INITIAL COMMENTS
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This report is a result of an on-site licensure renewal and methadone monitoring inspection conducted on November 2-3, 2023, by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, Clearfield 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 ten 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 22, 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
Clearfield CTC will ensure that all personnel trainings plans be granted a space for input from both the trainee and their respective supervisor beginning 12/6/23. A signature line will be included for both parties to sign. The director and quality team are responsible for monitoring this regulation. |
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 (SRFSR) form, the facility failed to ensure that employee # 7 received the minimum of 6 hours of HIV/AIDS training and at least 4 hours of TB/STD and other health related topics within the regulatory timeframe.
Employee #7 was hired as a counselor on August 3, 2021 and was still in this position at the time of the inspection. Employee # 7 was due to have the communicable disease trainings no later than August 3, 2022. There was no documentation in the personnel file of the completion of the TB/STD training as of the date of the inspection.
These findings were reviewed with facility staff during the licensing process.
This is a repeat citation from the November 30, 2018, December 10, 2020, December 2, 2021, and November 30, 2022, annual licensing inspections.
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Plan of Correction
Clinical Supervisor and clinical staff will review required trainings on a quarterly basis to ensure that TB/STD and all mandated trainings set forth by the state are completed within the first year of employment at Clearfield CTC. Clinical Supervisor will assist employee in scheduling any trainings that are required within the first year and not yet completed or scheduled at the quarterly check in. Clinical Supervisor will provide Clinic Director the identified dates to be monitored for completion. Employee #7 is scheduled to attend TB/STD training as of 12/5/23. Clinic Director will oversee to ensure that regulation is being met. |
709.34 (c) (4) LICENSURE Reporting of unusual incidents
§ 709.34. Reporting of unusual incidents.
(c) To the extent permitted by State and Federal confidentiality laws, the project shall file a written unusual incident report with the Department within 3 business days following an unusual incident involving:
(4) Event at the facility requiring the presence of police, fire or ambulance personnel.
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Observations
Based on a review of the facility unusual incident log, the facility failed to report to the Department within 3 business days an unusual incident involving an event at the facility requiring the presence of police, fire or ambulance personnel.
An event requiring the presence of an ambulance at the facility occurred on September 29, 2023, but was not reported to the Department within 3 business days.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Clinic Director will provide training to all staff on reportable incidents that need sent to the state. Any time an incident occurs, staff will cross reference the 709's and ensure that any reportable incident is submitted to the state within 72 hours. In the absence of Clinic Director, the Clinical Supervisor and Nurse Supervisor will oversee all reported incidents and ensure this regulation is being met. |
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 four of twelve patient records reviewed, the facility failed to provide documentation of an initial drug-screening urinalysis for each patient and a random urinalysis at least monthly thereafter in patient records # 7, 8, 11, and 12.
Patient # 7 was admitted on October 11, 2022, and was discharged on July 19, 2023. A random drug-screening urinalysis was not completed for the months of May and June 2023.
Patient # 8 was admitted on August 2, 2021, and was discharged on July 11, 2023. A random drug-screening urinalysis was not completed for the month of June 2023.
Patient # 11 was admitted on August 16, 2021, and was discharged on June 12, 2023. A random drug-screening urinalysis was not completed for the month of May 2023.
Patient # 12 was admitted on January 10, 2023, and was discharged on March 30, 2023. A random drug-screening urinalysis was not completed for the months of February and March 2023.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Nurse Supervisor, Clinic Director and Clinical Supervisor will monitor suspended and incarcerated patients that did not receive a monthly random drug screen urinalysis. Clinic Director will submit an exception to the state to excuse the missed urinalysis due to their status in treatment. Medical staff will complete documentation in the patient chart as to why this urinalysis was unable to be completed for the specific month. Nurse Supervisor will ensure that documentation is being completed. |
715.19(1) LICENSURE Psychotherapy services
A narcotic treatment program shall provide individualized psychotherapy services and shall meet the following requirements:
(1) A narcotic treatment program shall provide each patient an average of 2.5 hours of psychotherapy per month during the patient 's first 2 years, 1 hour of which shall be individual psychotherapy. Additional psychotherapy shall be provided as dictated by ongoing assessment of the patient.
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Observations
Based on one of nine applicable patient records reviewed, the narcotic treatment program failed to provide an average of 2.5 hours of psychotherapy per month during the patient 's first 2 years, 1 hour of which shall be individual psychotherapy in patient record # 12.
