INITIAL COMMENTS
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This report is a result of an on-site licensure renewal and a methadone monitoring inspection conducted on August 26-27, 2021 by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, Lebanon 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(c)(1) LICENSURE Mandatory Communicable Disease Training
704.11. Staff development program.
(c) General training requirements.
(1) Staff persons and volunteers shall receive a minimum of 6 hours of HIV/AIDS and at least 4 hours of tuberculosis, sexually transmitted diseases and other health related topics training using a Department approved curriculum. Counselors and counselor assistants shall complete the training within the first year of employment. All other staff shall complete the training within the first 2 years of employment.
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Observations
Based on a review of seven personnel files on August 26-27, 2021, the facility failed to ensure that all counselors were trained in HIV/AIDS and TB/STD within the first year of employment.
Employee #6 was hired on September 16, 2019 as a Counselor and is still current. There was no documentation that employee #6 received their six hours of mandatory HIV/AIDS training or their four hours of mandatory TB/STD training.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Employee #6 has completed TB/STD DDAP Training as of 9/20/21 and is scheduled for HIV training on 11/3 & 11/4/2021.
Clinical supervisor will review training plans with all staff quarterly to ensure completion of required trainings within specified timeframes, as well as work on training development plan at time of hire for all new staff.
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704.11(g)(1) LICENSURE Trng Req-Couns Asst
(g) Training requirements for counselor assistants.
(1) Each counselor assistant shall complete at least 40 clock hours of training the first year and 30 clock hours annually thereafter in areas such as:
(i) Pharmacology.
(ii) Confidentiality.
(iii) Client recordkeeping.
(iv) Drug and alcohol assessment.
(v) Basic counseling.
(vi) Treatment planning.
(vii) The disease of addiction.
(viii) Principles of Alcoholics Anonymous and Narcotics Anonymous.
(ix) Ethics.
(x) Substance abuse trends.
(xi) Interaction of addiction and mental illness.
(xii) Cultural awareness.
(xiii) Sexual harassment.
(xiv) Developmental psychology.
(xv) Relapse prevention.
(h) Training hours. Training hours are not cumulative from one personnel classification to another.
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Observations
Based on a review of seven personnel records on August 26-27, 2021, the facility failed to ensure that one applicable counselor assistant completed at least 40 clock hours of training the first year and 30 clock hours annually thereafter.
Employee #7 was hired on March 11, 2019 as a counselor assistant and is still current in that position. Employee #7 had did not have 40 clock hours of training for the first year. Only 26 hours and 55 minutes of training was documented.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Counselor assistant and Clinical supervisor have reviewed training needs for remainder of year. Staff has scheduled trainings accordingly to ensure that 30 hours are obtained for the year. Clinical supervisor will review training schedule quarterly with counselor assistant to ensure that annual training hours are met consistently.
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705.28 (d) (4) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(4) Maintain a written fire drill record including the date, time, the amount of time it took for evacuation, the exit route used, the number of persons in the facility at the time of the drill, problems encountered and whether the fire alarm or smoke detector was operative.
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Observations
Based on a review of the past year ' s fire drill records on August 26-27, 2021, the facility failed to include the exit route used or if the alarm or smoke detector were operative at the time of the fire drill that was conducted on July 7, 2021.
These findings were reviewed with the facility staff during the licensing process.
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Plan of Correction
Drill reporting was reviewed and discussed with health & safety staff on 8/30/2021 to ensure complete reporting to include exit routes going forward. Staff will include operational status of smoke alarm and detectors at time of drill.
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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 doctor's hours and program census from April 25, 2021 through July 31, 2021, the narcotic treatment program was unable to provide documentation that the narcotic treatment physician provided services at least 1 hour per week onsite for every ten patients.
The week of April 25-May 1, 2021, the program census was 403. The documented narcotic treatment physician hours were 23 rather than the required 40.3 hours.
The week of May 2-May 8, 2021, the program census was 402. The documented narcotic treatment physician hours were 16.5 rather than the required 40.2 hours.
The week of May 9- May 15, 2021 the program census was 400. The documented narcotic treatment physician hours were 16.5 rather than the required 40.0 hours.
The week of May 16-May 22, 2021, the program census was 398. The documented narcotic treatment physician hours were 16.5 rather than the required 39.8 hours.
