INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection and methadone monitoring inspection conducted on September 25-26, 2023, by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, Harrisburg 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 a review of eleven personnel records, 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 November 7, 2021 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
Training plans will be created for employees to include documentation of input from both the employee and the supervisor. Clinic Director and Clinical Supervisors review training plans quarterly to ensure completion and accuracy. |
704.11(d)(2) LICENSURE Annual Training Requirements
704.11. Staff development program.
(d) Training requirements for project directors and facility directors.
(2) A project director and facility director shall complete at least 12 clock hours of training annually in areas such as:
(i) Fiscal policy.
(ii) Administration.
(iii) Program planning.
(iv) Quality assurance.
(v) Grantsmanship.
(vi) Program licensure.
(vii) Personnel management.
(viii) Confidentiality.
(ix) Ethics.
(x) Substance abuse trends.
(xi) Developmental psychology.
(xii) Interaction of addiction and mental illness.
(xiii) Cultural awareness.
(xiv) Sexual harassment.
(xv) Relapse prevention.
(xvi) Disease of addiction.
(xvii) Principles of Alcoholics Anonymous and Narcotics Anonymous.
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Observations
Based one of one applicable employee personnel records reviewed, the facility failed to provide documentation of at least 12 clock hours of annual training required for a facility director for the training year January-December 2022.Employee # 2 was hired as the facility director on August 30, 2021 and was still in this position at the time of the inspection. After a review of employee # 1 ' s personnel record, there were only 6.4 training hours documented.This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
Facility Director will ensure that at least 12 hours of annual training is completed each year. Regional Director and Facility Director will review required training hours monthly during supervision to ensure required training is completed. |
704.11(f)(2) LICENSURE Trng Hours Req-Coun
704.11. Staff development program.
(f) Training requirements for counselors.
(2) Each counselor shall complete at least 25 clock hours of training annually in areas such as:
(i) Client recordkeeping.
(ii) Confidentiality.
(iii) Pharmacology.
(iv) Treatment planning.
(v) Counseling techniques.
(vi) Drug and alcohol assessment.
(vii) Codependency.
(viii) Adult Children of Alcoholics (ACOA) issues.
(ix) Disease of addiction.
(x) Aftercare planning.
(xi) Principles of Alcoholics Anonymous and Narcotics Anonymous.
(xii) Ethics.
(xiii) Substance abuse trends.
(xiv) Interaction of addiction and mental illness.
(xv) Cultural awareness.
(xvi) Sexual harassment.
(xvii) Developmental psychology.
(xviii) Relapse prevention.
(3) If a counselor has been designated as lead counselor supervising other counselors, the training shall include courses appropriate to the functions of this position and a Department approved core curriculum or comparable training in supervision.
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Observations
Based on two of six applicable employee personnel records reviewed, the facility failed to provide documentation of at least 25 clock hours of annual training required for a counselor for the training year January-December 2022 in employee records # 8 and # 10.Employee # 8 was hired as a counselor on September 7, 2021 and was still in this position at the time of the inspection. After a review of employee # 8 ' s personnel record, there were only 7.89 training hours documented.Employee # 10 was hired as a counselor on September 15, 2020 and was still in this position at the time of the inspection. After a review of employee # 8 ' s personnel record, there were only 23 training hours documented.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The facility shall ensure that all employees complete their required training hours annually. Clinic Director and Clinical Supervisors will review training attendance and hours completed at least once a month during supervision. Training hours completed by each employee will be tracked in facility training binder. |
709.28 (c) LICENSURE Confidentiality
§ 709.28. Confidentiality.
(c) The project shall obtain an informed and voluntary consent from the client for the disclosure of information contained in the client record.
