INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection and methadone monitoring inspection conducted on November 14 & 15, 2023, by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, Farrell 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(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 nine 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 deficiency was reviewed with Employee #1 and he is aware that all future training plans need to be developed with input from both himself and his supervisor. Employee #1 and his supervisor will ensure that all future training plans will have this, and both will sign as confirmation. |
705.28 (a) (1) (i) LICENSURE Fire safety.
705.28. Fire safety.
(a) Exits.
(1) The nonresidential facility shall:
(i) Ensure that stairways, hallways and exits from rooms and from the nonresidential facility are unobstructed.
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Observations
Based on a physical plant inspection, the facility failed to ensure that exits from rooms and from the nonresidential facility were unobstructed.
The emergency exit doors in the lobby were locked from the inside.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Clinic Director has contacted local vendor New Castle Lock & Key to have them install ergonomic exit paddles on this exit so that they can remain locked from the outside and openly easily from inside in event of fire. This will ensure meeting this regulation, while maintaining security of the building. Director is waiting to hear back from vendor for a scheduled date for this job to be completed. In the meantime, this exit will remain unlocked during operating hours. |
705.28 (d) (2) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(2) Conduct fire drills during normal staffing conditions.
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Observations
Based on a review of the facility fire drill log for the months of December 2022 through October 2023, the facility failed to conduct fire drills during normal staffing conditions. All documented fire drills except October 2023 occurred after 10:00 am which is after dosing hours.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Clinic Director reviewed this citation with staff during All Staff Meeting on 11/16/23. Clinic Director will ensure that future monthly fire drills will be completed during normal staffing conditions and that drills are conducted various time throughout the day. |
705.28 (d) (6) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(6) Conduct fire drills on different days of the week, at different times of the day and on different staffing shifts.
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Observations
Based on a review of the facility fire drill log for the months of December 2022 through October 2023, the facility failed to conduct fire drills at different times of the day or night and on different shifts. Fire drills were only conducted between 11:00 am and 12:00 pm the months of December 2022, January, February, April, May, June, July, August, and September 2023.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Clinic Director reviewed this deficiency with staff during All Staff Meeting on 11/16/23. Clinic Director will ensure future monthly fire drills are completed during different times of day, including during dosing hours. This facility only has one shift which is 5AM-1:30 PM. |
715.14(a) LICENSURE Urine testing
(a) A narcotic treatment program shall complete an initial drug-screening urinalysis for each prospective patient and a random urinalysis at least monthly thereafter.
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Observations
Based on four of twelve patient records reviewed, the facility failed to provide documentation of a complete random drug-screening urinalysis for each patient at least monthly in patient records # 8, 10, 11, and 12.
Patient # 8 was admitted on February 2, 2017, and was discharged October 6, 2023. There was no documentation of a random drug-screening urinalysis for the month of September 2023.
Patient # 10 was admitted on January 9, 2023, and was discharged October 10, 2023. There was no documentation of a random drug-screening urinalysis for the month of August 2023.
Patient # 11 was admitted on February 20, 2017, and was discharged September 6, 2023. There was no documentation of a random drug-screening urinalysis for the month of August 2023.
Patient # 12 was admitted on December 28, 2022, and was discharged June 16, 2023. There was no documentation of a random drug-screening urinalysis for the month of May 2023.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Clinic Director reviewed the deficiency with staff during All Staff Meeting on 11/16/23. Clinic Director determined that the patients cited for not having monthly drug screens completed were patients that were AWOLing and Acadia does not automatically discharge a patient who is AWOL until 30 days have passed. Clinic Director will review the AWOL Patients report weekly to determine who can be discharged in a more timely manner to avoid this deficiency in the future. |
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 three of three applicable patient records reviewed, the facility failed to document the rational prior to permitting take-home medication in patient records # 3, 5, and 10.
Patient # 3 was admitted on June 30, 2023, and was still active at the time of the inspection. Patient # 3 was permitted 2 day take-homes on July 1, 2023, however, the documentation required by the narcotic physician was not provided in the patient record until November 3, 2023.
Patient # 5 was admitted on December 1, 2020, and was still active at the time of the inspection. Patient # 5 was permitted 13 day take-homes on July 6, 2023. The 13-day take-home was rescinded on October 19, 2023, however, the patient was still permitted 2 day take homes and documentation required by the narcotic physician was not provided in the patient record.