Patient # 12 was admitted on January 10, 2023, and was discharged on March 30, 2023. There were not at least 2.5 hours of psychotherapy documented for the months of February and March 2023.
The findings were reviewed with facility staff during the licensing process.
This is a repeat citation from the November 30, 2022, annual licensing inspection.
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Plan of Correction
Primary counselor will ensure that each patient on their caseload is scheduled for individual psychotherapy within the first two weeks of the new month. If a patient fails to show for their scheduled session, We Care Calls will be completed by the primary counselor in addition to a No Show note documented in the patient's chart. A hard hold will also be placed on the patient's account to reschedule the missed session. If patient does not return to treatment then documentation detailing why the psychotherapy session wasn't completed will be added to the counselor's end of month report. Clinical supervisor will monitor noncompliance and discharge will then be considered. |
715.20(3) 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.
(3) The transferring narcotic treatment program shall document what materials were sent to the receiving narcotic treatment program.
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Observations
Based on one of one applicable patient record reviewed, the facility failed to provide documentation of what materials were sent to the receiving narcotic treatment program.
Patient # 8 was admitted on August 2, 2021, and discharged on July 11, 2023. Patient # 8 was transferred to another facility and the materials sent to the receiving narcotic treatment program were not documented in the patient record.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Clinical supervisor will conduct a group supervision thoroughly explaining that transfer process and identify all the required paperwork that is needed. All documentation gathered for a successful transfer will then be scanned and uploaded to the patients chart. Clinical supervisor will add "Transfer Paperwork Completed and Uploaded" to the discharge audit to ensure that all transfer paperwork has been scanned into the EMR and sent to the desired location. |
709.93(a)(9) LICENSURE Client records
709.93. Client records.
(a) There shall be a complete client record on an individual which includes information relative to the client's involvement with the project. This shall include, but not be limited to, the following:
(9) Aftercare plan, if applicable.
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Observations
Based on two of two applicable client records reviewed, the facility failed to provide an aftercare plan according to the facility ' s policies and procedures. The policy and procedures indicate that as soon as discussion of discharge or transition to another program begins, a transition/aftercare plan is developed with input and participation of the patient, family, and concerned persons, and the patient receives a copy of their transition plan prior to discharge.
Client # 8 was admitted on August 2, 2021, and was transferred on July 11, 2023. There was no documentation of an aftercare plan in the client record.
Client # 10 was admitted on May 5, 2021, and was successfully discharged on August 3, 2023. There was no documentation of an aftercare plan in the client record.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Clinical Supervisor and primary counselor will review potential discharge patients during individual clinical supervision. During this time, the discharge plan will be reviewed and a copy will be made to give to the patient by the primary counselor at their next scheduled session. Clinical Supervisor will oversee this to ensure that compliance is being met. |
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, the facility failed to conspicuously display, to the general public, the hours of the project operation.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Health and Safety Chairperson and Clinic Director posted facility hours of operation and crisis number on the front door of the facility on 11/3/23. Health and Safety Chairperson and Clinic Director will monitor postings on a monthly basis to ensure that information continues to be displayed for the general public. |
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, the facility failed to conspicuously display, to the general public, a telephone number for emergency purposes.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Health and Safety Chairperson and Clinic Director posted an emergency number on the front door of the facility on 11/3/23. Health and Safety Chairperson and Clinic Director will monitor postings on a monthly basis to ensure that information continue to be displayed for the general public. |
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 documentation and patient records, the facility failed to follow plans of correction approved by the Department.
Plans of correction for not providing an average of 2.5 hours psychotherapy hours a month during the patient ' s first 2 years in treatment were submitted and approved by the Department for the November 30, 2022, annual licensing inspection. Not providing an average of 2.5 hours psychotherapy hours a month during the patient ' s first 2 years in treatment were again found to be a deficiency in the November 2-3, 2023, annual licensing inspection.
Plans of correction for staff persons and volunteers to receive mandatory communicable disease training within the regulatory time frame were submitted and approved by the Department for the November 30, 2018, December 10, 2020, December 2, 2021, and November 30, 2022, annual licensing inspections. Staff persons and volunteers to receive mandatory communicable disease training within the regulatory time frame was again found to be a deficiency in the November 2-3, 2023, annual licensing inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Clinic Director and Clinical Supervisor will keep copies of approved plans of correction to reference in order to ensure those plans of correction are being followed. Clinic Director will review past citations and plans of corrections with Clinical Supervisor on a quarterly basis during individual supervision to ensure that compliance is being met.
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