INITIAL COMMENTS
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This report is a result of an on-site licensure renewal and methadone monitoring inspection conducted on October 24, 2024 through October 25, 2024, 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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704.9(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
Based on a review of nine personnel records, the facility failed to ensure that one counselor assistant was counseling clients under the supervision of a trained counselor or clinical supervisor based on their education.Employee # 9 was promoted to the position of counselor assistant on December 3, 2023. Employee # 9 had a high school diploma at the time of promotion and 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. Employee # 9 did not receive documented direct observation from December 3, 2023 - March 3, 2024 or documented close supervision from March 3, 2024 through the date of the inspection. Direct observation is defined by regulation as follows: "In person observation of staff working in a clinical setting for the purpose of planning, oversight, monitoring and evaluating their activities." In accordance with 28 Pa. Code 704.9(a), a counselor assistant must be supervised by a fulltime clinical supervisor or a full-time counselor. The fully qualified clinical supervisor or counselor is then responsible for weekly supervision notes relating to the counselor assistant. Clear documentation in the weekly notes and in the pertinent client charts must also demonstrate that direct observation is occurring.Close supervision is defined by regulation as follows: "Formal documented case review and an additional hour of direct observation by a supervising counselor or a clinical supervisor once a week."Documented supervision did not identify that direct observation was occurring in the dates noted above. These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Pottstown CTC Clinical Supervisor will ensure all Counselor Assistants providing counseling to patients is done so only under the direct observation of a trained counselor or clinical supervisor for the first 3 months of employment. For the next 9 months, Clinical Supervisor will ensure the counselor assistant counsel clients only under the close supervision of a lead counselor or a clinical supervisor. Documentation of such supervision will be reviewed by Clinical Supervisor. This regulation was reviewed during All-staff meeting on November 14, 2024. Compliance to this regulation will be monitored by Clinic Director. Clinical Supervisor will directly observe individual counseling sessions twice weekly for the next 3 months. Documentation of such observation will be indicated in the Pt's EMR. |
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 client records, the facility failed to obtain an informed and voluntary consent from the client for the disclosure of information that included all of the specific information to be disclosed in nine of ten records reviewed. Client # 1 was admitted on May 6, 2024 and was active at the time of the inspection. Per a discussion with the Facility Director, information such as the client's diagnosis was disclosed to the funding source; however, the consent to release information forms to the funding source, which were signed by the client on May 6, 2024 and October 17, 2024, did not allow for the release of that information.Client # 2 was admitted on August 21, 2023 and was discharged on February 12, 2024. Per a discussion with the Facility Director, information such as the client's diagnosis was disclosed to the funding source; however, the consent to release information form to the funding source, which was signed by the client on August 21, 2023, did not allow for the release of that information.Client # 3 was admitted on February 24, 2020 and was discharged on March 17, 2024. Per a discussion with the Facility Director, information such as the client's diagnosis was disclosed to the funding source; however, the consent to release information form to the funding source, which was signed by the client on February 1, 2023, did not allow for the release of that information.Client # 4 was admitted on January 8, 2024 and was discharged on March 28, 2024. Per a discussion with the Facility Director, information such as the client's diagnosis was disclosed to the funding source; however, the consent to release information form to the funding source, which was signed by the client on January 8, 2024, did not allow for the release of that information.Client # 5 was admitted on June 20, 2024 and was active at the time of the inspection. Per a discussion with the Facility Director, information such as the client's diagnosis was disclosed to the funding source; however, the consent to release information forms to the funding source, which were signed by the client on June 20, 2024 and August 21, 2024, did not allow for the release of that information.Client # 6 was admitted on March 1, 2023 and was active at the time of the inspection. Per a discussion with the Facility Director, information such as the client's diagnosis was disclosed to the funding source; however, the consent to release information form to the funding source, which was signed by the client on March 1, 2023, did not allow for the release of that information.Client # 7 was admitted on February 23, 2024 and was discharged on April 11, 2024. Per a discussion with the