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 April 6, 2022 through April 7, 2022 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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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 six personnel records, the facility failed to ensure that staff received at least four hours of TB/STD training and six hours of HIV/AIDS training in two records reviewed.Employee # 4 was hired as a counselor on March 15, 2021 and was due to have the TB/STD and HIV/AIDS trainings no later than March 15, 2022. There was no documentation in the personnel file of the completion of the TB/STD or HIV/AIDS trainings as of the date of the inspection.Employee # 6 was hired as a counselor on December 14, 2020 and was due to have the TB/STD and HIV/AIDS trainings no later than December 14, 2021. There was no documentation in the personnel file of the completion of the TB/STD or HIV/AIDS trainings as of the date of the inspection.The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Clinical Supervisors (CS) will review with each new hire the necessary trainings and timelines for same. In addition CS's will monitor all new staff members to ensure that they have signed up and/or completed all required trainings by the end of their probationary period. Employee # 4 is now scheduled for HIV/AIDS on 5/9/22 & 5/10/22 and is scheduled for TB/STD/Hepatitis on 5/19/22. Employee # 6 is scheduled for HIV/AIDS on 4/25/22 and TB/STD/Hepatitis on 5/19/22. Utilizing alternate training methods, such as virtual and SCA provided trainings, will be considered when needed to ensure sustained compliance to §704.11(c)(1). |
705.23 (3) LICENSURE Counseling or activity areas and office space
705.23. Counseling or activity areas and office space.
The nonresidential facility shall:
(3) Ensure privacy so that counseling sessions cannot be seen or heard outside the counseling room. Counseling room walls shall extend from the floor to the ceiling.
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Observations
The facility failed to ensure privacy so that counseling sessions cannot be seen or heard outside the counseling room, as a session could be heard outside of the counselor ' s door immediately inside the entrance on the right to Building B at 11:30 a.m. on April 6, 2022.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
As of April 15, 2022, all inoperative 'white-noise/sound machines' have been replace and are operational. All staff will ensure that their sound machines are turned on at the beginning of each day and will remain on during all counseling hours of operation. This will be monitored by the CD and Clinical Supervisors to ensure compliance to §705.23(3). |
709.24 (a) LICENSURE Treatment/rehabilitation Management.
§ 709.24. Treatment/rehabilitation management.
(a) The governing body shall adopt a written plan for the coordination of client treatment and rehabilitation services which includes, but is not limited to:
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Observations
Based on a review of the facility ' s policy and procedure manual, the facility was not following their counseling documentation guidelines for admissions and orientation. The policy and procedures detailed a description of documentation that was required while a patient is in treatment. The facility failed to discharge clients that were deemed to not need treatment following the intake appointment. Due to the facility not discharging those clients who were not in need of services, those patients were considered active patients and therefore missing required all documentation.Client # 1 was admitted on December 2, 2021 and discharged February 1, 2022.Client # 4 was admitted on September 22, 2021 and discharged October 1, 2021.Client # 5 was admitted on March 23, 2022 and was active at the time of the inspection.Client # 6 was admitted on August 27, 2021 and discharged October 12, 2021.The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Clinic Director met with the Clinical Supervisors on April 15, 2022 to review the process for those community members who arrive on site seeking only a SUD Assessment only; and adherence to §709.24(a). From this meeting any and all those seeking only a SUD Assessment will be discharged within 24 hours, providing they are not deemed appropriate for MAT services. A presentation and training of this process will be provided to all staff and personnel by April 22, 2022. Both Clinical Supervisors will monitor this process for sustained compliance. |
709.24 (a) (3) LICENSURE Treatment/rehabilitation management.
§ 709.24. Treatment/rehabilitation management.
(a) The governing body shall adopt a written plan for the coordination of client treatment and rehabilitation services which includes, but is not limited to:
(3) Written procedures for the management of treatment/rehabilitation services for clients.
