INITIAL COMMENTS
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This report is a result of an on-site licensure renewal and methadone monitoring inspection conducted on October 24-25, 2023, by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, Pittsburgh 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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704.11(b)(1) LICENSURE Individual training plan.
704.11. Staff development program.
(b) Individual training plan.
(1) A written individual training plan for each employee, appropriate to that employee's skill level, shall be developed annually with input from both the employee and the supervisor.
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Observations
Based on one of nine personnel records reviewed, the facility failed to provide a written individual training plan to include documentation of input from both the employee and the supervisor in employee record # 1.
Employee # 1 was hired as the Project director on April 1, 2018 and was still in this position at the time of the inspection. A training plan was acknowledged by the employee on January 4, 2023, however, there was no documentation of input from both the employee and the supervisor.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
"Effective 1/31/24, all personnel training plans be granted a space for input from both the trainee and their respective supervisor. A signature line will be included for both parties to sign. The director and quality team are responsible for monitoring this regulation." |
705.28 (d) (2) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(2) Conduct fire drills during normal staffing conditions.
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Observations
Based on a review of the facility fire drill log for the months of November 2022 through September 2023, the facility failed to conduct fire drills during normal staffing conditions. All documented fire drills occurred after 11:00 am which is after dosing hours when normal staffing conditions have changed.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Pittsburgh Health and Safety Team will continue to conduct fire drills monthly during different hours throughout the day.
Director and Nurse Manager will meet quarterly and plan out fire drills for each quarter to ensure we hit different times of days that patients are at our facility. |
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 a review of the facility fire drill log for the months of November 2022 through September 2023, the facility failed to conduct fire drills at different times of the day or night and on different shifts. Fire drills times were between 11:30 am and 12:30 pm the months of November, December 2022, January, February, March, April, May, June, and July 2023.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Pittsburgh Health and Safety Team will continue to conduct fire drills monthly during different hours throughout the day
Director and Nurse Manager will meet quarterly and plan out fire drills for each quarter to ensure we hit different times of days that patients are at our facility. Director will ensure this is completed on the quarterly reports. |
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 one of twelve patient records reviewed, the facility failed to provide documentation of a random urinalysis at least monthly.
Patient # 8 was admitted on March 14, 2019, and was discharged on September 11, 2023. There was no documentation of a random urinalysis the month of June 2023.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
For pt 8 that did not have a drug screen in June he was randomly selected for one on 6/29 but he was AWOL that day and for 3 more days after that. The pt did provide a drug screen the next day they came in for dosing. Nurse Manager will continue to review to ensure that all patients have provided a drug screen for that month. |
715.16(a)(3) LICENSURE Take-home privileges
(a) A narcotic treatment program shall determine whether a patient may be provided take-home medications.
(3) The narcotic treatment physician shall document in the patient record the rationale for permitting take-home medication.
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Observations
Based on four of five applicable patient records reviewed, the facility failed to document the rational prior to permitting take-home medication in patient records # 1, 2, 3, and 7.
Patient # 1 was admitted on August 2, 2023, and was still active at the time of the inspection. Patient # 1 was permitted 2 day take-homes, however, the documented rational required by the narcotic physician was not provided in the patient record.
Patient # 2 was admitted on July 11, 2023, and was still active at the time of the inspection. Patient # 2 was permitted 2 day take-homes, however, the documented rational required by the narcotic physician was not provided in the patient record.
Patient # 3 was admitted on June 9, 2023, and was still active at the time of the inspection. Patient # 3 was permitted 2 day take-homes, however, the documented rational required by the narcotic physician was not provided in the patient record.
Patient # 7 was admitted on February 3, 2023, and was discharged July 18, 2023. Patient # 7 was permitted 2 day take-homes, however, the documented rational required by the narcotic physician was not provided in the patient record.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Medical Director will place orders in the records and/or physical exams. Counselor will document rationale in the tx plans.
Clinical Supervisor and Director will review during monthly chart reviews |
715.20(1) LICENSURE Patient transfers
A narcotic treatment program shall develop written transfer policies and procedures which shall require that the narcotic treatment program transfer a patient to another narcotic treatment program for continued maintenance, detoxification or another treatment activity within 7 days of the request of the patient.
(1) The transferring narcotic treatment program shall transfer patient files which include admission date, medical and psychosocial summaries, dosage level, urinalysis reports or summary, exception requests, and current status of the patient, and shall contain the written consent of the patient.
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Observations
Based on one of two applicable patient records reviewed, the facility failed to provide documentation of a psychosocial summary in one patient file transferred to another narcotic treatment program.
Patient # 11 was admitted on October 22, 2019, and was discharged on August 15, 2023. The psychosocial summary was not included in the transfer paperwork.
The findings were reviewed with facility staff during the licensing process.
This is a repeat citation from the November 16, 2022 annual licensing inspection.
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Plan of Correction
Clinical Supervisor and Director will develop an internal checklist when patients are transferring to another facility. Clinical Supervisor and/or Director will review this for compliance in the discharge audits. |
709.92(a) LICENSURE Treatment and rehabilitation services
709.92. 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 three of six applicable client records reviewed, the facility failed to document an individual treatment and rehabilitation plan developed with the client within thirty days in accordance with the facility policy and procedure manual.
Client # 1 was admitted on August 2, 2023, and was still active at the time of the inspection. A treatment and rehabilitation plan was due no later than September 2, 2023. The treatment and rehabilitation plan was not documented until September 28, 2023.
Client # 2 was admitted on July 11, 2023, and was still active at the time of the inspection. A treatment and rehabilitation plan was due no later than August 11, 2023. The treatment and rehabilitation plan was not documented until September 6, 2023.
Client # 10 was admitted on February 17, 2023, and was discharged June 5, 2023. A treatment and rehabilitation plan was due no later than March 18, 2023. The treatment and rehabilitation plan was not documented until April 3, 2023.
These findings were reviewed with facility staff during the licensing process.
This is a repeat citation from the March 11, 2022 and November 16, 2022 annual licensing inspections.
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Plan of Correction
We have hired several new clinical staff and we plan to be fully staffed again by the end of the year. Clinical Supervisor will work with counselors to ensure that the treatment plans are completed by or before the due date. Clinical Supervisor and Director will review treatment plans daily. We will review these weekly in supervision and provide additional training to our clinical staff. |
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 client records, the facility failed to comply with plans of correction that were approved by the Department.
Plans of correction for developing treatment and rehabilitation plans were submitted and approved by the Department for the March 11, 2022, and November 16, 2022, annual licensing inspections. Developing treatment and rehabilitation plans was again found to be a deficiency in the October 24-25, 2023 licensing inspection.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
We were not able to achieve this due to losing several clinical staff members and training new staff to complete the tx plans by the due date. Clinical Supervisor and Director will review tx plans daily, Supervisor will follow up during weekly supervision. Will discuss our plan in team meeeting on 12/5/23.
We have hired several new clinical staff over the past several months and lost 2 clinical staff members recently. We plan to be fully staffed again by the end of the year. |