INITIAL COMMENTS
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This report is a result of an on-site licensure renewal, provisional license follow-up and methadone monitoring inspection conducted on October 12-14, 2022 by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, Habit OPCO, Inc. - Pottstown 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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704.6(e) LICENSURE Supervisory Meetings
704.6. Qualifications for the position of clinical supervisor.
(e) Clinical supervisors are required to participate in documented monthly meetings with their supervisors to discuss their duties and performance for the first 6 months of employment in that position. Frequency of meetings thereafter shall be based upon the clinical supervisor's skill level.
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Observations
Based on a review of employment files, the facility failed to submit documentation for monthly meetings between the clinical supervisor and their supervisor for the first six months of employment in that position.Employee #3 was hired on November 16, 2020 and promoted to clinical supervisor on May 15, 2022.The finding was reviewed with facility staff during the licensing inspection.
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Plan of Correction
Pottstown CTC will ensure that all documentation of monthly supervision between Clinical Supervisor and their supervisor is evident and maintained onsite, thus available during all audits. Clinic Director will monitor monthly to ensure compliance is maintained. |
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 a review of employee files, the facility failed to provide a individual training plan annually for each employee. Employee #5 was hired as a counselor on December 7, 2021 and was still in that position at the time of the inspection. Their 2022 training plan was not completed until May 28, 2022. The finding was reviewed with facility staff during the licensing inspection.
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Plan of Correction
Pottstown CTC will ensure that every employee completes an individual training plan annually. A review of the staff members adherence to this regulation was reviewed and presented during the full staff monthly meeting held on October 21, 2022. CTC Director will ensure that individual training plan is accurately represented in ones' personnel file. This effort will remain ongoing and monitored monthly to ensure this is not a repeat deficiency for Pottstown CTC. |
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 form, the facility failed to ensure that employees received the minimum of six hours of HIV/AIDS training and at least four hours of TB/STD and other health related topics within the regulatory timeframe.Employee #2 was hired as a facility director on August 10, 2020 and was still in that position at the time of the inspection. The employee was due to have the HIV/AIDS training by August 10, 2022; however, it was not completed at the time of the inspection.Employee #4 was hired as a counselor on April 14, 2021 and was still in that position at the time of the inspection. The employee was due to have the communicable disease trainings completed by April 14, 2022. The employee completed HIV/AIDS training on May 27, 2022 and had not completed the TB/STD training as of the time of the inspection.Employee #8 was hired as a counselor on September 20, 2021 and was still in that position at the time of the inspection. The employee was due to have the communicable disease trainings completed by September 20, 2022; however, neither training was completed at the time of the inspection.These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
Employee # 2 Completed PA DDAP "HIV for Substance Use Disorder Professionals" training on 11/15/22. Pottstown CTC 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 21, 2022. Also discussed was that the staff ensure that certificates of completion of trainings are provided to the Clinical Supervisor so that it may be accurately represented in ones' personnel file. This effort will remain ongoing and monitored monthly by Clinical Supervisor to ensure this is not a repeat deficiency for Pottstown CTC. |
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 direct observation, the facility failed to keep grounds of the facility in good repair as the sidewalk had holes which possessed a safety risk to patients, employees and visitors. The finding was reviewed with facility staff during the licensing inspection.
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Plan of Correction
Pottstown CTC Clinic Director reviewed with property owner the area requiring repair. Sidewalk repair was completed on November 12, 2022. Pottstown CTC Clinic Director will monitor facility grounds to ensure facility grounds do not pose a safety risk to patients, employees and visitors. This will be ongoing and monitored weekly by Clinic Director. |
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 a review of personnel files, the facility failed to train employees to perform assigned tasks during emergencies.Employee #5 was hired as a counselor on December 7, 2021 and was still in that position at the time of the inspection.Employee #6 was hired as a counselor assistant on July 5, 2022 and promoted to position of counselor on September 4, 2022 in which he/she still holds.Employee #7 was hired as a counselor on August 29, 2022 and was still in that position at the time of the inspection.Employee #9 was hired as a counselor on September 19, 2022 and was still in that position at the time of the inspection.These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
Pottstown CTC Clinic Director reviewed Emergency Preparedness Plan with all employees during staff meeting on October 21, 2022. This will be reviewed upon hire and annually with all employees. Evidence of such training will be documented and maintained in each employee's personnel file. The CTC Director will monitor compliance in this area by inspecting the Staff Training spreadsheet monthly. |
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 patient records, the facility failed to obtain an informed and voluntary consent form prior to releasing information in one out of nine applicable records.Patient #6 was admitted on July 20, 2022 and was still active at the time of the inspection. There was no consent form for the funding source in the patient's record. Facility staff confirmed billing had occurred. The finding was reviewed with facility staff during the licensing inspection.