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Observations
Based on a review of the facility ' s written plan for the coordination of client treatment and rehabilitation services, the facility ' s written procedures for the management of treatment/rehabilitation services for clients indicated for the first year and annually thereafter a case consultation will be completed quarterly. Three of ten client records did not include quarterly case consultations.Client #10 was admitted to the Outpatient Maintenance activity on January 4, 2022 and was active at the time of the inspection. The client record did not contain documentation of quarterly case consultation notes.Client #11 was admitted to the Outpatient Maintenance activity on May 19, 2021 and was active at the time of the inspection. The client record did not contain documentation of quarterly case consultation notes.Client #15 was admitted to the Outpatient Maintenance activity on August 6, 2002 and was active at the time of the inspection. The client record did not contain documentation of an annual case consultation notes. These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
CD and Clinical Supervisors will meet with all counselors by April 22, 2022 to review Case Consult completion, quarterly for the first year of Treatment and annually thereafter, as denoted in §709.24(a)(3).
Clinical Supervisors will monitor and ensure that all case consultations are completed quarterly for all new admissions and annually thereafter.
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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 fifteen records, the facility failed to obtain an informed and voluntary consent from the patient for the disclosure of information in one record reviewed. Patient #12 was admitted on July 20, 2021 and was active at the time of the inspection. The record contained documentation of correspondence with an outside support agency on November 5, 2021, to whom the record contained no consent to release information form signed by the client. The findings were reviewed with facility staff during the licensing process.This is a repeat citation from inspections conducted on April 22, 2021, September 18, 2020 and March 20, 2019.
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Plan of Correction
On April 18, 2022 the CD and Clinical Supervisors conducted a full staff training to provide an overview of §255.5 Part 2 and 42 CFR. During this review was also a presentation and discussion surrounding the proper completion of authorizations to release information and appropriate content to same. During the clinical supervisors monthly chart audits and reviews, compliance to completed ROI's will be noted to ensure corrected and continued compliance to §709.28(c). |
709.28 (c) (2) 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. The consent must be in writing and include, but not be limited to:
(2) Specific information disclosed.
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Observations
Based on a review of fifteen records, the facility failed to ensure that an informed and voluntary consents from the client for the disclosure of information contained in the client record included specific information to be disclosed in two records reviewed.Client # 7 was admitted February 23, 2022 and was active at the time of the inspection. The record contained an informed and voluntary consents from the client for the disclosure of information to the funding source signed by the client on February 23, 2022, that did not indicate the specific information to be disclosed.Patient # 9 was admitted June 8, 2021 and was discharged on December 14, 2021. The record contained two informed and voluntary consents from the client for the disclosure of information to outside treatment providers signed by the client on November 30, 2021 and December 1, 2021, that did not indicate the specific information to be disclosed.The findings were reviewed with facility staff during the licensing process.This is a repeat citation from an inspection conducted on April 22, 2021.
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Plan of Correction
On April 18, 2022 the CD and Clinical Supervisors conducted a full staff training to provide an overview of §255.5 Part 2 and 42 CFR. During this review was also a presentation and discussion surrounding the proper completion of authorizations to release information and appropriate content to same. During the clinical supervisors monthly chart audits and reviews, compliance to completed ROI's will be noted to ensure corrected and continued compliance to §709.28(c). |
709.30 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.
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Observations
Based on a review of fifteen records, the facility failed to document written acknowledgement by clients that they have been notified of their client rights, in three records reviewed. Client #7 was admitted to the Outpatient Activity on February 23, 2022 and was active at the time of the inspection.Patient #11 was admitted to the Outpatient Maintenance Activity on May 19, 2021 and was active at the time of the inspection.Patient #12 was admitted to the Outpatient Maintenance Activity on July 20, 2021 and was active at the time of the inspection.The findings were reviewed with facility staff during the licensing process.This is a repeat citation from an inspection conducted on April 22, 2021.
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Plan of Correction
CD will prepare an Admission packet checklist that will include all documents to be obtained by each department, and signed by all new patients at the time of admission, including Patients' Rights.
