INITIAL COMMENTS
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This report is a result of an on-site licensure provisional license follow-up conducted on May 4-5, 2023 by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, Pottstown 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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704.6(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 with their supervisor that included discussion of duties and performance.
Employee #1 was hired on November 16, 2020 and promoted to clinical supervisor on May 15, 2022. There has been no documentation of monthly meetings that meet the requirements since date of promotion.
The finding was reviewed with facility staff during the licensing inspection.
This is a repeat citation from the October 14, 2022 licensing inspection.
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Plan of Correction
Pottstown CTC will ensure that all documentation of monthly supervision with Clinical Supervisor is maintained onsite, and available for review. Pottstown CTC Clinic Director reviewed this regulatory requirement with Regional Director and CS on May 30, 2023 and procured documentation from CTC Program Development staff. |
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 client records, the facility failed to obtain an informed and voluntary consent form prior to releasing information in three out of six applicable records reviewed.
Client # 1 was admitted on January 5, 2022 and discharged on April 8, 2023. A consent form dated March 18, 2023 to another narcotic treatment facility did not permit dose history to be released, which was provided on April 27, 2023.
Client #4 was admitted on March 1, 2023 and was still active at the time of the inspection. There was no active consent form for the funding source in the client's record. Facility staff confirmed billing had occurred.
Client #7 was admitted on December 12, 2022 and was still active at the time of the inspection. There was no completed consent form for another narcotic treatment facility. The facility was contacted on January 3, 2023.
The findings were reviewed with facility staff during the licensing inspection.
This is a repeat citation from the October 14, 2022 licensing inspection.
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Plan of Correction
Ongoing reviews will be conducted by the CD and CS to ensure all active ROI's are in place. Reviews of ROI's will be conducted as new admissions occur on a daily basis
During monthly staff meeting on Friday June 9, 2023, CD and RD provided an overview to this regulation and additional training will be held on June 30, 2023 facilitated by the RD, and CD and CS. Staff will encourage to attend to a DDAP approved Confidentiality/Release of Authorization training via PA TRAIN for follow-up. CD, CS and admin will continue with regular reviews to ensure all ROI's are obtained and available in patient record. This information was reviewed with administrative, clinical, and case management staff during the May 8, 2023 staff meeting for continued awareness and knowledge.
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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 receive all requested client lists was three hours.
The finding was reviewed with facility staff during the licensing inspection.
This is a repeat citation from the October 14, 2022 licensing inspection.
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Plan of Correction
Clinic Director will ensure access to patient records is timely when Department staff arrive to facility for unannounced and announced inspections. Admin, CS and CN staff will be trained by CD and RD on June 30, 2023 as to the commonly required documents to be gathered to assist in timely submission. Will continue to ensure that timely access to EMR is maintained. |
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 a complete monthly urinalysis in one out of seven applicable patient records.
Client #1 was admitted on January 5, 2022 and discharged on April 8, 2023. There was no urinalysis completed in December 2022.
The finding was reviewed with facility staff during the licensing inspection.
This is a repeat citation from the October 14, 2022 licensing inspection.
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Plan of Correction
The Charge Nurse will ensure that all active patients have completed their monthly random drug-screen. Charge Nurse will review SMART report at the beginning of the final week of each month to identify any and all patients who have yet to provide their auto-populated DSA per the EMR-SMART generated random monthly. The Charge Nurse will place a hard hold for DSA onto each Pt. record for the last business day of each month for those still pending UA screening. CN will keep EOM report verifying all random monthly UAs completed and will retain in CN office.
This regulation and Plan of action was reviewed during monthly all staff meeting on May 8, 2023 and reviewed again during the Friday June 9th staff meeting.
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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 six out of seven records reviewed.
Patient #1 was admitted on January 5, 2022 and discharged on April 8, 2023. In January 2023, the patient received 30 minutes of individual therapy. In February 2023, the patient did not receive any therapy with documentation of one no show for group counseling. In March 2023, there were no documented therapy sessions.
Patient #3 was admitted on December 28, 2022 and was still active at the time of the inspection. In January, February and March 2023, the patient received 30 minutes of individual therapy each month.
Patient #4 was admitted on March 1, 2023 and was still active at the time of the inspection. In March 2023, the patient received in total one 30 minute individual session. In April 2023, the patient received 30 minutes of individual therapy.
Patient #5 was admitted on December 14, 2020 and was still active at the time of the inspection. In December 2022, the patient did not receive any individual therapy.
Patient #6 was admitted on December 13, 2021 and was still active at the time of the inspection. In March 2023, the patient received 30 minutes of individual therapy.
Patient #7 was admitted on December 12, 2022 and was still active at the time of the inspection. In January 2023, the patient received no individual therapy. In February 2023, the patient did not receive any therapy sessions. In March 2023, the patient received 30 minutes of individual therapy.