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Observations
Based on three of fifteen client records reviewed, the facility failed to obtain an informed and voluntary consent from the client for the disclosure of information contained in the client record.Client # 2 was admitted on July 6, 2023 and was still active at the time of the inspection. There was documentation that information was sent to another treatment facility on July 27 and September 6, 2023. There was no informed and voluntary consent from the client for the disclosure of information documented in the client record.Client # 5 was admitted on February 27, 2023 and was still active at the time of the inspection. Authorizations for a funding source occurred on June 27, 2023. An informed and voluntary consent from the client for the disclosure of information to the funding source was not signed by the client until August 23, 2023. Authorizations for a secondary funding source occurred on March 1 and April 7, 2023, without an informed and voluntary consent from the client for the disclosure of information.Client # 9 was admitted on January 11, 2023 and was discharged on June 16, 2023. Authorizations for a funding source occurred on January 14, April 29, April 30, and June 16, 2023. There was no informed and voluntary consent from the client for the disclosure of information documented in the client record for the funding source.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The facility shall ensure that ROI's are completed with all Patient's prior to disclosing/releasing information. Peer chart reviews will be completed monthly. Clinical Supervisors will complete chart audits for all new Pt's to include completion of required ROIs. Clinical Supervisors and counselor's will review Pt charts at least once a month during supervision. Clinic Director will complete training with all staff 11/9/23 on the completion of ROIs. |
715.13(b) LICENSURE Patient identification
(b) A narcotic treatment program shall maintain onsite a photograph of each patient which includes the patient 's name and birth date. The narcotic treatment program shall update the photograph every 3 years.
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Observations
Based on one of eleven applicable patient records reviewed, the facility failed to maintain onsite a photograph of each patient which includes the patient 's name and birth date for patient # 4. Patient # 4 was admitted on April 3, 2023 and was still active at the time of the inspection. There was no documentation in the patient record of a photograph that includes the name and birth date of the patient.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Facility shall ensure that all Patients have a valid photo ID on record at the time of admission. Clinical Supervisors, intake counselor and admin will review each chart on the day of admission to ensure photo ID has been uploaded to the Pt's EMR. |
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 fifteen patient records reviewed, the facility failed to complete an initial drug-screening urinalysis for each prospective patient and a random urinalysis at least monthly thereafterPatient # 4 was admitted on April 3, 2023 and was still active at the time of the inspection. A random drug-screening urinalysis was not documented for the months of May, June, July, or August 2023.The findings were reviewed with facility staff during the licensing process.This is a repeat citation from the October 18, 2022 annual licensing inspection.
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Plan of Correction
The facility will obtain and document the results of random urinalysis each month for all Patients. Nurse Manager will review all urinalysis results weekly to ensure requested specimens have been provided. Pt's that have not provided a specimen when requested will be required to provide a Nurses Forced Test. Clinic Director and Nurse Manager will review pending urinalysis results with Clinical Science Laboratory bi-weekly to ensure those results are uploaded and copies of the results are sent to the facility. |
715.16(b)(1-8) LICENSURE Take-home privileges
(b) The narcotic treatment physician shall consider the following in determining whether, in exercising reasonable clinical judgment, a patient is responsible in handling narcotic drugs:
(1) Absence of recent abuse of drugs (narcotic or non-narcotic), including alcohol.
(2) Regular narcotic treatment program attendance.
(3) Absence of serious behavioral problems at the narcotic treatment program.
(4) Absence of known recent criminal activity.
(5) Stability of the patient 's home environment and social relationships.
(6) Length of time in comprehensive maintenance treatment.
(7) Assurance that take-home medication can be safely stored within the patient 's home.
(8) Whether the rehabilitative benefit to the patient derived from decreasing the frequency of attendance outweighs the potential risks of drug diversion.
