INITIAL COMMENTS
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This report is a result of an on-site licensure renewal and methadone monitoring inspection conducted on November 28, 2023, 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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704.6(c) LICENSURE Core Curriculum - Supervisor Training
704.6. Qualifications for the position of clinical supervisor.
(c) Clinical supervisors and lead counselors who have not functioned for 2 years as supervisors in the provision of clinical services shall complete a core curriculum in clinical supervision. Training not provided by the Department shall receive prior approval from the Department.
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Observations
Based on one of one applicable personnel record reviewed, the facility failed to provide documentation of at least two years experience as a supervisor in the provision of clinical services or the completion of a core curriculum in clinical supervision for employee # 3.
Employee # 3 was hired as a clinical supervisor on March 6, 2023, and was still in this position at the time of the inspection. Based on employee # 3's resume, there was no documentation of at least two years experience as a supervisor in the provision of clinical services or the completion of a core curriculum in clinical supervision.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Clinical Supervisor will possess at least two years of experience as a supervisor in the provision of clinical services or completion of the core curriculum in clinical supervision in accordance with 704.6(C)
Clinical Supervisor was scheduled for training and that training was canceled. On 12/8/2023 the clinical supervisor completed the required training for clinical supervision.
Clinic Director is responsible to ensure that Clinic Supervisor meets requirements. Clinic Director will ensure that any future clinic supervisor meets the requirements or completes training within 6 month time frame. |
704.11(b)(1) LICENSURE Individual training plan.
704.11. Staff development program.
(b) Individual training plan.
(1) A written individual training plan for each employee, appropriate to that employee's skill level, shall be developed annually with input from both the employee and the supervisor.
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Observations
Based on one of six personnel records reviewed, the facility failed to provide a written individual training plan to include documentation of input from both the employee and the supervisor in employee record # 1.
Employee # 1 was hired as the project director on April 22, 2018 and was still in this position at the time of the inspection. A training plan was acknowledged by the employee on January 4, 2023, however, there was no documentation of input from both the employee and the supervisor.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
This citation has been presented to the Project Director via the RD. The Individual Training Plan will be revised as per 704.11(b)(1) to include documented input from the Employee as well as their Supervisor and will included the additional signature line for both parties to sign and date accordingly. Such will be put into effect immediately.
The Clinic Director will ensure the Project Directors Individual training plan was reviewed and signed when received onsite. If both signatures are not present to show it was reviewed with project director the clinic director will work with the regional director to ensure it is completed. |
705.24 (5) LICENSURE Bathrooms.
705.24. Bathrooms.
The nonresidential facility shall:
(5) Ventilate bathrooms by exhaust fan or window.
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Observations
Based on a physical plant inspection conducted on November 28, 2023, the facility failed to ventilate bathrooms by exhaust fans or window.
A bathroom located in the lobby of the facility had an exhaust fan that was inoperable.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
On 11/28/2023 the bathroom fan in the lobby bathroom was not operational. On 12/05/2023 the bathroom fan in the lobby bathroom was serviced and is now functional and able to provide proper ventilation in the lobby bathroom.
To ensure that this is no reoccurrence the Clinic Director will add ventilation fan checks in restrooms to the monthly facility audit to ensure the fans are checked and in working order. |
705.28 (d) (3) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(3) Ensure that all personnel on all shifts are trained to perform assigned tasks during emergencies.
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Observations
Based on a review of personnel records, the facility failed to ensure that all personnel on all shifts are trained to perform assigned tasks during emergencies upon employment.
Employee # 2 was hired as a facility director on February 20, 2023, and was still in this position at the time of the inspection. Training to perform assigned tasks during emergencies was not documented to have occurred until March 10, 2023.
Employee # 5 was hired as a counselor on February 7, 2023, and was still in this position at the time of the inspection. Training to perform assigned tasks during emergencies was not documented to have occurred until March 10, 2023.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Emergency training for two employees occurred a month after hire. Emergency training should be completed within the first week of employment. The Clinic Director is ultimately responsible to ensure emergency training is completed as part of the onboarding process for new hires. The Clinic Director will review all staff files during the orientation process to ensure that this training is completed within the first week of hire. |
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 one of eight client records reviewed, the facility failed to obtain an informed and voluntary consent from the client for the disclosure of information contained in the client record.
