INITIAL COMMENTS
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This report is a result of an on-site licensure renewal and methadone monitoring inspection conducted on October 16-17, 2024 by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, Duncansville 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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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 the review of the facility's fire drill log for the months of October 2023 through September 2024, the facility failed to conduct fire drills on different days of the week, at different times of the day and night and on different staffing shifts.
Ten out of twelve fire drills were conducted between 10:00am and 11:15am.
The ten fire drills are October, November, December 2023, February, March, April, May, June, August and September 2024.
These findings were reviewed with facility staff during the licensing process.
This is a repeat citation from the October 19-20, 2023 annual licensing inspection.
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Plan of Correction
The clinic will conduct fire drills on different days of the week, at different times of the day and on different staffing shifts. The clinic director will utilize a drill calendar to assist in keeping drills sporadic in timing. This will be reviewed during the staff meeting November 14, 2024. The clinic director is responsible for monitoring this standard on an on-going basis.
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715.6(d) LICENSURE Physician Staffing
(d) A narcotic treatment program shall provide narcotic treatment physician services at least 1 hour per week onsite for every ten patients
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Observations
Based on a review of medical staff coverage, the facility failed to provide narcotic treatment physician services at least one hour per week onsite for every ten patients for one of seventeen weeks.
Physician service hours were reviewed from June 1, 2024 through September 28, 2024.
During the week of June 30, 2024 through July 6, 2024, the facility census was 381 patients. The facility was required to provide 38.1 hours of onsite physician services, however they provided only provided 35 hours.
This finding was reviewed with the facility staff during the licensing process.
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Plan of Correction
The physician will provide the required on-site hours. The physician is responsible for providing 1 hour for every 10 patients. This will be reviewed at the staff meeting November 12, 2024. The clinic director is responsible for monitoring and approving the hours spent on-site by the physician and physician assistant. This will be implemented immediately and monitored on a monthly basis by the clinic director. |
715.6(e) LICENSURE Physician Staffing
(e) A physician assistant or certified registered nurse practitioner may perform functions of a narcotic treatment physician in a narcotic treatment program if authorized by Federal, State and local laws and regulations, and if these functions are delegated to the physician assistant or certified registered nurse practitioner by the medical director, and records are properly countersigned by the medical director or a narcotic treatment physician. One-third of all required narcotic treatment physician time shall be provided by a narcotic treatment physician. Time provided by a physician assistant or certified registered nurse practitioner may not exceed two-thirds of the required narcotic treatment physician time.
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Observations
Based on a review of the facility ' s weekly census and physicians' hours, the facility failed to provide documentation of the narcotic treatment physician providing at least one-third of the required narcotic treatment physician time in seventeen of seventeen weeks reviewed.
The census for the week of June 1, 2024 through June 8, 2024 was 379. The required narcotic treatment physician time was 37.9. One-third of the required narcotic treatment physician time to be provided by the narcotic treatment physician was 12.6; however, there were only 7.5 hours documented.
The census for the week of June 9, 2024 through June 15, 2024 was 379. The required narcotic treatment physician time was 37.9. One-third of the required narcotic treatment physician time to be provided by the narcotic treatment physician was 12.6; however, there were only 11 hours documented.
The census for the week of June 16, 2024 through June 22, 2024 was 380. The required narcotic treatment physician time was 38. One-third of the required narcotic treatment physician time to be provided by the narcotic treatment physician was 12.6. There were only 11 hours documented.
The census for week June 23, 2024 through June 29, 2024 was 383. The required narcotic treatment physician time was 38.3. One-third of the required narcotic treatment physician time to be provided by the narcotic treatment physician was 12.7. There were only 11 hours documented.
The census for week June 30, 2024 through July 6, 2024 was 381. The required narcotic treatment physician time is 38.1. One-third of the required narcotic treatment physician time to be provided by the narcotic treatment physician was 12.7. There were only 11 hours documented.
The census for week July 7, 2024 through July 13, 2024 was 384. The required narcotic treatment physician time is 38.4. One-third of the required narcotic treatment physician time to be provided by the narcotic treatment physician was 12.8. There were only 11 hours documented.
The census for week July 14, 2024 through July 20, 2024, was 384. The required narcotic treatment physician time is 38.4. One-third of the required narcotic treatment physician time to be provided by the narcotic treatment physician was 12.8. There were only 11 hours documented.
The census for week July 21, 2024 through July 27, 2024 was 386. The required narcotic treatment physician time is 38.6. One-third of the required narcotic treatment physician time to be provided by the narcotic treatment physician was 12.8. There were only 7.5 hours documented.
The census for week July 28, 2024 through August 3, 2024 was 389. The required narcotic treatment physician time is 38.9. One-third of the required narcotic treatment physician time to be provided by the narcotic treatment physician was 12.9. There were only 7.5 hours documented.
The census for week August 4, 2024 through August 10, 2024 was 391. The required narcotic treatment physician time is 39.1. One-third of the required narcotic treatment physician time to be provided by the narcotic treatment physician was 13. There were only 7.5 hours documented.
The census for week August 11, 2024 through August 17, 2024 was 393. The required narcotic treatment physician time is 39.3. One-third of the required narcotic treatment physician time to be provided by the narcotic treatment physician was 13.1. There were only 7.5 hours documented.
The census for week August 18, 2024 through August 24, 2024 was 392. The required narcotic treatment physician time is 39.2. One-third of the required narcotic treatment physician time in 13. There were only 7.5 hours documented.