The week of May 23-May 29, 2021, the program census was 398. The documented narcotic treatment physician hours were 17.0 rather than the required 39.8 hours.
The week of May 30 -June 5, 2021 the program census was 398. The documented narcotic treatment physician hours were 19.5 rather than the required 39.8 hours.
The week of June 6-June 12, 2021, the program census was 402. The documented narcotic treatment physician hours were 16.5 rather than the required 40.2 hours.
The week of June 13-June 19, 2021, the program census was 401. The documented narcotic treatment physician hours were 17.0 rather than the required 40.1 hours.
The week of June 20-June 26, 2021 the program census was 404. The documented narcotic treatment physician hours were 16.25 rather than the required 40.4 hours.
The week of June 27-July 3, 2021, the program census was 405. The documented narcotic treatment physician hours were 18 rather than the required 40.5 hours.
The week of July 4-July 10, 2021, the program census was 404. The documented narcotic treatment physician hours were 13.0 rather than the required 40.4 hours.
The week of July 11-July 17, 2021 the program census was 408. The documented narcotic treatment physician hours were 17.0 rather than the required 40.8 hours.
The week of July 18-July 24, 2021, the program census was 411. The documented narcotic treatment physician hours were 25.0 rather than the required 41.1 hours.
The week of July 25-July 31, 2021 the program census was 414. The documented narcotic treatment physician hours were 12.0 rather than the required 41.4 hours.
The findings were reviewed with program staff during the licensing process.
This was a repeat citation from a licensing inspection that took place on October 11, 2019 and March 16, 2021.
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Plan of Correction
LTC is currently in the process of hiring a new mid-level practitioner, which will provide sufficient medical coverage to meet required hours. Anticipated start date is 10/12/2021.
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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 a review of ten client records on August 26-27, 2021, the facility failed to document treatment plan updates within the regulatory timeframe in five out of ten client records reviewed.
Client #1 was admitted on June 14, 2021 and was still active at the time of the inspection. A treatment plan update was completed on June 14, 2021, and the next update was due no later than August 13, 2021; however, the next update was not completed until August 17, 2021.
Client #2 was admitted on March 24, 2021 and was still active at the time of the inspection. A treatment plan update was completed on May 25, 2021 and the next update was due no later than July 24, 2021; however, was not completed until July 26, 2021.
Client #3 was admitted on March 8, 2021 and was still active at the time of the inspection. A treatment plan update was completed on April 8, 2021, and the next update was due no later than June 7, 2021; however, the next update was not completed until June 18, 2021
Client #9 was admitted on March 10, 2021 and was still active at the time of the inspection. A treatment plan update was completed on May 4, 2021 and the next update was due no later than July 3, 2021; however, the next update was not completed until July 7, 2021.
Client #10 was admitted on November 26, 2019 and was still active at the time of the inspection. A treatment plan update was completed on March 10, 2021 and the next update was due no later than May 9, 2021; however, the next update was not completed until June 3, 2021.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Treatment plan due dates have been reviewed with staff (clinical meeting 8/30/21). Clinical supervisor is actively monitoring caseloads and working with clinical staff to oversee completion of plans within required timeframes. Monthly reviews with clinical staff will be conducted weekly during supervisions to monitor timely completions.
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709.94(b) LICENSURE Project management services
709.94. Project management services.
(b) The hours of project operation shall be displayed conspicuously to the general public.
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Observations
Based on a physical plant inspection on August 27, 2021, the facility failed to display the hours of project operation conspicuously to the general public.
These findings were reviewed with the facility staff during the licensing process.
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Plan of Correction
Window clings were purchased on 8/27/21 indicating hours of operation and have been posted on external window and main entry door as of 9/3/2021.
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709.94(c) LICENSURE Project management services
709.94. Project management services.
(c) A telephone number shall be displayed conspicuously to the general public for emergency purposes.
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Observations
Based on a physical plant inspection on August 27, 2021, the facility failed to display a telephone number conspicuously to the general public for emergency purposes.
These findings were reviewed with the facility staff during the licensing process.
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Plan of Correction
Windown clings were purchased on 8/27/21 indicating main telephone number as well as after hours contact ,and have been posted on external window and main entry door as of 9/3/2021.
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