INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on April 18-20, 2017 by staff from the Division of Drug and Alcohol Program Licensure, for the approval to use Methadone and Buprenorphine in the treatment of narcotic addiction. 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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704.9(c) LICENSURE Supervised Period
704.9. Supervision of counselor assistant.
(c) Supervised period.
(1) A counselor assistant with a Master's Degree as set forth in 704.8 (a)(1) (relating to qualifications for the position of counselor assistant) may counsel clients only under the close supervision of a trained counselor or clinical supervisor for at least the first 3 months of employment.
(2) A counselor assistant with a Bachelor's Degree as set forth in 704.8 (a)(2) may counsel clients only under the close supervision of a trained counselor or clinical supervisor for at least the first 6 months of employment.
(3) A registered nurse as set forth in 704.8 (a)(3) may counsel clients only under the close supervision of a trained counselor or clinical supervisor for at least the first 6 months of employment.
(4) A counselor assistant with an Associate Degree as set forth in 704.8 (a)(4) may counsel clients only under the close supervision of a trained counselor or clinical supervisor for at least the first 9 months of employment.
(5) A counselor assistant with a high school diploma or GED equivalent as set forth in 704.8 (a)(5) may counsel clients only under the direct observation of a trained counselor or clinical supervisor for the first 3 months of employment. For the next 9 months, the counselor assistant may counsel clients only under the close supervision of a lead counselor or a clinical supervisor.
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Observations
Two personnel records were reviewed for the counselor assistant position on April 18, 2017. The facility failed to document the provision of direct observation for employee records # 12 and 13.
Employee # 12 was hired on 1/1/17 as a Bachelor's degree level counselor assistant. The employee requires close supervision for at least the first 6 months of employment. Weekly supervision notes were reviewed for the period of 1/5/17 - 3/30/17. The facility failed to demonstrate that weekly close supervision included an additional hour of direct observation at least once a week.
Employee # 13 was hired on 5/9/16 as a Bachelor's degree level counselor assistant. The employee required close supervision for at least the first 6 months of employment. Weekly supervision notes were reviewed for the period of 5/18/16 - 11/30/16. The facility failed to demonstrate that weekly close supervision included an additional hour of direct observation at least once a week.
These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
The Clinical Supervisor added a section on the Clinical Supervision Tracking sheet that clearly identifies direct observations. The Clinical Supervisors will be responsible for ensuring this updated form is used for any new hired Counselor Assistants. All new hired Counselor Assistants will meet with Clinical Supervisors for weekly supervision in addition to a direct observation. This information will be maintained and tracked by the Clinical Supervisors weekly. This will begin on 6/19/2017. |
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
Thirteen personnel records were reviewed on April 18, 2017. The facility failed to provide documentation of completed HIV/AIDS training for employee # 10.
Employee # 10 was hired as a counselor on 11/16/15. HIV/AIDS training was due to be completed no later than 11/16/16. Completion of this training was not documented in the employee's record.
This finding was reviewed with facility staff during the licensing inspection.
This is a repeat citation, as the facility was previously cited for noncompliance of this standard during the previous licensing renewal inspections, conducted on 2/18/16.
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Plan of Correction
Employee #10 was scheduled for a HIV/AIDS Training that was cancelled and was unable to find another training within the local area. Employee and Clinical Supervisors will continue to check the DDAP training system for upcoming trainings in the area. An approved training outside of DDAP will be utilized if nothing is added to the schedule by 6/30/2017. |
709.33 (a) LICENSURE Notification of termination.
§ 709.33. Notification of termination.
(a) Project staff shall notify the client, in writing, of a decision to involuntarily terminate the client ' s treatment at the project. The notice shall include the reason for termination.
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Observations
Twelve client records were reviewed on April 19-20, 2017. The facility failed to document that written notification of involuntary termination from treatment was provided to the client for client record # 7.
Client # 7 was admitted on 8/25/14 for methadone maintenance treatment and was involuntarily terminated from the facility on 1/17/17. The client's record did not contain documentation that the client was provided written notification of the facility's decision to involuntarily terminate the client's treatment.
This finding was reviewed with facility staff during the licensing inspection.
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Plan of Correction
A new tracking sheet will be created for all involuntary termination by 06/30/017. The Clinical Supervisors will be responsible for updating and maintaining the tracking sheet. If someone is tapered involuntarily, they will be added to the list and the form will identify that a letter was generated to ensure nothing is missed. A copy of the letters will be kept with the tracking sheet. If a patient is tapered for physical violence/threats, drug sells on the premises and other behaviors under Regulation 715.21, they will be immediately discharged and provided with a copy of referrals and a letter explaining that they are being discharged for violation of 715.12 and will not have a fir hearing. All fairing requests will be given to Clinic Director and Program Specialist to schedule fair hearing meeting.
A Fair Hearing will be held within seven (7) working days from the time of the patient's request.
The Fair Hearing committees' decision will be rendered no later than three (3) working days following the date of the hearing. The decision will be in writing and a copy of the Fair Hearing proceedings will be made available to the patient upon request. The Clinic Director and Program Specialist are responsible for sending the fair hearing response.
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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
An onsite licensing inspection was conducted on April 18-20, 2017. Based on the review of administrative documentation, the facility failed to continuously provide narcotic treatment physician services at least one hour per week onsite for every ten clients.
During the licensing process, weekly physician time sheets were reviewed for the time period of 11/1/16 - 3/30/17. Insufficient onsite physician hours were provided for one week out of the time period reviewed.
