INITIAL COMMENTS
|
This report is a result of an on-site licensure renewal and methadone and buprenorphine monitoring inspection conducted on July 15-16, 2025 by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, WPIC Narcotic Addiction Treatment Program 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:
|
Plan of Correction
|
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.
|
Observations
Based on applicable patient records reviewed, the facility failed to have an annual evaluation of each patient ' s status that was completed by the patient ' s counselor and was reviewed, dated, and signed by the medical director in one of three records. The annual evaluation period shall start on the date of the patient ' s admission to a narcotic treatment program.
Patient #1 was admitted to outpatient on June 26, 2013 and was still active at the time of the inspection. The last annual evaluation was documented on July 3, 2024. The annual evaluation was due by June 26, 2025; however it was not completed at the time of the inspection.
These findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
Program director and supervisor will educate all clinical staff on the findings from DDAP licensure at next staff meeting on 8/19/2025 and collect a signature page of staff's attendance. If a staff member is not in attendance, then supervisor will review the citations with the staff during supervision and have staff sign off on the education.
Effective 8/11/2025, supervisor will run a monthly report of all clients' annual evaluations that are due and share that report with clinical staff. Clinical staff will have a 10-day period to complete the annual evaluation. Supervisor will follow up with staff to ensure its completion.
Effective 9/4/2025, Supervisor will conduct monthly chart audits and review the client's annual evaluation to ensure its completed. |
711.92(c) LICENSURE Individual TX Plan
711.92. Treatment and rehabilitation services.
(c) An individual treatment and rehabilitation plan shall be developed with a client. This plan shall include, but not be limited to, written documentation of:
|
Observations
Based on applicable client records reviewed, the facility failed to provide documentation of an individual treatment and rehabilitation plan being developed with the client in four of five records.
Client #2 was admitted on December 5, 2024 and was discharged on February 11, 2025.
The comprehensive treatment and rehabilitation plan developed on January 6, 2025 did not include documentation of the plan being developed with the client.
Client #4 was admitted on March 4, 2025 and was discharged on May 16, 2025. The comprehensive treatment and rehabilitation plan developed on April 2, 2025 did not include documentation of the plan being developed with the client.
Client #6 was admitted on December 23, 2024 and was still active at the time of the inspection. The comprehensive treatment and rehabilitation plan developed on January 22, 2025 did not include documentation of the plan being developed with the client.
Client #7 was admitted on May 8, 2025 and was still active at the time of the inspection.
The comprehensive treatment and rehabilitation plan developed on June 10, 2025 did not include documentation of the plan being developed with the client.
These findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
By 7/28/25, Program director and supervisor educated all clinical staff on the findings from DDAP licensure and collect a signature page of staff's attendance. If a staff member is not in attendance, then supervisor will review the citations with the staff during supervision and have staff sign off on the education.
By 7/28/25, program director and supervisors informed clinical staff of the changes in workflow for intake. During intake, all clients will be informed of the mandatory requirement to meet with the clinician within the first 30 days so the comprehensive treatment plan can be completed. A flag has been put in Methasoft identifying when the client has their 1st appointment with clinical staff to complete the comprehensive treatment plan. If a client attempts to receive dosing, the nursing staff will inform the client that they have to see the clinical staff before getting their Methadone dosage.
By 9/1/2025, Supervisor will conduct monthly chart audits to ensure that clients have their comprehensive treatment plan within 30 days of intake. |
711.92(c)(2) LICENSURE Type & Frequency of TX
711.92. Treatment and rehabilitation services.
(c) An individual treatment and rehabilitation plan shall be developed with a client. This plan shall include, but not be limited to, written documentation of:
(2) Type and frequency of treatment and rehabilitation services.
|
Observations
Based on applicable client records reviewed, the facility failed to provide an individual treatment and rehabilitation plan developed with the client to include the type and frequency of treatment and rehabilitation services in three of five records.
Client #2 was admitted on December 5, 2024 and was discharged on February 11, 2025. A comprehensive treatment and rehabilitation plan was developed with the client on January 6, 2025, however, there was no documentation of type and frequency of services.
Client #3 was admitted on December 17, 2024 and was discharged on March 31, 2025. A comprehensive treatment and rehabilitation plan was developed with the client on January 29, 2025, however, there was no documentation of type and frequency of services.
Client #4 was admitted on March 4, 2025 and was discharged on May 16, 2025. A comprehensive treatment and rehabilitation plan was developed with the client on April 2, 2025, however, there was no documentation of type and frequency of services.
These findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
Program director and supervisor will educate all clinical staff on the findings from DDAP licensure at next staff meeting on 8/19/2025 and collect a signature page of staff's attendance. If a staff member is not in attendance, then supervisor will review the citations with the staff during supervision and have staff sign off on the education.
Program director and supervisor will educate all clinical staff at the next staff meeting on 8/19/25 on the use of a "smart phrase" to ensure that both type and frequency are included in the comprehensive treatment plan.
During monthly chart audits, starting Sept 1, 2025, supervisor will ensure that both "type and frequency" are included in the comprehensive treatment plan. If one or both are not present, supervisor will document outreach to clinician to update. Once updated, Supervisor will ensure accuracy of documentation.
It should be noted that all clients in this audit are discharged; therefore, no further updates are needed.
|