These findings were reviewed with facility staff during the licensing inspection.
This is a repeat citation from the November 15, 2019, December 30, 2020, November 5, 2021, April 21, 2022 and October 14, 2022 licensing inspection.
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Plan of Correction
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 May 8, 2023 at our Monthly Team Meeting. Clinical Supervisor will review the updated End of Day counselor checklist created to assist in tracking Pt. engagement. Staff who may require additional training and time management will be identified and offered opportunities to tend to such, along with weekly supervision to review same. CS will monitor to ensure each counselor runs their Direct Services Analysis reports daily and turn into the Clinical Supervisor, along with their end of day checklist as verification to patient compliance to psychotherapy. The Clinical Supervisor will review the reports in individual and group supervision monthly.
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 discussion of next steps. All attempts to meet or discuss non compliance with patient will be documented via a "no show" or "brief contact note" and will include appropriate documentation as to Tx compliance and follow up. CD will review compliance to this regulation during monthly meetings with CS.
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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 two out of two applicable patient records.
Patient #1 was admitted on January 5, 2022 and discharged on April 8, 2023.
Patient #2 was admitted on December 13, 2021 and discharged on January 5, 2023.
The findings were reviewed with facility staff during the licensing inspection.
This is a repeat citation from the October 14, 2022 licensing inspection.
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Plan of Correction
The Clinic Director, Clinical Supervisor and Charge Nurse will ensure that any and all Pt. transfer requests are compiled and reviewed at the point at which the Pt. and or alternate Program has provided the appropriate authorization for release of transfer packet information and do so the day of said notification is made or requested.
All management will complete weekly reviews, utilizing the Discharge by Type report from the EHR-SMART database and validate that all transferred patients listed in fact have confirmation of the transfer packets being sent and confirmation page uploaded into the Pt. record along with accompanying documentation in Pt. Case History....
Adherence to this regulation was reviewed and presented at monthly all staff meeting on May 8, 2023, and was also reviewed during the Monthly Staff meeting w/RD on June 9, 2023.
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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 #3 was admitted on December 28, 2022 and was still active at the time of the inspection.
Patient #4 was admitted on March 1, 2023 and was still active at the time of the inspection.
The findings were reviewed with facility staff during the licensing inspection.
This is a repeat citation from the October 14, 2022 licensing inspection.
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Plan of Correction
The Clinic Director, Clinical Supervisor and Charge Nurse will ensure that any and all Pt. transfers will be documented and communicated according to regulation 715.20(4).
On the date of the scheduled 'transfer', notification will be made by the Clinic Director and/or their management designee to confirm active patient transfer was completed. This was reviewed and presented to all staff during the Monthly staff meeting on May 8th, and was also reviewed during the Monthly Staff meeting w/RD on June 9, 2023. Additional weekly follow up to compliance will be completed by the Clinic Director and Charge Nurse.
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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 four applicable records reviewed.
Patient #1 was admitted on January 5, 2022 and discharged on April 8, 2023. An annual physical was due on January 5, 2023; however, it was completed on January 13, 2023.
Patient #5 was admitted on December 14, 2020 and was still active at the time of the inspection. An annual physical was due on December 14, 2022; however, it was completed on December 31, 2022.
This is a repeat citation from the November 5, 2021, April 21, 2022 and October 14, 2022 licensing inspection.
The findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
At the beginning of each month, the Charge Nurse will complete a print out of the Services Due by Type via the EMR-SMART system, identifying any and all Annual Physical Examinations due per regulation 715.23(b)(5). All Active patients listed will be placed on the calendar to have their annual physical completed and notifications via the EMR and Kiosk system will be placed to notify Pt.'s of their upcoming appt. with Medical; as well as notifications being provided on the day of.
Charge Nurse will monitor Pt. compliance utilizing hard-holds for timely follow up to those non-compliant to same and with appropriate documentation being added to the Pt. record.
Adherence to this policy was reviewed during monthly all staff meeting on May 8, 2023 and was also reviewed during the Monthly Staff meeting w/RD on June 9, 2023.
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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 a review of client records, the facility failed to document an individualized comprehensive treatment plan in two out of the three applicable records reviewed.
Client #3 was admitted on December 28, 2022 and was still active at the time of the inspection. The non-individualized comprehensive treatment plan was dated January 12, 2023. Client #3's comprehensive treatment plan's goals were identical to ones on client #4's comprehensive treatment plan.
Client #4 was admitted on March 1, 2023 and was still active at the time of the inspection. The non-individualized comprehensive treatment plan was dated March 29, 2023. Client #4's comprehensive treatment plan's goals were identical to ones on client #3's comprehensive treatment plan.
This is a repeat citation from the November 5, 2021, April 21, 2022 and October 14, 2022 licensing inspection.