During the week of February 19-25, 2017, the patient census was 506. The facility was required to provide at least 50.6 physician hours onsite. There were 41.25 onsite physician hours documented for this week.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
To ensure there is always adequate coverage during medical staff vacation, Regional Director will work on contracting services with a NTP physician who can provide back up services for CTC programs throughout the Pennsylvania region for vacation/sick time. This will be done by 7/31/2017. The documentation of the back-up physician hours will be maintained by the Clinic Director in kept in a locked personnel file. |
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
Eleven client records were reviewed for the Methadone and Buprenorphine maintenance activities on April 19-20, 2017. The facility failed to document a random urinalysis at least monthly for client records # 3 and 5.
Client # 3 was re-admitted for methadone maintenance treatment on 7/6/16, and was still active in treatment. Urinalysis drug-screen results for the month of January 2017 were not documented in the client's record.
Client # 5 was admitted for methadone maintenance treatment on 6/8/16, and was then transferred to another narcotic treatment program on 1/25/17. Urinalysis drug-screen results for the month of October 2016 were not documented in the client's record.
The findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
A new tracking sheet was developed by the Director on Nursing on 4/24/2017 as an additional measure to ensure monthly urine drug screens are not missed. The assigned Dispensing Nurse is responsible for tracking the sheet weekly and rescheduling urinalysis that auto-failed in the system. The Urine Drug Screens that were not given were missed by oversight on the Auto-Fail report from the Dispensing System. Going forward, the new tracking sheet will helped to ensure no urine drug screens are missed. |
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
Eleven client records were reviewed for the Methadone and Buprenorphine maintenance activities on April 19-20, 2017. The facility failed to document the provision of 2.5 hours of psychotherapy per month, to include 1 hour of individual psychotherapy, for client records # 3, 5, and 9.
Client # 3 was admitted on 7/6/16 for methadone maintenance treatment, and was still active in treatment. Documentation in the client's record indicated that for the period of October 2016 - December 2016, the client received 4.375 hours of psychotherapy, an average of 1.46 hours per month. In addition, for the period of January 2017 - March 2017, the client received 5.5 hours of psychotherapy, an average of 1.83 hours per month.
Client # 5 was admitted on 6/8/16 for methadone maintenance treatment, and was then transferred to another narcotic treatment program on 1/25/17. Documentation in the client's record indicated that for the period of July 2016 - August 2016, the client received 6.5 hours of psychotherapy, an average 2.17 hours per month. In addition, for the period of October 2016 - December 2016, the client received 6.17 hours of psychotherapy, an average of 2.06 hours per month.
Client # 9 was admitted on 12/8/16 for buprenorphine maintenance treatment, and was still active in treatment. Documentation in the client's record indicated that for the period of January 2017 - March 2017, the client received 6 hours of psychotherapy, an average of 2 hours per month. In addition, the client's record indicated that client did not receive 1 hour of individual psychotherapy in the month on March 2017.
These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
On 5/1/2017, Clinical Supervisors developed a new tracking sheet to closely monitor counseling hours. Each week counselors have to submit their counseling hours. 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 moved to administrative taper. Clinical Supervisor will be responsible for monitoring counseling hours week over week.
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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
Twelve client records were reviewed on April 19-20, 2017. The facility failed to consistently document a treatment plan update at least every 60 days for client records # 3, 5, 7, 11, and 12.
Client # 3 was admitted into treatment on 7/6/16 and was still active in treatment. The first treatment plan update documented in the client's record was completed on 3/28/16. The subsequent treatment plan update was completed on 9/30/16. The following treatment plan updates documented in the client's record were completed on 11/11/16, 1/24/17, and 3/31/17.
Client # 5 was admitted into treatment on 6/8/16, and was transferred to another narcotic treatment program on 1/25/17. The first treatment plan update documented in the client's record was completed on 10/31/16. The subsequent treatment plan update was due to be completed by 12/31/16, and one was not documented in the client's record.
Client # 7 was admitted into treatment on 8/25/14, and was discharged on 1/17/17. A treatment plan update was completed for the client on 4/27/16. The subsequent treatment plan update documented in the client's record was completed on 7/27/16.
Client # 11 was admitted into treatment on 9/3/15 and was discharged on 3/16/17. A treatment plan update was completed for the client on 3/15/16. The subsequent treatment plan update documented in the client's record was completed on 6/1/16.
Client # 12 was admitted into treatment on 1/28/16 and was discharged on 6/22/16. A treatment plan update was completed for the client on 3/22/16. A subsequent treatment plan update was due to be completed for the client by 5/22/16, and one was not documented in the client's record.
This finding was reviewed with facility staff during the licensing process.
This is a repeat citation, as the facility was previously cited for noncompliance of this standard during the previous licensing renewal inspections, conducted on 2/18/16.
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Plan of Correction
On August 11th, the facility will have a new Electronic Medical Record that is completely electronic. It will enable Clinical Supervisors to closely monitor clinical documentation. The system is designed to show upcoming due dates for treatment plans. Clinical Supervisor will use the reporting capabilities in this system to ensure that Counselors are meeting with patients in the required time frames for their treatment plan updates. Patients that miss appointments will be held prior to medicating and will be given a non-complaint treatment plan to sign as needed. Until the system is created, the Clinical Supervisors will utilize a manually tracking sheet to track treatment plans to ensure they are completed before the due date. Treatment plans will continue to be done based on time in treatment. The Clinical Team will meet on 6/19/2017 during Clinical Supervision to receive training on the treatment plan process including ways to avoid missing treatment plan due dates. |