INITIAL COMMENTS
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This report is a result of an on-site provisional license follow-up inspection and methadone monitoring conducted on October 25 - 26, 2023 by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, Watsontown 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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704.11(a)(2) LICENSURE Overall Training plan
704.11. Staff development program.
(a) Components. The project director shall develop a comprehensive staff development program for agency personnel including policies and procedures for the program indicating who is responsible and the time frames for completion of the following components:
(2) An overall plan for addressing these needs.
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Observations
Based on the review of personnel files, the facility failed to provide a written individual training plan to include documentation of input from both the employee and the supervisor in one out of nine files reviewed.
Employee # 1 was hired as the project director on November 7, 2017 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.
The finding was reviewed with facility staff during the licensing inspection.
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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, verifying the collaborative process. |
709.33 (a) LICENSURE Notification of termination.
§ 709.33. Notification of termination.
(a) Project staff shall notify the client, in writing, of a decision to involuntarily terminate the client ' s treatment at the project. The notice shall include the reason for termination.
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Observations
Based on the review of client records, the facility failed to notify the client, in writing, of a decision to involuntarily terminate the client's treatment in one out of one applicable record reviewed.
Client #3 was admitted on January 5, 2023 and discharged on September 19, 2023.
The finding was reviewed with facility staff during the licensing inspection.
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Plan of Correction
CD will review with management team to ensure the 'notification of treatment termination' form is completed, client is notified and documentation is available within the Pt. record to same.
CD and RD reviewed the termination form with the Quality Director on day of state inspection. This form was revised on day of inspection according to 709.33.
Will review with staff on 12/13/23 to ensure compliance.
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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 the review of client records, the facility failed to develop a comprehensive treatment plan within the timeframe of 30 days as outlined in the facility's policy and procedures manual in eight out of nine applicable records reviewed.
Client #5 was admitted on February 13, 2023 and discharged on August 4, 2023. The comprehensive treatment plan was due no later than March 13, 2023; however, it was completed on March 16, 2023.
Client #9 was admitted on August 14, 2023 and was still active at the time of the inspection. The comprehensive treatment plan was due no later than September 14, 2023; however, if was completed on September 18, 2023.
Client #10 was admitted on August 14, 2023 and was still active at the time of the inspection. The comprehensive treatment plan was due no later than September 14, 2023; however, it was completed on
October 6, 2023.
Client #11 was admitted on September 20, 2023 and was still active at the time of the inspection. The comprehensive treatment plan was due no later October 20, 2023; however, it was completed on October 24, 2023.
Client #12 was admitted on June 2, 2023 and was discharged on August 23, 2023. The comprehensive treatment plan was due no later than July 2, 2023; however, it was completed on July 7, 2023.
Client #15 was admitted on July 18, 2023 and was still active at the time of the inspection. The comprehensive treatment plan was due no later than August 18, 2023; however, it was completed August 21, 2023.
Client #18 was admitted on May 26, 2023 and was still active at the time of the inspection. The comprehensive treatment plan was due no later than June 26, 2023; however, it was completed on June 27, 2023.
Client #19 was admitted on September 12, 2023 and was still active at the time of the inspection. The comprehensive treatment plan was due no later than October 12, 2023; however, it was completed on October 20, 2023.
These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
CD will review with CS to update the counseling end of day checklist to ensure the comprehensive treatment plan is completed within the 30 day timeframe according to Acadia's policy and procedures.
CS will continue to run the services due report daily and review for compliance at the end of each day. Any patient with services due will have a hold placed on their account to schedule to complete the service(s) timely, preferably the following day.
Will train/review with counseling staff at group counseling supervision meeting on 12/13/23.
CD and CS will follow up with record reviews to ensure compliance to same.
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