Client # 1 was admitted on October 11, 2023, and was still active at the time of the inspection. The client record contained documentation of a correspondence with another treatment facility that provided admission and dosing information dated October 11, 2023. The client record did not contain an informed and voluntary consent to disclose the information located in the record.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Client transferred from another treatment facility and the release sent from the treatment facility was for one way communication to our facility. Release was not completed for our facility to discuss patient with transfer site. Clinic will ensure all transfer patients complete a release on their intake for their previous treatment facility to coordinate the transfer. This was reviewed with the staff on 11/30/2023. Intake charts will be audited by clinic supervisor to ensure all needed releases are present for transfer. Clinic Director will monitor and randomly audit charts to ensure compliance. |
709.32 (b) LICENSURE Medication control
§ 709.32. Medication control.
(b) Verbal orders for medication can be given only by a physician or other medical professional authorized by State and Federal law to prescribe medication and verbal orders may be received only by another physician or medical professional authorized by State and Federal law to receive verbal orders. When a verbal or telephone order is given, it has to be authenticated in writing by a physician or other medical professional authorized by State and Federal law to prescribe medication. In detoxification levels of care, written authentication shall occur no later than 24 hours from the time the order was given. Otherwise, written authentication shall occur within 3 business days from the time the order was given.
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Observations
Based on four of eight client records reviewed, the facility failed to have verbal orders authenticated in writing by a physician or other medical professional authorized by State and Federal law to prescribe medication within 3 business days from the time the order was given in client records # 4, 5, 6, and 7.
Client # 4 was admitted on May 25, 2023, and was still active at the time of the inspection. A verbal order for medication was given by the physician on July 25, 2023, but was not authenticated in writing until July 31, 2023.
Client # 5 was admitted on May 23, 2023, and was discharged July 19, 2023. A verbal order for medication was given by the physician on May 23, 2023, but was not authenticated in writing by the physician. A verbal order was given by the physician on July 11, 2023, but was not authenticated in writing until July 17, 2023.
Client # 6 was admitted on July 17, 2023, and was discharged October 13, 2023. A verbal order for medication was given by the physician on August 15, 2023, but was not authenticated in writing by the physician until August 21, 2023.
Client # 7 was admitted on August 9, 2023, and was discharged October 4, 2023. A verbal order for medication was given by the physician on August 16, 2023, but was not authenticated in writing until August 21, 2023.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
All verbal orders for medication will be authenticated in writing within 3 business days in accordance with regulation 709.32(b). The Medical Director and Charge Nurse will review all medical documentation in the EMR for admission and interim charts to ensure that verbal medication orders have been signed within the appropriate timeframe. |
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
Based on one of five applicable patient records reviewed, the narcotic treatment program failed to provide 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 in patient record # 4.
Patient # 4 was admitted on May 25, 2023, and was still active at the time of the inspection. The record only documented thirty minutes of psychotherapy for June 2023 and sixty minutes for July 2023.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Wilkes-Barre CTC patients are informed of required 2.5 hours of psychotherapy per month during their first 2 years in treatment. The Clinic Director and Clinical Supervisor are responsible for ensuring compliance with psychotherapy services for all patients within this narcotic treatment program. The Clinical Supervisor reviews this regulation with each clinical team member during weekly individual and group supervision. Each counselor will enter "no show counseling" notes into the EMR when a patient does not attend a scheduled individual or group session and progressive interventions will be taken with patients who are non-compliant with treatment hours. Continued issues of counseling non-compliance after multiple intervention attempts will be brought to the Multi-Disciplinary Team, every Wednesday, for consideration of an Administrative Discharge. The Clinical Supervisor and Counseling staff will monitor compliance of all patients counseling requirements during weekly individual supervision as well as internal quality record reviews. |