INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection and methadone and buprenorphine monitoring inspection conducted on October 22 & 23, 2024 by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, Discovery House Inc. dba Wilkes Barre 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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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 document an annual evaluation of each patient ' s status and have it reviewed, dated and signed by the medical director in the regulatory timeframe in two out of two applicable patient records. Patient #3 was admitted on May 31, 2023 and discharged on June 26, 2024. An annual evaluation was due no later than May 31, 2024; however, it was completed on June 10, 2024.Patient #6 was admitted on June 9, 2023 and was still active at the time of the inspection. An annual evaluation was due no later than June 9, 2024; however, it was completed on June 28, 2024. These finding were reviewed with facility staff during the licensing process.
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Plan of Correction
In response to compliance to 715.23 (c) (1-7), to complete and have signed by the medical director the annual evaluations within the regulatory timeframe, the clinical supervisor will monitor during end of day reviews, weekly supervision and during monthly group supervision to ensure annual evaluations are completed and signed on time. Additionally, the CS will monitor via the quality record review process. The clinic director and clinical supervisor will discuss expectations during staff meeting on 10/31/24. |
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 that an individual treatment and rehabilitation plan was developed with the client per the facility ' s policy and procedure manual in two out of five records reviewed. The facility ' s policy and procedure manual states that the individual treatment and rehabilitation plan is developed within thirty days of admission. Client #2 was admitted on April 8, 2024 and was still active at the time of the inspection. An individual treatment and rehabilitation plan was due no later than May 8, 2024; however, it was completed on May 31, 2024. Client #7 was admitted on September 4, 2024 and was still active at the time of the inspection. An individual treatment and rehabilitation plan was due no later than October 4, 2024; however, it was completed on October 15, 2024. These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
In response to compliance to 709.92 (a), to complete treatment plans by the specified due date. Based on these findings the clinical supervisor will monitor during end of day reviews, weekly supervision and during monthly group supervision to Pt. Treatment plans are completed and signed by the specified due date Additionally, the CS will monitor monthly via the quality record review process. The clinic director and clinical supervisor will discuss expectations during staff meeting on 10/31/24. |
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 a review of client records, the facility failed to document treatment plan updates within the regulatory timeframe in four out of six applicable records reviewed.Client #2 was admitted on April 8, 2024 and was still active at the time of the inspection. A treatment plan update was completed on August 9, 2024, and the next update was due no later than October 8, 2024; however, it was completed on October 14, 2024. Client #4 was admitted on November 20, 2023 and discharged on August 16, 2024. A treatment plan update was completed on March 23, 2024, and the next update was due no later than May 22, 2024; however, it was completed on June 7, 2024. Client #5 was admitted on June 12, 2024 and was still active at the time of the inspection. A treatment plan was completed on August 7, 2024, and the next update was due no later than October 6, 2024; however, it was completed on October 14, 2024. Client #6 was admitted on June 9, 2023 and was still active at the time of the inspection. A treatment plan was completed on February 2, 2024, and the next update was due no later than April 2, 2024; however, it was completed on April 6, 2024. A treatment plan update was completed on August 6, 2024, and the next update was due no later than October 5, 2024; however, it was completed on October 8, 2024. These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
In response to compliance to 709.92 (b) to review and update treatment plans every 60 days. Based on these findings the clinical supervisor will monitor during end of day reviews, weekly supervision and during monthly group supervision to ensure are reviewed and updated every 60 days. Additionally, the CS will monitor via the quality record review process. The clinic director and clinical supervisor will discuss expectations during staff meeting on 10/31/24. |
709.93(a)(8) LICENSURE Client records
709.93. Client records.
(a) There shall be a complete client record on an individual which includes information relative to the client's involvement with the project. This shall include, but not be limited to, the following:
(8) Case consultation notes.
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Observations
Based on the review of client records, the facility failed to document case consultations per the facility ' s policy and procedure manual in three out of five applicable client records. The facility ' s policy and procedure manual states that case consultation occurs every ninety days the first year and then yearly thereafter. Client #3 was admitted on May 31, 2023 and discharged on June 26, 2024. A case consultation was due no later than May 31, 2024; however, it was completed on June 10, 2024. Client#4 was admitted on November 20, 2023 and discharged on August 16, 2024. A case consultation was due no later than May 20, 2024; however, it was completed on June 7, 2024. Client #6 was admitted on June 9, 2023 and was still active at the time of the inspection. A case consultation was due no later than June 9, 2024; however, it was completed on July 2, 2024. These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
In response to compliance to 709.93 (a) (8) to ensure case consultation occur every 90 days for the first year and annually thereafter per the facilities policies. Based on these findings the clinical supervisor will monitor during end of day reviews, weekly supervision and during monthly group supervision to ensure case consolations are completed within facilities policy timelines. Additionally, the CS will monitor monthly via the quality record review process. The clinic director and clinical supervisor will discuss expectations during staff meeting on 10/31/24.
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