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Plan of Correction
Pottstown CTC Clinic Director and Administrative staff will ensure that all release of information forms are obtained for all patients. All releases of information will be reviewed for accuracy and that these releases of information are completed in its entirety on a monthly basis. This information was presented during the October 21, 2022 staff meeting to ensure compliance to this regulation. The CTC Director will monitor compliance in this area. |
709.29 (a) LICENSURE Retention of client records
§ 709.29. Retention of client records.
(a) Client records, regardless of format, shall be readily accessible for a minimum of 4 years following the discharge of a client.
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Observations
During the on-site inspection, the facility failed to have patient records readily accessible as the wait time to gain access for the Department staff was four hours.The finding was reviewed with facility staff during the licensing inspection.
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Plan of Correction
Pottstown CTC Clinic Director will ensure access to patient records will be readily available timely when Department staff arrive to facility for unannounced and announced inspections. |
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
Based on a review of patient records, the facility failed to notify patients that reasons for removing sections shall be documented in the record in five out of five applicable records. Patient #1 was admitted on July 25, 2022 and was still active at the time of the inspection.Patient #4 was admitted on November 29, 2021 and was still active at the time of the inspection.Patient #5 was admitted on December 13, 2021 and was still active at the time of the inspection.Patient #6 was admitted on July 20, 2022 and was still active at the time of the inspection.Patient #9 was admitted on March 17, 2022 and was still active at the time of the inspection.These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
Pottstown CTC has such policy in place (1.2.1) and we will continue to adhere to such policy in accordance with the DDAP standards. All patients are provided with a copy of this policy as evidenced by their signing of the Patient Rights acknowledgement form at admission. Patients are also provided with a copy in their patient handbook which is also acknowledged on the "Patient Orientation" form. Clinical Supervisor will monitor for ongoing compliance. |
709.33 (b) LICENSURE Notification of termination.
§ 709.33. Notification of termination.
(b) The client shall have an opportunity to request reconsideration of a decision terminating treatment.
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Observations
Based on the review of patient records, the facility failed to provide the opportunity to request reconsideration of a decision terminating treatment in one out of one applicable record. Patient #3 was admitted on May 15, 2022 and discharged on July 29, 2022. The finding was reviewed with facility staff during the licensing inspection.
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Plan of Correction
Pottstown CTC Clinical Management Team will ensure patient records will have documented evidence of patient's opportunity to request reconsideration of a decision terminating treatment. CTC Clinic Director reviewed this requirement during monthly all staff meeting on October 21, 2022. CTC Clinic Director will monitor for compliance to this regulation. |
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 for June 5 - October 1, 2022, the facility failed to provide at least one hour of physician time a week, onsite for every ten patients.During the week of June 5 - 11, 2022, the patient census was 359. The facility was required to provide at least 35.9 physician hours. There were 30 physician hours documented. During the week of June 12 - 18, 2022, the patient census was 356. The facility was required to provide at least 35.6 physician hours. There were 34 physician hours documented. During the week of June 19 - 25, 2022, the patient census was 355. The facility was required to provide at least 35.5 physician hours. There were 34 physician hours documented. During the week of June 26 - July 2, 2022, the patient census was 353. The facility was required to provide at least 35.3 physician hours. There were 34 physician hours documented. During the week of July 3 - 9, 2022, the patient census was 355. The facility was required to provide at least 35.5 physician hours. There were 22.5 physician hours documented.During the week of July 10 - 16, 2022, the patient census was 352. The facility was required to provide at least 35.2 physician hours. There were 34 physician hours documented. During the week of July 17 - 23, 2022, the patient census was 348. The facility was required to provide at least 34.8 physician hours. There were 34 physician hours documented. During the week of July 24 - 30, 2022, the patient census was 345. The facility was required to provide at least 34.5 physician hours. There were 34 physician hours documented. During the week of July 31 - August 6, 2022, the patient census was 342. The facility was required to provide at least 34.2 physician hours. There were 30 physician hours documented. During the week of August 7 - 13, 2022, the patient census was 340. The facility was required to provide at least 34 physician hours. There were 30 physician hours documented. During the week of August 14 - 20, 2022, the patient census was 340. The facility was required to provide at least 34 physician hours. There were 28 physician hours documented. During the week of August 21 - 27, 2022, the patient census was 340. The facility was required to provide at least 34 physician hours. There were 31 physician hours documented. These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
Pottstown CTC Clinic Director has reviewed §715.6 and will ensure that appropriate coverage is in place for all Pt.'s per same. Additional coverage is being provided by MD and Mid-Level Practitioner pending the identification of new Mid-Level Practitioners to join the Pottstown CTC Team; job posting for same being filed on 11/29/2022.
