INITIAL COMMENTS
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This report is a result of an on-site licensure renewal and buprenorphine monitoring inspection conducted on November 13-14, 2024 by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, Caron Treatment Centers 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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704.9(c) LICENSURE Supervised Period
704.9. Supervision of counselor assistant.
(c) Supervised period.
(1) A counselor assistant with a Master's Degree as set forth in 704.8 (a)(1) (relating to qualifications for the position of counselor assistant) may counsel clients only under the close supervision of a trained counselor or clinical supervisor for at least the first 3 months of employment.
(2) A counselor assistant with a Bachelor's Degree as set forth in 704.8 (a)(2) may counsel clients only under the close supervision of a trained counselor or clinical supervisor for at least the first 6 months of employment.
(3) A registered nurse as set forth in 704.8 (a)(3) may counsel clients only under the close supervision of a trained counselor or clinical supervisor for at least the first 6 months of employment.
(4) A counselor assistant with an Associate Degree as set forth in 704.8 (a)(4) may counsel clients only under the close supervision of a trained counselor or clinical supervisor for at least the first 9 months of employment.
(5) A counselor assistant with a high school diploma or GED equivalent as set forth in 704.8 (a)(5) may counsel clients only under the direct observation of a trained counselor or clinical supervisor for the first 3 months of employment. For the next 9 months, the counselor assistant may counsel clients only under the close supervision of a lead counselor or a clinical supervisor.
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Observations
Based on a review of personnel files, the facility failed to provide supervision for counselor assistants according to the employee's qualifications.
Employee #6 was hired on April 8, 2024 as a counselor assistant with a Master's Degree. There was no documentation of supervision occurring from April 10 - May 1, 2024.
The finding was reviewed with facility staff during the licensing inspection.
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Plan of Correction
The Executive Director educated the Clinical Supervisors regarding Counselor Assistant supervision requirements and documentation during group clinical supervision on 11/14/24. The Executive Director will audit the supervision notes for each Counselor Assistant on a bimonthly basis to ensure documentation requirements are being met. |
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 personnel records and the facility's Staffing Requirement Facility Summary Report form, the facility failed to ensure that employees received at least four hours of TB/STD and other health related topics within the regulatory timeframe.
Employee #21 was hired as a certified nursing assistant on February 21, 2022 and was still in the position at the time of the inspection. The TB/STD training was due to be completed on February 21, 2024; however, it was not completed at the time of the inspection.
This is a repeat citation from the January 20, 2023 and December 21, 2023 annual licensing inspections.
The finding was reviewed with facility staff during the licensing inspection.
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Plan of Correction
Employe #21 is scheduled for TB/STD training on 1/3/25.
New employees will be scheduled for the 4-hour TB/STD training as part of their initial individual training plan. If the employee does not attend the TB/STD training as scheduled, they will receive a written warning and the training will be rescheduled. If the employee does not attend the re-scheduled training, they will receive a written warning.
An automated Training Compliance Report will be generated and sent to team supervisors. This report will inform the supervisors if they have employees who have not yet completed their mandatory trainings, including TB/STD.
The Supervisor of Training and Education will also monitor the completion of the TB/STD training for new employees on a monthly basis to ensure staff receive the required training within the required regulatory timeframes.
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705.7 (b) (5) LICENSURE Food service.
705.7. Food service.
(b) A residential facility may operate a central food preparation area to provide food services to multiple facilities or locations. A residential facility that operates an onsite food preparation area or a central food preparation area shall:
(5) Keep cold food at or below 40F, hot food at or above 140F, and frozen food at or below 0F.
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Observations
Based on a physical plant inspection on November 14, 2024, the facility failed to ensure cold food was at or below 40 degrees F and frozen food was at or below 0 degrees F. The facility did not have a mechanism to ensure the temperature of cold food was at or below 40F in the women ' s lounge refrigerator. Additionally, the facility did not have a mechanism to ensure the temperature of frozen food was at or below 0 degrees F in the grand view lounge freezer and adolescent boys lounge freezer.
These findings were reviewed with facility staff during the licensing inspection process.
