INITIAL COMMENTS
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This report is a result of an on-site licensure renewal and methadone and buprenorphine monitoring inspection conducted on March 6, 2025 through March 7, 2025 by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, Coatesville Treatment Center was found not to be in compliance with the applicable chapters of 28 PA Code which pertain to the facility. The following deficiencies were identified during this inspection:
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Plan of Correction
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705.26 (2) LICENSURE Heating and cooling.
705.26. Heating and cooling.
The nonresidential facility:
(2) May not permit in the facility heaters that are not permanently mounted or installed.
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Observations
Based on a physical plant inspection on March 7, 2025, the facility failed to ensure that heaters were permanently mounted as a space heater was found in the Facility Director ' s office.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The space heater has since been removed from the office. CD will reach out to the building owner by April 1, 2025, to conduct an inspection of the current heating system to ensure it is working properly. The CD will consider submitting for a waiver for this regulation as there is a window and a door that leads outside. Air seeps in from both the door and window resulting in an unusually cold office at times. We will conduct monthly office inspections to ensure no one is using any heaters that are not approved by the company. Walkthrough inspections will begin April 2, 2025, and will be conducted by the CS. Reports will be submitted to the CD 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 nine client records, the facility failed to obtain an informed and voluntary consent to release information form from the client for the disclosure of information contained in four records reviewed.
Client # 2 was admitted on May 7, 2024 and was active at the time of the inspection. The consent to release information form to the funding source expired on July 24, 2024; however, there was evidence of billing between July 25, 2024 and the date of the inspection.
Client # 5 was admitted on February 11, 2020 and was active at the time of the inspection. The consent to release information form to the funding source expired on February 26, 2023; however, there was evidence of billing between February 27, 2023 and the date of the inspection.
Client # 6 was admitted on September 10, 2024 and was discharged on October 23, 2024. The record did not contain an informed and voluntary consent form to the funding source; however, there was evidence of billing.
Client # 8 was admitted on September 15, 2020 and was active at the time of the inspection. The consent to release information form to the funding source expired on August 29, 2024; however, there was evidence of billing between August 30, 2024 and the date of the inspection.
This is a repeat citation from the March 29, 2024 and March 31, 2023 annual licensing renewal inspections.
These findings were discussed with facility staff during the licensing process.
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Plan of Correction
March 31, 2025, all counselors will be provided with a training on how to ensure that an appropriate Release of Information (ROI) is completed during admission, readmission, and annual updates as required. CS will monitor this practice during monthly chart reviews via the Quality Record Review Process. CD will spot-check this practice during the Chart to Charge Audit Process. Deficiencies will be reviewed with the CS and returned to the counselor to ensure there is fluid communication to correct such practices within 30 days. Pt #2 is completed on 4/02/2025; Pt #5 was completed on 3/10/2025; Pt #8 is completed on 4/2/2025
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715.16(a)(3) LICENSURE Take-home privileges
(a) A narcotic treatment program shall determine whether a patient may be provided take-home medications.
(3) The narcotic treatment physician shall document in the patient record the rationale for permitting take-home medication.
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Observations
Based on a review of patient records, the narcotic treatment physician failed to document in the patient record the rationale for permitting take-home medication in one of three applicable records reviewed.
Patient # 8 was admitted on September 15, 2020 and was active at the time of the inspection. Take-home medications were received on January 18, 2025 and the rationale for take-home medication was not documented by the physician as of the date of the inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The medical director will ensure that all orders are signed off in a timely manner. The Charge Nurse will review orders before dispensing to ensure accuracy. Any inaccuracies will be referred to the medical director for correction. The medical director will ensure that the rationale for take-home medication is documented in the order. The charge nurse will continue to monitor monthly via the quality record review process. |
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 an observation of medication administration on March 7, 2025, the nurse in the first medication window was observed to be preparing take-home medications or looking at a computer monitor, instead of observing the patients when ingesting the agent at 07:47 A.M., 07:50 A.M., 07:52 A.M., and 07:55 A.M.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The nurse involved was immediately counseled on the importance of direct observation during medication ingestion to ensure compliance with federal and state regulations. A staff meeting was held on March 31, 2025, to reinforce the Medication Administration Policy, with a focus on direct patient observation. The Charge Nurse will conduct trainings where she can observe the medication dispensing and provide real-time guidance on a monthly basis. |
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 a review of nine patient records, the receiving narcotic treatment program failed to document in writing that it notified the transferring narcotic treatment program of the admission of the patient and the date of the initial dose in one applicable record reviewed.