In doing so, the Clinic Director will also ensure that the appropriate percentage of Practitioner coverage is in place per regulation [and/or exception if filed??]
CD will continue to complete a weekly documented review of physician hours which is submitted to the Regional Director every Monday for the preceding week, as per direction.
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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
Based on the review of physician timesheets from June 5 - October 1, 2022, the facility failed to provide one-fifth of all physician time by a narcotic treatment physician as required under the facility's granted exception request.During the week of August 21 - 27, 2022, the patient census was 340. The facility was required to provide at least 34 total physician hours, of which 6.8 needed to be provided by the narcotic treatment physician. There were four documented narcotic treatment physician hours. The finding was reviewed with facility staff during the licensing inspection.
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Plan of Correction
Pottstown CTC Clinic Director has reviewed §715.6 and will ensure that appropriate coverage is in place for all Pt.'s per same. Additional coverage is being provided by MD and Mid-Level Practitioner pending the identification of new Mid-Level Practitioners to join the Pottstown CTC Team; job posting for same being filed on 11/29/2022.
In doing so, the Clinic Director will also ensure that the appropriate percentage of Practitioner coverage is in place per regulation.
CD will continue to complete a weekly documented review of physician hours which is submitted to the Regional Director every Monday for the preceding week, as per direction.
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715.7(b) LICENSURE Dispensing or Administering Staffing
(b) Dispensing time shall be prorated for patient census. There shall be sufficient dispensing staff to ensure that all patients are medicated within 15 minutes of arrival at the dispensing area.
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Observations
Based on the review of a wait time report and interviews with patients, the facility failed to medicate within 15 minutes of arrival at the dispensing area, as wait times can be up to 1.5 hours. The findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
Pottstown CTC is presently in compliance to the regulation and will ensure continued compliance with the ability to maintain a competent staff schedule to same. Additional per diem Nursing staff have been hired/utilized when full-time nursing staff are absent.
This corrective measure will ensure continued adherence to this regulation and in meeting the needs of Pt.'s served.
Additionally such will be reviewed by the CD during regular meeting with the nursing team and schedule creation review.
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715.13(a) LICENSURE Patient identification
(a) A narcotic treatment program shall use a system for patient identification for the purpose of verifying the correct identity of a patient prior to administration of an agent.
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Observations
Based on the observation of medication administration, the facility failed to properly verifythe correct identity of a patient prior to administration of an agent. Section 6.1.1, #7d ofthe facility's policy and procedures manual states "patients will present at the dispensing windowwithout hats or sunglasses. There were four observed occurrences where the patients were notasked to remove their hat prior to dosing.This finding was reviewed with facility staff during the licensing inspection.
