INITIAL COMMENTS
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This report is a result of an on-site provisional license and methadone monitoring follow-up inspection conducted on April 1, 2025 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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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
A narcotic treatment program shall provide narcotic treatment physician services at least 1 hour per week onsite for every ten patients.
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 four of seventeen weeks.
Physician service hours were reviewed from December 1, 2024 through March 29, 2025.
During the week of December 22, 2024 through December 28, 2024, the facility ' s census was 404 patients. The facility was required to provide 40.4 hours of onsite physician services, however they provided only provided 32 hours.
During the week of December 29, 2024 through January 4, 2025, the facility ' s census was 398 patients. The facility was required to provide 39.8 hours of onsite physician services, however they provided only provided 39.5 hours.
During the week of January 19, 2025 through January 25, 2025, the facility ' s census was 406 patients. The facility was required to provide 40.6 hours of onsite physician services, however they provided only provided 39.5 hours.
During the week of February 9, 2025 through February 15, 2025, the facility ' s census was 411 patients. The facility was required to provide 41.1 hours of onsite physician services, however they provided only provided 35.5 hours.
This finding was reviewed with the facility staff during the licensing process.
This is a repeat citation from the October 16-17, 2024 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 1 hour for every 10 patients. This was reviewed with the physician at a meeting on April 8th and April 10th 2025. In addition the clinic director applied for an exception to 715.6(e) Physician staffing which was granted on January 15, 2025. 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.
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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 the facility ' s weekly census and physicians' hours, the facility failed to provide the required physician time for six of sixteen weeks. December 1, 2024 through January 4, 2025 required the physician to provide one-third of the hours. The facility failed to provide one-third physician hours in five of five weeks. The facility received an exception on January 9, 2025 approving the narcotic treatment physician to provide at least one-fifth of the required physician time. The facility failed to provide one-fifth physician hours in one of eleven weeks.
The census for the week of December 1, 2024 through December 7, 2024 was 403. The required narcotic treatment physician time was 40.3. One-third of the required narcotic treatment physician time to be provided by the narcotic treatment physician was 13.2; however, there were only 11 hours documented.
The census for the week of December 8, 2024 through December 14, 2024 was 402. The required narcotic treatment physician time was 40.2. One-third of the required narcotic treatment physician time to be provided by the narcotic treatment physician was 13.2; however, there were only 11 hours documented.
The census for the week of December 15, 2024 through December 21, 2024 was 402. The required narcotic treatment physician time was 40.2. One-third of the required narcotic treatment physician time to be provided by the narcotic treatment physician was 13.2; however, there were only 11 hours documented.
The census for the week of December 22, 2024 through December 28, 2024 was 404. The required narcotic treatment physician time was 40.4. One-third of the required narcotic treatment physician time to be provided by the narcotic treatment physician was 13.3; however, there were only 11 hours documented.
The census for the week of December 29, 2024 through January 4, 2025 was 398. The required narcotic treatment physician time was 39.8. One-third of the required narcotic treatment physician time to be provided by the narcotic treatment physician was 13.1; however, there were only 11 hours documented.
The census for week January 19, 2025 through January 25, 2025 was 406. The required narcotic treatment physician time is 40.6. One-fifth of the required narcotic treatment physician time to be provided by the narcotic treatment physician was 8.12. 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 16-27, 2024 and October 19-20, 2023 annual licensing inspections.
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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. On January 15, 2025, DDAP approved an exception to 715.6(e) and granted the facilities physician assistants and nurse practitioners may provide up to four-fifths of the required narcotic treatment physician time. This was reviewed with physicians at a meeting on April 8th and April 10th, 2025. 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 seven of seven records.
Patient #1 was admitted on December 12, 2021 and was still active at the time of the inspection. An annual evaluation was completed on December 11, 2024, but was not reviewed, dated, and signed by the Medical Director.
Patient #2 was admitted on February 17, 2011 and was still active at the time of the inspection. An annual evaluation was completed on February 17, 2025, but was not reviewed, dated, and signed by the Medical Director.
Patient #3 was admitted on March 13, 2015 and was still active at the time of the inspection. An annual evaluation was completed on March 14, 2025, but was not reviewed, dated, and signed by the Medical Director.
Patient #4 was admitted on January 20, 2012 and was still active at the time of the inspection. An annual evaluation was completed on January 14, 2025, but was not reviewed, dated, and signed by the Medical Director.
Patient #5 was admitted on January 18, 2019 and was still active at the time of the inspection. An annual evaluation was completed on January 10, 2025, but was not reviewed, dated, and signed by the Medical Director.
Patient #6 was admitted on January 17, 2012 and was still active at the time of the inspection. An annual evaluation was completed on January 9, 2025, but was not reviewed, dated, and signed by the Medical Director.
Patient #7 was admitted on February 1, 2019 and was still active at the time of the inspection. An annual evaluation was completed on February 4, 2025, but 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 16-17, 2024, 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 the 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 reviews due. The medical director will review date and sign the evaluation. The issue was addressed at the counselor meeting on April 10, 2025 and with the physicians on April 14th and 17th 2025. This will be monitored by the clinical supervisor during the monthly record review. |
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 administrative information and 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 16-17, 2024, 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 April 1, 2025 licensing inspection.
Plans of correction for physician providing the required narcotic physician time were submitted and approved by the Department for the October 16-17, 2024 and October 19-20, 2023 annual licensing inspections. Physicians providing the required narcotic physician time was again found to be a deficiency in the April 1, 2025 licensing inspection.
These findings were reviewed with facility staff during the licensing process.
This is a repeat citation from the October 16-27, 2024 and October 19-20, 2023 annual licensing inspections.
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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. |