, 2024.Client # 4 was admitted on November 17, 2020 and was discharged on December 4, 2023. The consent to release information form to the funding source expired on June 14, 2023; however, there was evidence of billing between June 14, 2023 and the date of discharge. Client # 8 was admitted on February 15, 2023 and was active at the time of the inspection. The consent to release information form to the funding source expired on May 10, 2023; however, there was evidence of billing between May 10, 2023 and the date of the inspection. This is a repeat citation from the March 31, 2023 annual licensing renewal inspection.These findings were discussed with facility staff during the licensing process.
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Plan of Correction
A training session on confidentiality and release of information procedures was conducted by the Clinical Supervisor (CS) on April 1, 2024. The training session provided an overview of §255.5 Part 2 and 42 CFR, Release renewals will occur monthly, coinciding with patients' anniversary dates. During this review we also covered the proper completion of authorizations to release information and appropriate content to same. There was a specific focus on ensuring to obtain a consent before releasing any information outside of the clinic. Compliance will be monitored through monthly chart audits via the quality record review process and peer reviews, with weekly service requirement reviews conducted by the CS. Bi-annual chart audits will be performed by the Clinic Director via the Chart to Charge process. The ROI for patient #8 will be obtained by May 3, 2024 |
709.34 (c) (1) LICENSURE Reporting of unusual incidents
§ 709.34. Reporting of unusual incidents.
(c) To the extent permitted by State and Federal confidentiality laws, the project shall file a written unusual incident report with the Department within 3 business days following an unusual incident involving:
(1) Physical or sexual assault by staff or a client.
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Observations
Based on the review of the unusual incident logbook, the project failed to file a written unusual incident report with the Department within three business days following an unusual incident involving the physical or sexual assault by staff or a client.There was documentation of a patient assault on August 4, 2023; however, there was no documentation that a written unusual incident report was ever filed with the Department.These findings were reviewed with project staff during the licensing process.
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Plan of Correction
The CD will ensure written unusual incident reports are submitted to DDAP within three business days of the date the incident occurred. A tickler file will be used by the CD to outline reporting procedures for unusual incidents. The tickler file will be used to ensure all reporting steps are completed and in compliance with regulation 709.34(c)(1). Compliance with this regulation will be further monitored during weekly supervisor with the RD to ensure that unusual incident reports are recorded and reported in accordance with §709.34(C)(1). The three incident reports in question were submitted on April 25, 2024. |
709.34 (c) (4) LICENSURE Reporting of unusual incidents
§ 709.34. Reporting of unusual incidents.
(c) To the extent permitted by State and Federal confidentiality laws, the project shall file a written unusual incident report with the Department within 3 business days following an unusual incident involving:
(4) Event at the facility requiring the presence of police, fire or ambulance personnel.
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Observations
Based on the review of the unusual incident logbook, the project failed to file a written unusual incident report with the Department within three business days following an unusual incident involving the presence of police, fire, or ambulance personnel.There was documentation of the presence of ambulance personnel on February 1, 2024, as well as police personnel on October 13, 2023 and August 4, 2023; however, there was no documentation that written unusual incident reports were ever filed with the Department.These findings were reviewed with project staff during the licensing process.
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Plan of Correction
The CD will ensure written unusual incident reports are submitted to DDAP within three business days of the incident. A tickler file will be implemented by the CD to outline reporting procedures for unusual incidents. The RD will monitor compliance with regulation 709.34(c)(4) during weekly supervision. The three incidents in questions were submitted to the DDAP incident report portal on April 25, 2024 |
715.6(d) LICENSURE Physician Staffing
(d) A narcotic treatment program shall provide narcotic treatment physician services at least 1 hour per week onsite for every ten patients
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Observations
Based on the review of physician timesheets from October 29, 2023 through February 24, 2024, the facility failed to provide at least one hour of physician time a week onsite for every ten patients in one week reviewed.During the week of December 24, 2023 through December 30, 2023, the patient census was 449. The facility was required to provide at least 44.9 physician hours. There were only 40.25 physician hours documented. This is a repeat citation from the March 31, 2023 annual licensing renewal inspection.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Starting on April 1, 2024, and based on the appropriate ratio required for Physician coverage under §715.6(e) the Clinic Director (CD) and Medical Director (MD) will plan accordingly to ensure that appropriate medical coverage is in place during any/all vacation and/or missed MD time due to illness, inclement weather and/or other emergencies during the week in question.