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Plan of Correction
Dispensing nurses will ensure that every patient removes hats and/or sunglasses in order to verify identity prior to medication administration. Clinic Director reviewed this process with dispensing nurse staff for consistency with dispensing nurse staff and presented this information during the staff meeting on October 21, 2022. The Charge Nurse and CTC Director will monitor compliance in this area. |
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 the review of patient records, the facility failed to document an initial drug-screening urinalysis or random monthly urinalysis in two out of nine records reviewed.Patient #4 was admitted on November 29, 2021 and was still active at the time of the inspection. There was no documented results for the initial urine collected on November 29, 2021.Patient #5 did not have a random monthly urine in July 2022.These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
Pottstown CTC will ensure there is documented evidence of an initial drug-screening urinalysis or random monthly urinalysis for all patients. Clinical Supervisor will ensure that any urinalysis results that do not auto-populate from facility's contracted laboratory into patient's EMR is printed and scanned to patient record as documented evidence. This regulation was reviewed during monthly all staff meeting on October 21, 2022. Clinic Director will monitor for ongoing compliance. |
715.15(d) LICENSURE Medication dosage
(d) A narcotic treatment program shall label all take-home medication with the patient 's name and the narcotic treatment program 's name, address and telephone number and shall package all take-home medication as required by Federal regulation.
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Observations
Based on direct observation during medication administration, the facility failed on one occasion to inspection take home bottles upon return to ensure the labels are intact per the facility's 6.2.11 policy and procedures manual.The finding was reviewed with facility staff during the licensing inspection.
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Plan of Correction
Pottstown CTC will ensure dispensing nurses will properly inspect take home bottles upon return to ensure the labels are intact per the facility's 6.2.11 policy and procedures manual. Adherence to this regulation was reviewed during monthly all staff meeting October 21, 2022. Clinic Director will monitor for ongoing compliance. |
715.17(c)(1)(i-vi)) LICENSURE Medication control
(c) A narcotic treatment program shall develop and implement written policies and procedures regarding the medications used by patients which shall include, at a minimum:
(1) Administration of medication.
(i) A narcotic treatment physician shall determine the patient 's initial and subsequent dose and schedule. The physician shall communicate the initial and subsequent dose and schedule to the person responsible for the administration of medication. Each medication order and dosage change shall be written and signed by the narcotic treatment physician.
(ii) An agent shall be administered or dispensed only by a practitioner licensed under the appropriate Federal and State laws to dispense agents to patients.
(iii) Only authorized staff and patients who are receiving medication shall be permitted in the dispensing area.
(iv) There shall be only one patient permitted at a dispensing station at any given time.
(v) Each patient shall be observed when ingesting the agent.
(vi) Administering and dispensing shall be conducted in a manner that protects the patient from disruption or annoyance from other individuals.
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Observations
Based on observation of medication administration, the facility failed to follow their policy and Procedures manual in regard to administration of medication. Section 6.1.1 of the policy and procedures manual requires patients to speak to the nurse assuring that medication has not been diverted. One patient was not asked to speak prior to leaving the dispensingarea.The finding was reviewed with facility staff during the licensing inspection.
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Plan of Correction
Pottstown CTC will ensure dispensing nurses require all patients to speak to the nurse after receiving medication and prior to leaving pt. dispensing area assuring that medication has not been diverted. Adherence to this regulation was reviewed during monthly all staff meeting on October 21, 2022. Charge Nurse will monitor for ongoing compliance to this regulation. |
715.17(c)(2) LICENSURE Medication control
(c) A narcotic treatment program shall develop and implement written policies and procedures regarding the medications used by patients which shall include, at a minimum:
(2) Drug storage areas. A narcotic treatment program shall develop and implement written policies and procedures regarding storage of medications and access to the medication storage area. Agents shall be stored in a locked safe that has been approved by the DEA under 21 CFR 1301.72 and 1301.74 (relating to physical security controls; and other security controls).
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Observations
Based on direct observation, the facility failed to follow their policy and procedures manual for drug storage areas. The hallway door to the dispensing area was found ajar during medication administration hours on October 13, 2022 at approximately 10:45am. The facility's policy and procedures manual, 6.1.2.6, states "the electronic door between the reception area and medication area must always be locked". The finding was reviewed with facility staff during the licensing inspection.