A review and training of Patients' rights was part of the April 18, 2022 meeting with staff. Staff will document accordingly the presentation of patients rights' along with all other documentation upon admission and such will be monitored by the clinical supervisors during regular, monthly chart audits/reviews. Additional discussions will be held during regular weekly group supervision and individually as needed.
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709.31 (a) LICENSURE Data collection system
§ 709.31. Data collection system.
(a) A data collection and recordkeeping system shall be developed that allows for the efficient retrieval of data needed to measure the project ' s performance in relationship to its stated goals and objectives.
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Observations
Based on the Department ' s request to access client records on April 6, 2022, the facility ' s data collection and recordkeeping system failed to allow for the efficient retrieval of data needed to measure the project ' s performance in relationship to its stated goals and objectives. It took the facility staff two hours to make the requested data and records available.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The CD will ensure a more timely submission to access to the secure network prior to an onsite audit. This submission will be at least one week prior to the scheduled audit allowing for CTC staff to check network access prior to auditor's arrival. |
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 three months of physician timesheets, the facility failed to provide at least one hour of physician time a week on site for every ten patients in three weeks reviewed. During the week of November 8, 2021 through November 14, 2021, the patient census was 516. The facility was required to provide at least 51.6 physician hours. There were 45 hours documented.During the week of November 22, 2021 through November 28, 2021, the patient census was 516. The facility was required to provide at least 51.6 physician hours. There were 41.5 hours documented.During the week of December 27, 2021 through January 2, 2022, the patient census was 504. The facility was required to provide at least 50.4 physician hours. There were 35.5 hours documented.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Based on the appropriate ratio required for Physician coverage under §715.6(d) the CD and MD will plan accordingly to ensure appropriate medical coverage is in place during any/all vacation and/or missed MD time due to illness during the week in question.
Additionally the CD has hired an additional mid-level nurse practitioner who will be scheduled to provide a minimum of 10 hours of patient services per week. The anticipated start date is May of 2022.
CD and MD will continue to monitor for compliance. CD will send weekly report to the Regional Director to monitor and ensure physician/mid-level coverage and full adherence to §715.6(d).
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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 three months of physician time sheets, the facility failed to provide the required number of hours onsite for the physician based on the census for one week reviewed. The facility has been granted an exception request which permits the physician to provide one-fifth of the required hours with a certified registered nurse practitioner or physician's assistant providing the remaining four-fifths of the required hours. During the week of December 27, 2021 through January 2, 2022, the patient census was 504. The physician was required to provide one-fifth of the 50.4 hours, which equals to 10.08 hours. The physician provided 0 hours. These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Based on the appropriate ratio required for Physician coverage under §715.6(e) the CD and MD will plan accordingly to ensure appropriate medical coverage is in place during any/all vacation and/or missed MD time due to illness during the week in question.
Additional Physician service personnel will be added to ensure compliance is readily available, to which CD and MD will continue to monitor and plan accordingly for sustained MD coverage on site. Effective April 11, 2022, CD will send weekly report to the Regional Director to monitor and ensure physician/mid-level coverage and full adherence to §715.6(e).
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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
During an observation of medication administration on April 7, 2022, two nurses were observed preparing take home medications for patients instead of observing patients when ingesting the agent. These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The CD and Charge Nurse conducted a meeting on April 14, 2022 with all nursing/dispensing personnel to review proper patient observation and monitoring during dispensing.
Charge Nurse will routinely monitor continued and sustained compliance to patient ingestion of medication and adhere to appropriate take home preparation after the fact; engaging the Pt. in continued dialogue to ensure complete ingestion of medication.
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715.19(2) LICENSURE Psychotherapy services
A narcotic treatment program shall provide individualized psychotherapy services and shall meet the following requirements:
(2) A narcotic treatment program shall provide each patient at least 1 hour per month of group or individual psychotherapy during the third and fourth year of treatment. Additional psychotherapy shall be provided as dictated by ongoing assessment of the patient.
