INITIAL COMMENTS
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This report is a result of an on-site complaint investigation conducted on June 4-5, 2024, by staff from the Bureau of Program Licensure. Based on the findings of the on-site complaint investigation, Pottstown Comprehensive Treatment Center was found not to be in compliance with the applicable chapters of 28 PA Code which pertain to the facility.
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Plan of Correction
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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
Based on a physical plant inspection, it was observed that the facility failed to be kept in good repair at all times for the safety and well-being of clients, employees and visitors. The thermostat mounted on the wall of the Conference Room/Group Room had a broken cover with wires exposed.
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Plan of Correction
Wall-mounted thermostat cover in Conference Room/Group Room was replaced on 6/19/24. Clinic Director will monitor compliance in this area to ensure thermostats covers remain in good repair for the safety and well-being of patients, employees and visitors. |
705.23 (2) LICENSURE Counseling or activity areas and office space
705.23. Counseling or activity areas and office space.
The nonresidential facility shall:
(2) Maintain counseling areas with furnishings which are in good repair.
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Observations
Based on a physical plant inspection, it was observed that the facility failed to maintain counseling area furnishings in good repair.Eleven chairs in the Conference Room/Group Room were observed to have the material worn off the seats of the chairs.
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Plan of Correction
Conference Room/Group Room chairs were replaced on 6/14/24.
Clinic Director will ensure compliance is maintained in this area. CD will monitor during monthly Health and Safety compliance review, and replace furnishings as needed. |
705.26 (2) LICENSURE Heating and cooling.
705.26. Heating and cooling.
The nonresidential facility:
(2) May not permit in the facility heaters that are not permanently mounted or installed.
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Observations
Based on a physical plant inspection, it was observed that the facility contained a heater that was not permanently mounted or installed.A portable heater was observed sitting on the floor of the Conference Room/Group Room. This heater was not permanently mounter or installed.
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Plan of Correction
Clinic Director removed portable heater from Conference Room/Group Room immediately upon notification from auditor.
CD reviewed with all staff on 6/4/24 and 6/5/24 that portable heaters are not permitted in facility. CD will regularly monitor for continued compliance in this area. |
715.15(b) LICENSURE Medication dosage
(b) The narcotic treatment physician shall determine the proper dosage level for a patient, except as otherwise provided in this section. If the narcotic treatment physician determining the initial dose is not the narcotic treatment physician who conducted the patient examination, the narcotic treatment physician shall consult with the narcotic treatment physician who performed the examination before determining the patient 's initial dose and schedule.
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Observations
Based on a review of patient records and the Dose Changes After Induction Period (Medication Maintenance Phase) policy, the facility's narcotic treatment physician failed to determine the proper dosage level for a patient.The Dose Changes After Induction Period (Medication Maintenance Phase) policy indicates that for routine medication dose change requests, the patient will meet with clinical/medical staff and a Dose Evaluation form will be completed in the patient record. The physician/physician extender will review the Dose Evaluation form and document determination. Patient # 2 was admitted on June 12, 2015, and was an active patient at the time of the complaint investigation. A Dose Evaluation form dated 3/6/24 requesting to decrease the current methadone dose of 80 mg, by 1 mg per week was observed in the chart. The facility physician signed the Dose Evaluation on 3/20/24 stating the request was received for a dose evaluation and the dose was to increase to 85 mg. There was no documentation in the chart indicating why the methadone dosage was increased by 5 mg instead of decreased as requested.
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Plan of Correction
Clinic Director met with Medical Director, Charge Nurse and Clinical Supervisor on 6/5/2024, and Nurse Practitioner on 6/6/24 to review dose changes and Dose Evaluation policy/procedures to ensure dose change requests are addressed, determination documented in pt. record. MD determination will be reviewed with pt before dosing. Charge Nurse reviewed Dose Eval policy and procedures with all nursing staff on 6/7/24 and 6/8/24. Charge Nurse will monitor for compliance in this area. |
715.19(3) LICENSURE Psychotherapy services
A narcotic treatment program shall provide individualized psychotherapy services and shall meet the following requirements:
(3) After 4 years of treatment, a narcotic treatment program shall provide each patient with at least 1 hour of group or individual psychotherapy every 2 months. 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 narcotic treatment program failed to provide individualized psychotherapy services, for at least 1 hour, every two months for a patient who has been in treatment for over 4 years, in one of five records reviewed.Patient # 2 was admitted on June 12, 2015, and was an active patient at the time of the complaint investigation. In December 2023, the patient had 30 minutes of individual therapy and 0 hours of group therapy. In January 2024, the patient had 0 minutes of individual therapy and 0 hours of group therapy. There was no documentation of patient no shows or cancellations during his time period.
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Plan of Correction
Clinical Supervisor reviewed with all clinical staff on 6/19/24 the regulatory guidelines for individualized psychotherapy services, and the policy/procedure for documentation of clinical services for patients who are both clinically-compliant and non-compliant. Clinical Supervisor will monitor during monthly chart reviews to ensure compliance is maintained in this area. |