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Plan of Correction
Pottstown CTC nursing staff will ensure hallway door to dispensary is locked at all times during medication administration hours. Adherence to this policy and regulation was reviewed during monthly all staff meeting on October 21, 2022. Charge Nurse will monitor for ongoing compliance. |
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 the review of patient records, the facility failed to provide 2.5 hours of psychotherapy per month, one hour of which shall be individual psychotherapy, during the patient's first two years in two out of five applicable records.Patient #5 was admitted on December 13, 2021 and was still active at the time of the inspection. During July 2022, the patient received 30 minutes of individual therapy.Patient #9 was admitted on March 17, 2022 and was still active at the time of the inspection. During July 2022, the patient received 30 minutes of individual therapy and zero hours in August 2022.This is a repeat citation from the November 15, 2019, December 30, 2020, November 5, 2021, and April 21, 2022 licensing inspections. These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
Pottstown 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 21, 2022. As of October 24, 2022, each counselor will 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.
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.
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715.20(1) 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.
(1) The transferring narcotic treatment program shall transfer patient files which include admission date, medical and psychosocial summaries, dosage level, urinalysis reports or summary, exception requests, and current status of the patient, and shall contain the written consent of the patient.
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Observations
Based on a review of patient records, the facility failed to transfer patient files in one out of one applicable record. Patient #7 was admitted on September 24, 2019 and discharged on April 7, 2022.The finding was reviewed with facility staff during the licensing inspection.
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Plan of Correction
Pottstown CTC will ensure transfer patient files which include admission date, medical and psychosocial summaries, dosage level, urinalysis reports or summary, exception requests, and current status of the patient are transferred to receiving facility as per regulatory guidelines. Adherence to this regulation was reviewed and presented at monthly all staff meeting on October 21, 2022. Clinical Supervisor will review all transfer procedures are completed per regulation for transferring patients and monitor for compliance. |
715.20(4) 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.
(4) The receiving narcotic treatment program shall document in writing that it notified the transferring narcotic treatment program of the admission of the patient and the date of the initial dose given to the patient by the receiving narcotic treatment program.
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Observations
Based on the review of patient records, the facility failed to notify the transferring narcotic treatment program of the admission of the patient in two out of two applicable records.Patient #4 was admitted on November 29, 2021 and was still active at the time of the inspection.Patient #9 was admitted on March 17, 2022 and was still active at the time of the inspection.These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
Pottstown CTC will ensure proper written notification of the admission of a patient is sent to the transferring narcotic treatment program as per regulatory guidelines. Administrative staff will send written notification to transferring treatment program upon admission to Pottstown CTC. Adherence to this regulation was presented and reviewed during monthly all staff meeting on October 21, 2022. Clinical Supervisor will ensure and monitor compliance. |
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
Based on a review of patient records, the facility failed to document an annual reevaluation by the narcotic treatment physician in two out of two applicable records.Patient #2 was admitted on October 2, 2018 and was still active at the time of the inspection. An annual physical was due on October 2, 2022, however; one was not documented in the record. Patient #3 was admitted on May 15, 2020 and discharged on July 29, 2022. An annual physical was due on May 15, 2022; however, it was not completed until June 13, 2022.This is a repeat citation from the November 5, 2021 and April 21, 2022 licensing inspections. The findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
Pottstown CTC Medical staff will ensure all patient records reflect annual physical examination as per regulatory guidelines. CTC Charge Nurse will review the services due report in the EHR for the upcoming month and schedule annual physicals with the physicians and patients. Holds will be placed on patients to not only remind them of upcoming appointments, but also on the day of their appointment. CTC Charge Nurse will monitor compliance weekly. CTC Clinic Director will monitor monthly for compliance. Adherence to this policy was reviewed during monthly all staff meeting on October 21, 2022. |
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 a review of patient records, the facility failed to document an annual clinical evaluation in two out of two applicable records. Patient #2 was admitted on October 2, 2018 and was still active at the time of the inspection. An annual physical was due on October 2, 2022, however; one was not documented in the record. Patient #3 was admitted on May 15, 2020 and discharged on July 29, 2022. An annual physical was due on May 15, 2022; however, it was not completed until June 13, 2022.This is a repeat citation from the November 5, 2021 and April 21, 2022 licensing inspections.The findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
Pottstown CTC will ensure annual clinical evaluation is completed as per regulatory guidelines.