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Observations
Based on two of eight applicable patient records reviewed, the facility failed to document that the narcotic treatment physician considered the following in determining whether, in exercising reasonable clinical judgment, a patient is responsible in handling narcotic drugs:(1) Absence of recent abuse of drugs (narcotic or non-narcotic), including alcohol.(2) Regular narcotic treatment program attendance.(3) Absence of serious behavioral problems at the narcotic treatment program.(4) Absence of known recent criminal activity.(5) Stability of the patient 's home environment and social relationships.(6) Length of time in comprehensive maintenance treatment.(7) Assurance that take-home medication can be safely stored within the patient 's home.(8) Whether the rehabilitative benefit to the patient derived from decreasing the frequency of attendance outweighs the potential risks of drug diversion.Patient # 7 was admitted on November 3, 2020 and was still active at the time of the inspection. Patient # 7 was permitted 5 day take-homes on May 16, 2023, however, there was no documentation of the narcotic physician determining if the patient is responsible in handling narcotic drugs.Patient # 8 was admitted on March 24, 2017 and was still active at the time of the inspection. Patient # 8 was permitted 13 day take-homes on April 24, 2023, however, there was no documentation of the narcotic physician determining if the patient is responsible in handling narcotic drugs.The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Clinic Director has reviewed take home policy and procedure, and the completion of 8-point evaluations with all clinical staff during staff meeting 10/3/23. Clinic Director will provide training to each program physician individually during the month of November 2023 focusing on the completing 8-point evaluations. CD and CS's will monitor compliance through monthly chart reviews. |
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 seven of eight 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 records # 2, 3, 4, 5, 6 and # 11.Patient # 2 was admitted on July 6, 2023 and was still active at the time of the inspection. There was not at least 2.5 hours of psychotherapy documented the month of August 2023.Patient # 3 was admitted on June 2, 2023 and was still active at the time of the inspection. There was not at least 2.5 hours of psychotherapy documented the months of June, July, and August 2023.Patient # 4 was admitted on April 3, 2023 and was still active at the time of the inspection. There was not at least 2.5 hours of psychotherapy documented the months of April, May, June, July, and August 2023.Patient # 5 was admitted on February 27, 2023 and was still active at the time of the inspection. There was not at least 2.5 hours of psychotherapy documented the months of March, April, May, June, July, and August 2023.Patient # 6 was admitted on July 5, 2023 and was still active at the time of the inspection. There was not at least 2.5 hours of psychotherapy documented the months of July and August 2023.Patient # 9 was admitted on January 11, 2023 and was discharged June 16, 2023. There was not at least 2.5 hours of psychotherapy documented the months of February, March, April, And May 2023.Patient # 11 was admitted on June 27, 2022 and was discharged January 5, 2023. There was not at least 2.5 hours of psychotherapy documented the month December 2022.These findings were reviewed with facility staff during the licensing process.This is a repeat citation from the October 18, 2022 annual licensing inspection.
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Plan of Correction
Program Director will provide a training to clinical staff addressing the requirements for individualized psychotherapy services. The requirements would consist of 2.5 hours of psychotherapy per month during the patient's first 2 years, 1 hour of individual psychotherapy for years 3 and 4. Training will also review documentatation of Pt no-shows for counseling appts. Additional psychotherapy shall be provided as dictated by ongoing patient assessments. The Program Director and Clinical Supervisors will review for compliance quarterly. |
715.19(2) LICENSURE Psychotherapy services
A narcotic treatment program shall provide individualized psychotherapy services and shall meet the following requirements:
(2) A narcotic treatment program shall provide each patient at least 1 hour per month of group or individual psychotherapy during the third and fourth year of treatment. Additional psychotherapy shall be provided as dictated by ongoing assessment of the patient.