Additional Physician service
personnel will be added to ensure compliance is readily available. CD and MD will continue to monitor and plan accordingly for sustained MD coverage on site. While we remain committed to ensuring there is adequate patient coverage in accordance with regulation 715.6(d), should we find the need arises, we will seek an exception to these regulations but only as a last resort.
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715.9(a)(2) 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:
(2) Verify the individual 's identity, including name, address, date of birth, emergency contact and other identifying data.
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Observations
Based on a review of patient records, the facility failed to ensure that emergency contact information was obtained during the intake process in one of four records reviewed.Patient # 1 was admitted on December 5, 2023 and was active at the time of the inspection. Emergency contact information was not obtained until February 7, 2024, and the record contained no documentation showing that the patient declined to provide it during the intake process or that there was a lapse in attendance preventing the information from being gathered. The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
On April 1, 2024, the Clinical Supervisor (CS) will review the admission process with all counseling staff, emphasizing obtaining signatures on releases such as Emergency Contacts and Insurance Providers on admission day. Other pertinent contacts requiring immediate attention will also be addressed. Monitoring will occur during monthly intake chart reviews, CS's monthly quality record reviews, and CD's bi-annual Chart to Charge chart audits. |
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 a review of patient records the facility failed to provide each patient an average of 2.5 hours of psychotherapy per month during the patient 's first 2 years, in three of four applicable records.Patient # 1 was admitted on December 5, 2023 and was active at the time of the inspection. The patient only received 1 hour of psychotherapy for the months of January and February 2024.Patient # 5 was admitted on May 2, 2023 and was discharged on February 1, 2024. The patient only received 1 hour of psychotherapy for the month of June 2023 and 1.5 hours in the month of July 2023.Patient # 6 was admitted on August 29, 2023 and was discharged on January 3, 2024. The patient only received 1.25 hours of psychotherapy for the month of September 2023, and only received 1 hour for the months of October 2023 and November 2023.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Effective April 1, 2024, we have instructed counselors to use the EHR SMART calendar system to schedule individual and group sessions. Using this system has prompts for the primary counselor (PC) to reschedule missed sessions the following day and record a no-show note. At month-end, a general note will be completed by the PC for any services missed during the month. A refresher training was provided by the Clinical Supervisor (CS) on April 8, 2024. Compliance with regulation 715.19 (1) will be monitored during supervision, monthly CS Quality Record Reviews, and Bi-annual Chart to Charge Clinic Director chart audits. |
715.23(c)(1-7) LICENSURE Patient records
(c) An annual evaluation of each patient 's status shall be completed by the patient 's counselor and shall be reviewed, dated and signed by the medical director. The annual evaluation period shall start on the date of the patient 's admission to a narcotic treatment program and shall address the following areas:
(1) Employment, education and training.
(2) Legal standing.
(3) Substance abuse.
(4) Financial management abilities.
(5) Physical and emotional health.
(6) Fulfillment of treatment objectives.
(7) Family and community supports.
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Observations
Based on the review of patient records, the facility failed to document a completed annual clinical evaluation signed by the medical director within the regulatory timeframe in two out of four applicable records reviewed.Patient # 3 was admitted on May 22, 2019 and was discharged on November 2, 2023. The annual clinical evaluation was due on May 22, 2023; however, it was not completed until June 19, 2023.Patient # 8 was admitted on February 15, 2023 and was active at the time of the inspection. The annual clinical evaluation completed on February 9, 2024 was not signed by the medical director.This is a repeat citation from the March 31, 2023 annual licensing renewal inspection.The finding was reviewed with facility staff during the licensing process.