Clinical Supervisor will monitor Annual Evaluations due on a weekly basis in supervision with staff. This will be accomplished by utilizing the Services Due report via the EMR for respective staff. Weekly review of evaluations will be completed by the CS to ensure completion and signatures will be verified.
CTC clinic director will meet with the Medical Director in order to review the necessity for the Medical Director to review and sign off on all clinical annual evaluations completed by the primary clinicians.
The CTC Director will monitor compliance in this area. Adherence to this regulation was presented and reviewed during monthly all staff meeting on October 21, 2022.
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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 the review of patient records, the facility failed to document a comprehensive treatment plan within the timeframe of 30 days after admitted as outlined in the facility's policy and procedures manual in one out of two applicable records.Patient #6 was admitted on July 20, 2022 and was still active at the time of the inspection. A comprehensive treatment plan was due on August 20, 2022; however, it was not completed until August 30, 2022.This is a repeat citation from the November 5, 2021 and April 21, 2022 licensing inspections. The finding was reviewed with facility staff during the licensing inspection.
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Plan of Correction
The Clinic Director met with the Clinical Supervisor to review regulation 709.92(a). 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. Adherence to this regulation was presented and reviewed during monthly all staff meeting on October 21, 2022. During that same meeting, CTC clinical supervisor required that all counseling staff complete internal audits of patient electronic records on a weekly basis. Compliance will be reviewed with counselors during individual and group supervision. The Clinical Supervisor will monitor compliance in this area.
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709.92(b) LICENSURE Treatment and rehabilitation services
709.92. Treatment and rehabilitation services.
(b) Treatment and rehabilitation plans shall be reviewed and updated at least every 60 days.
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Observations
Based on the review of patient records, the facility failed to update treatment plans at least every 60 days in two out of six applicable records. Patient #1 was admitted on July 25, 2022 and was still active at the time of the inspection. A comprehensive treatment plan was completed on August 3, 2022 with an update due on October 3, 2022; however, it was completed on October 6, 2022.Patient #4 was admitted on November 29, 2021 and was still active at the time of the inspection. A treatment plan update was completed on July 27, 2022 with an update due September 27, 2022; however, it was not completed at the time of the inspection.This is a repeat citation from the November 5, 2021 and April 21, 2022 licensing inspections. These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
The Clinic Director met with the Clinical Supervisor to review regulation 709.92(b). 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. Adherence to this regulation was presented and reviewed during monthly all staff meeting on October 21, 2022. During that same meeting, CTC clinical supervisor required that all counseling staff complete internal audits of patient electronic records on a weekly basis. Compliance will be reviewed with counselors during individual and group supervision. The Clinical Supervisor will monitor compliance in this area.
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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 the review of patient records, the facility failed to ensure that the patients received counseling services according to their individual comprehensive treatment plan in six out of six applicable records reviewed.Patient #1 was admitted on July 25, 2022 and was still active at the time of the inspection. The treatment plan dated August 3, 2022 indicated one individual and group session weekly. There were no individual sessions between August 28 - September 3, and September 11 - 17, 2022. In addition, there were no group sessions between August 21 - September 3, and September 25 - October 1, 2022.Patient #2 was admitted on October 2, 2018 and was still active at the time of the inspection. A treatment plan dated June 2, 2022 indicated 30 minutes of individual therapy every other week and 1 hour of group therapy every other week. There were no individual sessions between June 21 - July 11, and after August 23, 2022. Patient #4 was admitted on November 29, 2021 and was still active at the time of the inspection. A treatment plan dated July 27, 2022 indicated two individual and four group sessions per month. In September 2022, there was one individual session. There were two group sessions in each month of July and August 2022, and one group session in September 2022.Patient #5 was admitted on December 13, 2021 and was still active at the time of the inspection. An August 8, 2022 treatment plan indicated individual sessions every other week and group sessions weekly. There were no individual sessions between August 23 - September 11, 2022. In addition, there were no group sessions between August 17 - September 5, 2022.Patient #6 was admitted on July 20, 2022 and was still active at the time of the inspection. A treatment plan dated August 30, 2022 indicated individual sessions twice a month and group sessions four times per month. There was one group session in September 2022. Patient #9 was admitted on March 17, 2022 and was still active at the time of the inspection. A July 22, 2022 treatment plan indicated individual sessions twice a month and group sessions four times per month. The patient did not receive any individual sessions in August 2022.This is a repeat citation from the November 5, 2021 and April 21, 2022 licensing inspections. These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
The Clinic Director met with the Clinical Supervisor to review regulation 709.92(c). 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. Adherence to this regulation was presented and reviewed during monthly all staff meeting on October 21, 2022. During that same meeting, CTC clinical supervisor required that all counseling staff complete internal audits of patient electronic records on a weekly basis. Compliance will be reviewed with counselors during individual and group supervision. The Clinical Supervisor will monitor compliance in this area.