Patient # 10 was admitted on January 9, 2023, and was discharged October 10, 2023. Patient # 10 was permitted 2 day take-homes beginning June 10, 2023, however, the documentation required by the narcotic physician was not provided in the patient record.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Clinic Director reviewed this deficiency with staff during an All Staff Meeting on 11/16/2023. Clinic Director, Medical Director, and Physician will ensure that any patient receiving takehome status will have the necessary required documentation placed in the patient's chart by the physician as to why takehomes are being granted. |
715.20(1) LICENSURE Patient transfers
A narcotic treatment program shall develop written transfer policies and procedures which shall require that the narcotic treatment program transfer a patient to another narcotic treatment program for continued maintenance, detoxification or another treatment activity within 7 days of the request of the patient.
(1) The transferring narcotic treatment program shall transfer patient files which include admission date, medical and psychosocial summaries, dosage level, urinalysis reports or summary, exception requests, and current status of the patient, and shall contain the written consent of the patient.
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Observations
Based on two of two applicable patient records reviewed, the facility failed to provide documentation of psychosocial summaries in transfer files for patients # 7 and 9.
Patient # 7 was admitted on September 8, 2020, and was discharged on July 24, 2023. The psychosocial summary was not included in the transfer paperwork.
Patient # 9 was admitted on December 7, 2022, and was discharged on February 9, 2023. The psychosocial summary was not included in the transfer paperwork.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Clinic Director reviewed this deficiency with staff during an All Staff Meeting on 11/16/2023. Staff were informed that the psychosocial summary must be included in the transfer paperwork that is provided when a patient transfers to another facility. Clinic Director provided staff with a list of all required documents that must be included in this transfer paperwork. Staff will ensure that all necessary documents are faxed and that the successful fax transmittal sheet along with transfer paperwork is scanned into the patient's EHR. Clinic Director and Clinical Supervisor will monitor compliance. |
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 four of six applicable patient records reviewed, the facility failed to document an annual evaluation of each patient 's status completed by the patient 's counselor and reviewed, dated and signed by the medical director in patient records # 1, 5, 6, and 8.
Patient # 1 was admitted on August 12, 2022, and was still active at the time of the inspection. An annual evaluation was completed on July 28, 2023, however, the annual evaluation was not reviewed, dated, and signed by the medical director.
Patient # 5 was admitted on December 1, 2020, and was still active at the time of the inspection. An annual evaluation was completed on November 10, 2023, however, the annual evaluation was not reviewed, dated, and signed by the medical director.
Patient # 6 was admitted on September 20, 2021, and was still active at the time of the inspection. An annual evaluation was completed on September 21, 2023, however, the annual evaluation was not reviewed, dated, and signed by the medical director.
Patient # 8 was admitted on February 2, 2017, and was discharged October 6, 2023. An annual evaluation was completed on January 10, 2023, however, the annual evaluation was not reviewed, dated, and signed by the medical director.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Clinic Director informed Medical Director and the Physician about the regulation stating that all Annual Clinical Evaluations must be reviewed and signed by the Medical Director. Physician was signing these when Medical Director was not on site. Physician is aware that he must leave these for the Medical Director to review and sign. Clinic Director will monitor compliance. |
709.93(a)(9) 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:
(9) Aftercare plan, if applicable.
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Observations
Based on three of three applicable client records reviewed, the facility failed to provide an aftercare plan in accordance with facility policy and procedure manual. The policy and procedure manual indicates a transition plan be developed approximately thirty days prior to transition/discharge and provided to the client at discharge.
Client # 8 was admitted on February 2, 2017, and discharged on October 6, 2023. There was no transition plan documented in the client record.
Client # 9 was admitted on December 7, 2022, and discharged on February 9, 2023. There was no transition plan documented in the client record.
Client # 11 was admitted on February 20, 2017, and discharged on September 6, 2023. There was no transition plan documented in the client record.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Clinic Director reviewed this deficiency with staff during an All Staff Meeting on 11/16/23. Counselors were informed that aftercare plans must be completed approximately 30 days prior to a planned discharge, or at time of discharge if patient is transitioning to another type of treatment. Counselors will ensure that this service is completed in accordance with Acadia policy. Clinical Supervisor will monitor compliance. |