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Plan of Correction
Training on monitoring monthly service due requirements was conducted on April 8, 2024, emphasizing peer review focus on annual clinical evaluations. Guidance was provided to ensure all clinical evaluations are signed by the medical director. Monthly quality record reviews will highlight clinical evaluations, with daily monitoring by the Clinical Supervisor (CS). The CS will address tardiness trends with the Primary Counselor (PC) during weekly supervision. Weekly service due reports will be checked by the CS on a weekly basis, with discrepancies addressed during weekly supervision with counselors. |
709.93(a)(10) LICENSURE Client records
709.93. Client records.
(a) There shall be a complete client record on an individual which includes information relative to the client's involvement with the project. This shall include, but not be limited to, the following:
(10) Discharge summary.
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Observations
Based on a review of client records, the facility failed to ensure a complete client record included information relative to the client's involvement with the project, to include a discharge summary within seven days of discharge, per facility policy, in three of five applicable records reviewed. Client # 3 was admitted on May 22, 2019 and was discharged on November 2, 2023. The discharge summary was not completed until December 28, 2023.Client # 4 was admitted on November 17, 2020 and was discharged on December 4, 2023. The record did not contain a discharge summary.Client # 5 was admitted on May 2, 2023 and was discharged on February 1, 2024. The record did not contain a discharge summary.The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
On April 8, 2024, training was provided on the completion of discharge summaries within seven days and discharge follow-ups within 30 days on of discharge. To ensure we remain in compliance with regulation 709.93(a)(11), counselors are reminded to strictly adhere to monthly service requirements, monitored through monthly peer reviews, Clinical Supervisor monthly quality record reviews, and Clinic Director bi-annual chart to charge chart audits. |
709.93(a)(11) LICENSURE Client records
709.93. Client records.
(a) There shall be a complete client record on an individual which includes information relative to the client's involvement with the project. This shall include, but not be limited to, the following:
(11) Follow-up information.
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Observations
Based on a review of client records, the facility failed to ensure a complete client record included information relative to the client's involvement with the project, to include follow-up information within 30 days of discharge, per facility policy, in three of five applicable records reviewed. Client # 3 was admitted on May 22, 2019 and was discharged on November 2, 2023. The follow-up was not completed until December 28, 2023.Client # 4 was admitted on November 17, 2020 and was discharged on December 4, 2023. The record did not contain follow-up information.Client # 5 was admitted on May 2, 2023 and was discharged on February 1, 2024. The record did not contain follow-up information.The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Training was provided on April 8, 2024, on discharge summaries within seven days and discharge follow-ups within 30 days. Counselors are reminded to strictly adhere to monthly service requirements, monitored through monthly peer reviews, Clinic Supervisor's monthly chart audits via the Quality Record Review Process, and Clinic Director's bi-annual chart audits via the Chart to Charge process. |
709.14(b)(3) LICENSURE Subchapter B.Licensing Procedures.Restriction
709.14. Restriction on license.
(b) The licensee, using Department forms, shall notify the Department within 90 days of the occurrence of any of the following conditions:
(3) Change in location of the facility.
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Observations
Based on an administrative review and discussion with the Facility Director, the facility failed to notify the Department within 90 days of a change in the location of the services provided. The facility is licensed to operate the outpatient activity at a singular location; however, it is providing drug and alcohol treatment services and medication management at a second location. These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The facility will submit a letter to DDAP indicating that we are transporting medication to Chester County and Delaware County prisons. The letter will include a description of the off-site service, who is providing it along with when and where the service is provided. The letter will be submitted to DDAP by April 30, 2024. The clinic will submit a waiver request as a last resort should all concerted efforts to maintain the proper ratios required in regulation 709.14 (b)(3). The CD will submit a letter notifying DDAP of any change in the location of services when a written service agreement is established. Once the CD is in possession of the written service delivery agreement, the CD will be prompted to draft a change in location of services letter and submit it to the Regional Director (RD) for review and approval. Once the RD has approved the change in services location letter, the CD will submit the letter to DDAP by email. The CD will ensure to complete this process within 30 days of receipt of the services agreement. The RD will monitor compliance of this regulation during weekly supervison. |