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Observations
Based on a review of seven patient records, the facility failed to provide one patient with the required number of individual psychotherapy hours in one record reviewed.Patient #13 was admitted on May 21, 2019 and was discharged on September 10, 2021. The patient was required to have at least one hour of individual or group psychotherapy per month. During the 2021 months of May, June, July, and August, the patient only received one half hour of individual therapy per month. These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Counselors will use the "hold" tool in the EHR to ensure that patients complete their required counseling hours as scheduled each day with weekly and monthly reviews to the same.
Any and all missed counseling sessions will be appropriately documented with a new Pt. 'hold' being placed for the patient to be held the next day to reschedule or complete the counseling session.
Clinical Supervisors will monitor such during individual and weekly group supervision sessions.
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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 to ensure a complete patient file, to include the results of all annual physical examinations in two of two applicable records reviewed.Patient #13 was admitted on May 21, 2019 and discharged on September 10, 2021. The annual reevaluation by the narcotic treatment physician on June 9, 2021, did not include results of annual physical examination. Patient #15 was admitted on August 6, 2002 and was active at the time of the inspection. The annual reevaluation by the narcotic treatment physician on August 19, 2021, did not include results of annual physical examination. These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
On April 19, 2022 the CD reviewed with MD and medical personnel §715.23(b)(5) and the schedule/timeline for the completion of all annual evaluations.
All Annual Evaluations will be monitored by the Charge Nurse and Mid-level practitioner(s) and will be scheduled for face to face visits prior to the actual due date, with medical staff.
The Charge Nurse will monitor this process weekly to ensure compliance.
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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, which included financial management abilities in two of two applicable records.Patient #13 was admitted on May 21, 2019 and was discharged on September 10, 2021. The annual clinical evaluation was completed on July 3, 2021.Patient #15 was admitted on August 6, 2002 and was active at the time of the inspection. The annual clinical evaluation was completed on August 9, 2021.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
A comprehensive review of the annual evaluation by the counselor is underway and will include the inclusion of a signature line for the Medical Director to sign.
Updates to the EHR will be completed timely.
Pending such, a medical notation will be entered into the Pt. record denoting the MD's review of the dated annual counseling evaluation and signed by the MD.
The Charge Nurse will ensure that the Medical Director signs off on all annual evaluations weekly.
The clinical Supervisor will train the counselor on how to develop more comprehensive, detail-oriented notes. Clinical Supervisors will provide training to all counselors on ensuring that all annual evaluations contain information that is inclusive of Pt.'s financial management abilities. This training will be conducted on May 2, 2022. To ensure that financial management abilities for all Pts are documented properly during each annual evaluation, the Clinic Director will monitor this deficiency during weekly management meetings and Clinical Supervisors will include this as a
part of their Counselor end-of-day checklist and included in clinical monthly and quarterly standing chart audit schedules.
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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 a review of client records, the facility failed to ensure that counseling services were provided according to the individual treatment and rehabilitation plans in two of four applicable records reviewed.Client #3 was admitted on May 18, 2021 and was discharged on November 5, 2021. The treatment plan update completed on October 12, 2021, indicated the amount of individual counseling to be one hour per month; however, the client only received a half hour of individual counseling from October 12, 2021 through the date of discharge. Client #8 was admitted on June 22, 2021 and was discharged on December 2, 2021. The treatment plan update completed on August 27, 2021, indicated the amount of individual counseling to be one hour per month; however, the client only received three quarters of an hour of individual counseling for the month of October 2021.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Counselors will use the "hold" tool in the EHR to ensure patients attend to their required counseling hours as scheduled each day with weekly and monthly reviews to the same.
Any and all missed counseling sessions will be appropriately documented, noting Pt.'s missed appt. and counselor follow up outreach to same, along with any noted Tx plan non-compliance at that time.
A new Pt. 'hold' will be placed for the patient to be held the next day to reschedule or complete the counseling session.
Clinical Supervisors will monitor staff compliance and will review during individual and weekly group supervision sessions.
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