Patient # 4 was admitted on October 1, 2024 and was transferred on February 5, 2025.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
During the mandatory staff meeting held on March 31, 2025, a review of the Pt. Transfer Policies was reinforced, and a 'checklist' was provided to all staff to be used for all Pt. transfers. The front desk office manager has been assigned to complete the patient transfer. CS and CN will actively monitor each transfer and approve paperwork to be sent prior to the initial send and will review policy/procedures during weekly supervision with their respective teams. This will be monitored monthly via the Quality Record Review process as well as in weekly management meetings. |
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 ensure an annual physical reevaluation in one of four applicable records reviewed.
Patient # 5 was admitted on February 11, 2020 and was active at the time of the inspection. The most recent annual physical was completed on February 8, 2024.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The annual was completed for this patient on March 10,2025. To ensure all annual physicals are completed accurately and on time, the CRNP/MD will receive a daily "Services Due" list outlining upcoming evaluations. The front desk manager will assist with scheduling these patients by making the appointment and placing the scheduled physical on the CRNP/MD's calendar. The CD will monitor this in weekly supervision during which I will review completion status and documentation accuracy. The monthly Quality Record Reviews conducted by the CD will ensure compliance with all regulatory standards. Any discrepancies or delays will be addressed promptly by the CD to maintain thorough and timely evaluations. |
715.23(c)(1-7) LICENSURE Patient records
(c) An annual evaluation of each patient 's status shall be completed by the patient 's counselor and shall be reviewed, dated and signed by the medical director. The annual evaluation period shall start on the date of the patient 's admission to a narcotic treatment program and shall address the following areas:
(1) Employment, education and training.
(2) Legal standing.
(3) Substance abuse.
(4) Financial management abilities.
(5) Physical and emotional health.
(6) Fulfillment of treatment objectives.
(7) Family and community supports.
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Observations
Based on the review of patient records, the facility failed to document a completed annual evaluation signed by the medical director in one of four applicable records.
Patient # 5 was admitted on February 11, 2020 and was active at the time of the inspection. The annual evaluation was due to be completed by February 11, 2025; however, the annual evaluation was not completed as of the date of the inspection.
This is a repeat citation from the March 29, 2024 and March 31, 2023 annual licensing renewal inspections.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
To ensure all Annual evaluations are completed thoroughly and timely, staff will continue to be provided with their 'Services Due' list printout each day and such will be reviewed with the Counselor End of Day Checklist that is to be presented, in person to the CS daily. Weekly reviews for content and thoroughness will be conducted during regular supervision. Chart documentation will also be monitored monthly via the Quality Record Review Process. |
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 obtaining client signed consent to release information forms prior to disclosures of information was submitted and approved by the Department for the March 29, 2024 and March 31, 2023, annual licensing inspections. Obtaining client signed consent to release information forms prior to disclosing information was again found to be a deficiency in the March 6, 2025 through March 7, 2025 licensing inspection.
A plan of correction for completing annual clinical evaluations was submitted and approved by the Department for the March 29, 2024 and March 31, 2023, annual licensing inspections. Annual clinical evaluations were again found to be a deficiency in the March 6, 2025 through March 7, 2025 licensing inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Clinic Director has overall responsibility to ensure that plans of corrections are implemented. Plans of corrections will be implemented with additional staff training and bi-weekly chart monitoring by the clinical supervisor. The CD will review compliance quarterly to ensure long-term adherence. |