Facility Director, information such as the client's diagnosis was disclosed to the funding source; however, the consent to release information form to the funding source, which was signed by the client on February 23, 2024, did not allow for the release of that information.Client # 8 was admitted on July 31, 2024 and was discharged on September 7, 2024. Per a discussion with the Facility Director, information such as the client's diagnosis was disclosed to the funding source; however, the consent to release information form to the funding source, which was signed by the client on September 7, 2024, did not allow for the release of that information.Client # 10 was admitted on April 1, 2024 and was active at the time of the inspection. Per a discussion with the Facility Director, information such as the client's diagnosis was disclosed to the funding source; however, the consent to release information form to the funding source, which was signed by the client on April 1, 2024, did not allow for the release of that information.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Pottstown CTC Clinic Director and Clinical Supervisor will ensure that all release of information forms will indicate a specific purpose of the disclosure to named parties, and specific information to be disclosed within the ROI prior to any release of information is given. All releases of information will be reviewed for accuracy and that these releases of information are completed in its entirety on a quarterly basis. This information was presented during the November 14, 2024 All-Staff meeting to ensure compliance to this regulation. Progress on this plan will be monitored by the Clinical Supervisor monthly via the Quality Record Review Process, as well as addressed in individual and group supervision. ROI trainings to be offered, as needed. ROI's for active clients will be updated to reflect pt. diagnosis within 60 days.
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715.9(a)(2) LICENSURE Intake
(a) Prior to administration of an agent, a narcotic treatment program shall screen each individual to determine eligibility for admission. The narcotic treatment program shall:
(2) Verify the individual 's identity, including name, address, date of birth, emergency contact and other identifying data.
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Observations
Based on a review of patient records, the facility failed to ensure that verification of the individual's identity was obtained during the intake process in one of six applicable records reviewed.Patient # 1 was admitted on May 6, 2024 and was active at the time of the inspection. The record did not contain documentation that the individual's identity was verified during intake, and there was no documentation showing that the patient declined to provide it during the intake process or that there was a lapse in attendance preventing the information from being gathered. The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Pottstown CTC will verify the identity and obtain a copy of each patient's identity in the form of a state issued photo ID, driver's license, and/or birth certificate and social security card prior to the initial administration of medication. The Administrative Asst/office manager will monitor each patients chart on a weekly basis to ensure that patient identification is present. This information was presented during an All-Staff meeting on November 14, 2024. Progress on this plan, and monitoring to ensure compliance will be reviewed by the Clinical Supervisor and Clinic Director monthly via the Quality Record Review Process. |
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 applicable record reviewed. Patient # 6 was admitted on March 1, 2023 and was active at the time of the inspection. The patient received take-home medications on August 28, 2024, and the rationale for take-home medication was not documented by the physician until September 5, 2024.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Pottstown CTC medical providers will ensure the rationale for permitting Take-home medications be documented in the patient record. Clinic Director reviewed this regulation with Medical Director and nursing staff during medical dept meeting on November 6, 2024. To ensure compliance to this regulation, this will be monitored by the Charge Nurse monthly via the Quality Record Review Process, as well as Medical Director via quarterly peer chart reviews. |
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 include employment, education and training, and legal standing in the patient's annual evaluation in two of three applicable records. Patient # 3 was admitted on February 24, 2020 and was discharged on March 17, 2024. The annual evaluation was completed on February 23, 2024.Patient # 9 was admitted on April 18, 2011 and was active at the time of the inspection. The annual evaluation was completed on April 16, 2024.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Pottstown CTC will ensure that the annual evaluation will address all required areas including: (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. This requirement was reviewed by Clinical Supervisor during All-staff meeting on November 14, 2024. To ensure compliance, the Clinical Supervisor will review all submitted clinical evaluations on a monthly basis. documentation
The 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.
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