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Observations
Based on one of three applicable patient records reviewed, the narcotic treatment program failed to provide at least one hour of psychotherapy per month during the patient 's third and fourth year of treatment in patient record # 7.Patient # 7 was admitted on November 3, 2020 and was still active at the time of the inspection. There was not at least one hour of psychotherapy documented the month of March and May 2023.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Program Director will provide a training to clinical staff addressing the requirements for individualized psychotherapy services. The requirements would consist of 2.5 hours of psychotherapy per month during the patient's first 2 years, 1 hour of individual psychotherapy for years 3 and 4. Training will also review documentatation of Pt no-shows for counseling appts. Additional psychotherapy shall be provided as dictated by ongoing patient assessments. The Program Director and Clinical Supervisor will review for compliance quarterly. |
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 record reviewed, the facility failed to include medical and psychosocial summaries and urinalysis reports or summary in the transfer paperwork provided to the receiving facility in patient record # 11.Patient # 11 was admitted on June 27, 2022 and discharged on January 5, 2023. Patient #11 was transferred to another facility and the documented transfer paperwork did not include the patient ' s medical and psychosocial summaries or urinalysis reports or summary.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Facility will include medical and psychosocial summaries and urinalysis reports or summary in the transfer paperwork provided to the receiving facility. Policy regarding required documentation that is to be sent when transferring a Pt to another NTP was reviewed with staff during MDT meeting 10/3/23. Clinic Director and Clinical Supervisors will review all transfer documentation prior to sending to ensure all required documentation is sent. |
715.20(4) 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.
(4) The receiving narcotic treatment program shall document in writing that it notified the transferring narcotic treatment program of the admission of the patient and the date of the initial dose given to the patient by the receiving narcotic treatment program.
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Observations
Based on one of two applicable patient records reviewed, the facility failed to provide, in writing, documentation that it notified the transferring narcotic treatment program of the admission of the patient and the date of the initial dose given to the patient by the receiving narcotic treatment program.Patient # 3 was admitted on June 2, 2023 and was still active at the time of the inspection. There was no documentation in the patient record of the admission of the patient or initial dose given to the patient by the receiving treatment program.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The facility will ensure that all Patients transferring in or out will have a transferred acknowledgement documented in their chart, which will include the date of transfer and date of first dose. Policy has been reviewed with all staff during MDT meeting 10/3/23. Clinic Director and Clinical Supervisors will review all Pt transfer charts to ensure that the transfer acknowledgement has been completed and uploaded to the EMR. |
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.
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Observations
Based on one of six applicable patient records reviewed, the facility failed to provide documentation of an annual evaluation of each patient 's status completed by the patient 's counselor and reviewed, dated, and signed by the medical director.Patient # 1 was admitted on June 13, 2016 and was still active at the time of the inspection. An annual evaluation was due no later than June 13, 2023. There was not an annual evaluation documented in the patient record. The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The facility will complete annual clinical evaluations for all Patients no later than the stated due date. Clinical Supervisors will review counselor services due during supervision to ensure services are being completed with due dates. Clinical Supervisors will complete chart reviews of all Pts that have annual paperwork due each month. |
715.28(c)(1-5) LICENSURE Unusual incidents
(c) A narcotic treatment program shall file a written Unusual Incident Report with the Department within 48 hours following an unusual incident including the following:
(1) Complaints of patient abuse (physical, verbal, sexual and emotional).
(2) Death or serious injury due to trauma, suicide, medication error or unusual circumstances.
(3) Significant disruption of services due to a disaster such as a fire, storm, flood or other occurrence.
(4) Incidents with potential for negative community reaction or which the facility director believes may lead to community concern.
(5) Drug related hospitalization of a patient.
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Observations
Based on a review of the facility unusual incident logbook, the facility failed to file a written unusual incident report to the Department within 48 hours following an unusual incident including Incidents with potential for negative community reaction or which the facility director believes may lead to community concern.Incidents requiring police presence occurred on January 27 and June 5, 2023 and an event requiring an ambulance occurred on February 1, February 17, June 7, July 24, and August 1, 2023. There was no documentation of these events being reported to the department.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Clinic Director will ensure that unusual incidents are reported to the Department within 48 hours of the occurence. These will include all incidents with the potential for negative community reaction, i.e. police and/or EMS services called to the facility. |