The 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(a) on May 8, 2023 and to complete a review of patient files. The Clinical Supervisor will ensure that at the time of their 'approval' of submitted Tx plans, that such will be returned, if they do not possess evidence to support a more 'personalized plan'. Doing so may impact the timeliness of the Treatment Plan completion and a corresponding exception will be filed with Licensure to that end denoting same. Such submission of request will be uploaded into the Pt. record in support of the necessary delay.
The Clinical Supervisor will continue to address timeliness and individualized treatment plan development such during individual and group supervision sessions.
The Clinic Director and Clinical Supervisor will review such during weekly Mgmt. Team Meetings to ensure compliance. Adherence to this regulation was presented and reviewed during monthly all staff meeting on May 8, 2023, and again, with all counselors during group clinical supervision on May 10, 2023. Presentation was made to all staff during the Monthly Staff meeting on June 9, 2023 and an initial training date for same will be set for Friday June 30, 2023.
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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 client records, the facility failed to update treatment plans at least every 60 days in three out of five applicable records reviewed.
Client #3 was admitted on December 28, 2022 and was still active at the time of the inspection. A treatment plan update was completed on January 30, 2023 with the next update due on March 30, 2023; however, if was completed on April 19, 2023.
Client #6 was admitted on December 13, 2021 and was still active at the time of the inspection. A treatment plan update was completed on February 3, 2023 with the next update due on April 3, 2023; however, it was completed on April 6, 2023.
Client #7 was admitted on December 12, 2022 and was still active at the time of the inspection. A treatment plan update was completed on January 31, 2023 with the next update due on March 31, 2023; however, it was completed on April 7, 2023.
This is a repeat citation from the November 5, 2021, April 21, 2022 and October 14, 2022 licensing inspections.
These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
During an in-service Treatment Plan training session on Friday, June 30, 2023 all counseling personnel and Supervisors will participate in various aspects of Treatment Plan completion and preparation, to include time-management and timeliness submission of Pt. Treatment plans.
If needed, additional trainings or in-services will be offered to staff and encouraged to attend outside trainings.
The EHR-SMART Services Due report will continue to be printed daily, and reviewed against EHR services provided report to ensure compliance and during weekly management meetings.
Adherence to this regulation was presented and reviewed during the monthly all staff meeting on May 8, 2023, and again, with all counselors during group clinical supervision on May 10, 2023.
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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 client records, the facility failed to ensure that the clients received counseling services according to their individual comprehensive treatment plan in three out of seven applicable client records.
Client #1 was admitted on January 5, 2022 and discharged on April 8, 2023. A treatment plan dated December 20, 2022 and February 20, 2023 indicated individual sessions one time per month and group sessions twice a month. There were no documented completed sessions in February and March 2023 with one no show group session in February 2023.
Client #5 was admitted on December 14, 2020 and was still active at the time of the inspection. Treatment plans dated December 1, 2022 and January 31, 2023 indicated individual sessions one time per month and group sessions twice a month. In December 2022, February 2023 and March 2023, the client received no individual sessions.
Client #7 was admitted on December 12, 2022 and was still active at the time of the inspection. A comprehensive treatment plan dated January 11, 2023 indicated individual sessions one time per month and group sessions twice a month. In January 2023, the client did not receive any individual sessions. In February 2023, the client did not receive any individual or groups sessions.
This is a repeat citation from the November 5, 2021, April 21, 2022, and October 14, 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 met on May 8, 2023 to review regulation 709.92(c).
CS will conduct Weekly review of patient records will be conducted to ensure counseling staff are completing necessary paperwork and documentation in a timely manner.
Continuing to utilize the EMH with reviewing services provided reports.
Adherence to this regulation was presented and reviewed during monthly all staff meeting on May 8, 2023, and again, with all counselors during group clinical supervision on May 10, 2023.
Compliance will be reviewed with Clinical Supervisor and counselors during individual and group supervision. An additional review was held on the June 9, 2023 staff meeting and will be on the agenda for June 30, 2023 meeting.
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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 client 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, April 21, 2022, and October 14, 2022 licensing inspection.
A plan of correction for individualized 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, April 21, 2022 and October 14, 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, April 21, 2022 and October 14, 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, April 21, 2022 and October 14, 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, April 21, 2022 and October 14, 2022.
A plan of correction for failure to follow approved plans of correction were submitted and approved by the Department for the November 5, 2021, April 21, 2022 and October 14, 2022.
This is a repeat citation from the November 5, 2021, April 21, 2022 and October 14, 2022 licensing inspection.
These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
: Pottstown CTC Management will identify any and all issues with proposed plans of correction as presented 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.
RVP, RD/CD, CS and CN will be meeting weekly and monthly to review the plan of corrections and ensure follow-up and compliance according to plan.
Per the above RD/CD, CS, CN will ensure that if any adjustments or edits to plans are needed, update to this submitted POC will be provided to Licensing via the email portal.
The technical training was offered by the auditor and has been scheduled for 7/13/23
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