The census for week August 25, 2024 through August 31, 2024 was 391. The required narcotic treatment physician time is 39.1. One-third of the required narcotic treatment physician time in 13. There were only 9 hours documented.
The census for week September 1, 2024 through September 7, 2024 was 394. The required narcotic treatment physician time is 39.4. One-third of the required narcotic treatment physician time in 13.1. There were only 9 hours documented.
The census for week September 8, 2024 through September 14, 2024 was 397. The required narcotic treatment physician time is 39.7. One-third of the required narcotic treatment physician time in 13.2. There were only 9 hours documented.
The census for week September 15, 2024 through September 21, 2024 was 397. The required narcotic treatment physician time is 39.7. One-third of the required narcotic treatment physician time in 13.2. There were only 9 hours documented.
The census for week September 22, 2024 through September 28, 2024 was 397. The required narcotic treatment physician time is 39.7. One-third of the required narcotic treatment physician time in 13.2. There were only 7.5 hours documented.
These findings were reviewed with facility staff during the licensing process.
This is repeat citation from the October 19-20, 2023 annual licensing inspection.
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Plan of Correction
The physician will provide the required on-site hours. The physician is responsible for providing one-third of all required narcotic treatment time. Time provided by the PA-C may not exceed two-thirds of the required narcotic treatment physician time. This will be reviewed at the staff meeting November 12, 2024. The clinic director is responsible for monitoring and approving the hours spent on-site by the physician and PA-C. This will be implemented immediately and monitored on a monthly basis by the clinic director. |
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 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 three of four records.
Patient #2 was admitted on June 14, 2011 and was discharged on July 2, 2024. An annual evaluation was due to be completed on June 11, 2024, but was not completed prior to discharge.
Patient #5 was admitted on December 30, 2014 and was still active at the time of the inspection. An annual evaluation was completed on December 21, 2023. The annual evaluation was signed by a physician, not the Medical Director, on December 26, 2023.
Patient #6 was admitted on June 15, 2015 and was still active at the time of the inspection. An annual evaluation was due to be completed on June 16, 2024, but was not completed until June 28, 2024. The annual evaluation was not reviewed, dated, and signed by the Medical Director.
These findings were reviewed with facility staff during the licensing process.
This is a repeat citation from the October 19-20, 2023, November 2-3, 2022, December 2-3, 2021, December 10-11, 2020, and February 4-6, 2020 annual licensing inspections.
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Plan of Correction
DHBC counselors will perform an annual evaluation of each patient the review will be documented in the patient's medical record. The DHBC counselor will review the clients due for their annual evaluation at the beginning of each month, by utilizing their services due report from the EMR. The counselor will complete the annual evaluation prior to the client's anniversary date. DHBC counselors will report weekly to the clinical supervisor the status of the annual evaluations due. The medical director will review date and sign the evaluation. The issue will be addressed at the staff meeting November 14, 2024. This will be monitored by the clinical supervisor during the monthly record review. |
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 client records reviewed, the facility failed to review and update the treatment and rehabilitation plan at least every sixty days in three of seven applicable records.
Client #1 was admitted on October 19, 2021 and was still active at the time of the inspection. A treatment and rehabilitation plan was developed on December 7, 2023. A treatment and rehabilitation plan update was due no later than February 7, 2024, but was not completed until February 19, 2024.
Client #2 was admitted on June 14, 2011 and was discharged on July 2, 2024. A treatment and rehabilitation plan was developed on December 11, 2023. A treatment and rehabilitation plan update was due no later than February 11, 2024, but was not completed until February 14, 2024.A treatment and rehabilitation plan was developed on April 14, 2024. A treatment and rehabilitation plan update was due no later than June 14, 2024, but was not completed until June 25, 2024.
Client #5 was admitted on December 30, 2014 and was still active at the time of the inspection. A treatment and rehabilitation plan was developed on June 27, 2024. A treatment and rehabilitation plan update was due no later than August 27, 2024, but was not completed until August 30, 2024.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
DHBC counselors will review and update patient's treatment plans on a regular basis but at least every sixty (60) days. The review will be documented in the patient's medical record. This issue will be addressed at the staff meeting November 14, 2024. This will be monitored by the clinical supervisor during the monthly records review to ensure compliance. |
709.17(a)(3) LICENSURE Subchapter B.Licensing Procedures.Refusal/rev
709.17. Refusal or revocation of license.
(a) The Department may revoke or refuse to issue a license for any of the following reasons:
(3) Failure to comply with a plan of correction approved by the Department, unless the Department approves an extension or modification of the plan of correction.
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Observations
Based on a review of patient records, the facility failed to comply with plans of correction that were approved by the Department.
Plans of correction for annual clinical evaluations were submitted and approved by the Department for the October 19-20, 2023, November 2-3, 2022, December 2-3, 2021, December 10-11, 2020, and February 4-6, 2020 annual licensing inspections. Annual clinical evaluations were again found to be a deficiency in the October 16-17, 2024 annual licensing inspection.
These findings were reviewed with facility staff during the licensing process.
This is a repeat citation from the October 19-20, 2023 annual licensing inspection.
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Plan of Correction
A Plan of correction for deficiencies approved by the department will be monitored by the clinic director and reported at the monthly supervisor staff meeting to ensure they are being followed and implemented.
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