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Plan of Correction
Thermometers were placed in the women's lounge refrigerator, Grandview lounge freezer and adolescent male unit lounge freezer on 11/14/24. During the monthly safety tours, the safety team members checklist will now include that they verify that all refrigerators and freezers have a thermometer and that the thermometer is functioning properly. They will document on their safety tour checklist that the thermometer is in the refrigerator/freezer and report to maintenance any missing thermometers. A staff member from the Safety and compliance department will follow up with maintenance to ensure that any documented issues are corrected. |
705.10 (c) (3) LICENSURE Fire safety.
705.10. Fire safety.
(c) Fire extinguisher. The residential facility shall:
(3) Ensure fire extinguishers are inspected and approved annually by the local fire department or fire extinguisher company. The date of the inspection shall be indicated on the extinguisher or inspection tag. If a fire extinguisher is found to be inoperable, it shall be replaced or repaired within 48 hours of the time it was found to be inoperable.
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Observations
Based on a physical plant inspection, it was observed that the facility failed to ensure fire extinguishers are inspected and approved annually by the local fire department or fire extinguisher company. The fire extinguishers in the older adult office area and the yoga room were not inspected in the last year.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
On 11/14/24, the fire extinguishers in the older adult office area and the yoga room were replaced with fire extinguishers that were inspected and approved. The Director of Facilities or designee will contact the fire extinguisher company the month prior to when all extinguishers need to have their annual inspection to ensure Caron is on the schedule. During the annual inspection process a maintenance staff member will have a check list of all fire extinguishers and their locations. They will accompany the fire extinguisher inspector to ensure all extinguishers are inspected. This check list will be given to the Director of Facilities for review and verification. |
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 a review of detoxification buprenorphine patients, the facility failed to complete an initial drug-screening urinalysis prior to administering an agent in one out of seven records reviewed.
Patient #17 was admitted on March 17, 2024 and transferred to in-patient rehab on March 18, 2024. The patient's first dose of buprenorphine was administered on March 17, 2024. The first drug-screening urinalysis was collected on March 18, 2024.
The finding was reviewed with facility staff during the licensing inspection.
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Plan of Correction
The Associate Medical Director will re-educate the medical staff regarding the requirement for an initial drug screening urinalysis to be completed on each prospective patient, prior to the administration of Buprenorphine. This will be done during a medical team meeting by 12/31/24. The nursing team will do chart audits monthly to ensure that this is occurring, and will report progress to the Quality Committee on a quarterly basis. |
709.52(a) LICENSURE Individual TX and REHAB Plan
709.52. 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 rehabilitation client records, the facility failed to complete treatment plans according to the facility's policy and procedures manual. The manual states the treatment plan needs to be completed by day 8 following admission.
Client #9 was admitted to residential treatment on October 14, 2024 and was still active at the time of the inspection. A treatment plan was due no later than October 21, 2024; however, it was not completed until October 24, 2024.
Client #12 was admitted to residential treatment on June 7, 2024 and discharged on July 1, 2024. A treatment plan was due no later than June 15, 2024; however, it was completed on June 18, 2024.
Client #14 was admitted to residential treatment on September 30, 2024 and discharged on October 29, 2024. A treatment plan was due no later than October 8, 2024; however, it was not completed until October 9, 2024.
These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
The Clinical Supervisors will re-educate their individual teams on the process for the development of individual treatment and rehabilitation plans in a timely manner during group supervision by 12/13/24. The Executive Director will review this with the clinical team again during their monthly clinical team meeting on 1/29/24. The Clinical Supervisors will conduct chart reviews on a monthly basis to ensure that individual treatment and rehabilitation plans are completed on time. The Quality Analyst will conduct quarterly chart reviews to review compliance with the process and will report progress to leadership. |
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 personnel records, the facility failed to comply with plans of correction that were approved by the Department.
A plan of correction for mandatory communicable disease training were submitted and approved by the Department for the January 20, 2023 and December 21, 2023 annual licensing inspections. Mandatory communicable disease training was again found to be a deficiency in the November 13-14, 2024 licensing inspection.
This finding was reviewed with facility staff during the licensing inspection.
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Plan of Correction
The Supervisor of Training and Education is responsible for the implementation of this Plan of Correction. The Supervisor of Training and Education will monitor progress of the Plan of Correction on a monthly basis. The Compliance Department will also monitor the progress of this Plan of Correction on a quarterly basis to ensure compliance. |