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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.A plan of correction for patients to receive an average of 2.5 hours of psychotherapy per month during the patient's first two years were submitted and approved by the Department for the November 15, 2019, December 30, 2020, November 5, 2021, and April 21, 2022 licensing inspections.A plan of correction for comprehensive treatment plans to be completed within 30 days of admission, according to the facility's policy and procedures manual, were submitted and approved by the Department for the November 5, 2021 and April 21, 2022 licensing inspections.A plan of correction for not providing treatment services according to the patient's individualized treatment plan were submitted and approved by the Department for the November 5, 2021 and April 21, 2022 licensing inspections.A plan of correction for not updating treatment plans within the regulatory timeframe were submitted and approved by the Department for the November 5, 2021 and April 21, 2022 licensing inspections.A plan of correction for failure to conduct an annual physical examination in the regulatory timeframe were submitted and approved by the Department for the November 5, 2021 and April 21, 2022 licensing inspections. A plan of correction for failure to complete an annual evaluation by the counselor were submitted and approved by the Department for the November 5, 2021 and April 21, 2022 licensing inspections.This is a repeat citation from the November 5, 2021 and April 21, 2022 licensing inspections.These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
Pottstown CTC will identify issues with proposed plans of correction as they present and formulate protocols to ensure that repeat citations are avoided in the future. The current plans of correction for this audit period are believed to be attained and maintained with current staffing and policies in place.
Counseling Requirements: If a patient does not meet the minimum counseling requirement during the month, the reason for such will be documented in the patient file. Counselors will continue to attempt to contact patients who are not meeting the minimum monthly counseling requirement immediately following a missed appointment, as evidenced by placing "holds" for pt. to meet with counselor prior to dosing. Patients who continue to refuse to meet minimum counseling requirements are placed on a Treatment Contract. A treatment team meeting will be held to review therapeutic interventions and strategies to increase session attendance. Approved interventions are incorporated into a Treatment Contract 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 counseling non-compliance. 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. Compliance to regulatory guidelines of 2.5 hours of psychotherapy will be reviewed and monitored biweekly by Clinical Supervisor.
Treatment Plans: All preliminary treatment and rehabilitation plans due will be reviewed weekly by the Clinical Supervisor with respective staff. CS will review plans for timeliness and patient input to include short and long-term goals for treatment as formulated by both staff and client via the EMR. Any issues will be addressed with staff in weekly individual and group supervision ongoing.
Treatment plan updates will be completed a minimum of every 60 days. The Clinical Supervisor will review the services due report in SMART (EMR) weekly to ensure compliance in Clinical Supervision. Further, compliance in this area will also be reviewed by the Clinical Supervisor during all Quality Record Reviews. Non-compliance in this area will be documented in writing and employee improvement plans will be presented if warranted. Clinic Director will review compliance to this regulatory guideline biweekly with Clinical Supervisor.
Annual Physical Examinations: CTC Charge Nurse 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 Charge Nurse/Physician as needed. Patients who miss scheduled appointments will have "holds" placed for patient to meet with Clinic Director to address non-compliance.
Annual Clinical Evaluations: CTC Clinical Supervisor will review the services due report in SMART (EMR) weekly to ensure compliance in Clinical Supervision. Further, compliance in this area will also be reviewed by the Clinical Supervisor during all Quality Record Reviews. Non-compliance in this area will be documented in writing and employee improvement plans will be presented if warranted. Clinic Director will review compliance to this regulatory guideline biweekly with Clinical Supervisor.
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