INITIAL COMMENTS
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This report is a result of an on-site licensure renewal and Methadone monitoring inspection conducted on November18-19, 2019 by staff from the Department of Drug and Alcohol Programs, Bureau of Quality Assurance for Prevention and Treatment. Based on the findings of the on-site inspection, Habit OPCO Dunmore 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(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
During a review of staffing records on November 18-19, 2019, the facility failed to have all staff persons and volunteers 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.
Staff #7 was hired on November 1, 2017 and was promoted to a counselor on September 28, 2018. The facility failed to have staff #7 receive HIV/AIDS and TB/STD training within a year of becoming a counselor.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
As of 01/01/2020, all newly hired staff will complete HIV/AIDS training within the first year of hire, in accordance with the State regulation. The Office Manager will monitor all training requirements on a quarterly basis and report updates to the CTC Director via a quarterly training report.
As of 01/10/2020, there are no available seats for the required HIV/AIDS and TB/STD trainings in the Northeast Region. When a training becomes available, Employee #7 will be registered to attend. It is expected that completion of these mandatory trainings will be by 03/31/2020. |
704.12(a)(6) LICENSURE OutPatient Caseload
704.12. Full-time equivalent (FTE) maximum client/staff and client/counselor ratios.
(a) General requirements. Projects shall be required to comply with the client/staff and client/counselor ratios in paragraphs (1)-(6) during primary care hours. These ratios refer to the total number of clients being treated including clients with diagnoses other than drug and alcohol addiction served in other facets of the project. Family units may be counted as one client.
(6) Outpatients. FTE counselor caseload for counseling in outpatient programs may not exceed 35 active clients.
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Observations
During review of the Staffing Requirement Facility Summary Report Form on November 18-19, 2019, the FTE counselor caseload for counseling in outpatient programs exceeded 35 active clients.
The FTE counselor caseload for counseling was 40 active clients.
These findings wer reviewed with program staff during the licensing process.
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Plan of Correction
By March 15, 2020, Facility Director will hire two additional staff to correct the issue of ratio compliance. Based on the current census and those who meet the criteria of licensure alert 01-14, the facility will meet the 35:1 requirement. The Clinical Supervisor will monitor ratio weekly, when assigning new admissions to counselors. The CTC Director will monitor census weekly to ensure compliance with this regulation and hire additional staff as needed.
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705.24 (3) LICENSURE Bathrooms.
705.24. Bathrooms.
The nonresidential facility shall:
(3) Have hot and cold water under pressure. Hot water temperature may not exceed 120F.
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Observations
During a physical site inspection on November 19, 2019, the facility failed to have a hot water temperature that did not exceed 120 Fahrenheit.
The water temperature in the client bathroom for women was 128.5 degrees Fahrenheit.
These findings were reviewed with the facility during the licensing process.
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Plan of Correction
The Facility Director will hire a plumber by 01/31/2020 to reduce the temperature of the water heater, that directly impacts all facility faucets, to be within acceptable hot water limits, not to exceed 120 Fahrenheit. A monthly check of the water temperature will be completed monthly when the fire drill is completed.
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705.28 (d) (1) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(1) Conduct unannounced fire drills at least once a month.
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Observations
During a review of fire drills on November 18-19, 2019, the facility failed to conduct unannounced fire drills at least once a month.
The facility had no documentation of a fire drill in July of 2019.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Health and Safety Liaison will conduct at minimum one Fire drill per month and document the drill using the designated Emergency drill form. The CTC Director will monitor compliance of fire drills and the inspection the extinguishers and reviewing the Health and Safety documentation quarterly.
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705.28 (d) (4) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(4) Maintain a written fire drill record including the date, time, the amount of time it took for evacuation, the exit route used, the number of persons in the facility at the time of the drill, problems encountered and whether the fire alarm or smoke detector was operative.
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Observations
During a review of fire drills on November 18-19, 2019, the facility failed to maintain a written fire drill record that included problems encountered and whether the fire alarm or smoke detector was operative during fire drills on eleven occasions.
There was no documentation for problems encountered and whether the fire alarm or smoke detector was operative during the fire drills from January 2019 through November 2019.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Health and Safety Liaison will conduct at minimum one Fire drill per month and document the drill using the designated Emergency drill form which includes problems encountered and whether the fire alarm or smoke detector was operative during fire drills. The Habit Opco - Dunmore Comprehensive Treatment Center Director will monitor compliance in this area by reviewing the Health and Safety documentation monthly and compiling the Health and Safety activities performed quarterly.
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705.28 (d) (7) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(7) Set off a fire alarm or smoke detector during each fire drill.
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Observations
During a review of fire drills on November 18-19, 2019, the facility failed to document that they set off a fire alarm or smoke detector during each fire drill on eleven occasions.
There was no documentation that a fire alarm or smoke detector was set off during each fire drill for January 2019 through November 2019.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Health and Safety Liaison will conduct at minimum one Fire drill per month and document the drill using the designated Emergency drill form which includes whether the fire alarm or smoke detector was operative during fire drills. The Habit Opco - Dunmore Comprehensive Treatment Center Director will monitor compliance in this area by reviewing the Health and Safety documentation monthly and compiling the Health and Safety activities performed quarterly.
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709.30 (3) LICENSURE Client rights
709.30. Client rights.
The project shall develop written policies and procedures on client rights and document written acknowledgement by clients that they have been notified of those rights.
(3) Clients have the right to inspect their own records. The project, facility or clinical director may temporarily remove portions of the records prior to the inspection by the client if the director determines that the information may be detrimental if presented to the client. Reasons for removing sections shall be documented in the record.
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Observations
During a licensing inspection conducted on November 18, 2019 through November 19, 2019, the project failed to notify clients that when requesting to inspect their own record the reason for the facility removing sections shall be documented in the record in 10 out of 14 records reviewed.
Clients: #2, #4, #5, #6, #7, #8, #9, #10, #11 and #12 were not informed the reason for the facility removing sections shall be documented in the record.
These findings were reviewed with project staff during the licensing process.
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Plan of Correction
The CTC Director will work with the Director of Quality and Compliance to revise the Patient Rights to state that "The CTC Director may temporarily remove portions of the records prior to the inspection by the patient if the Director determines that the information may be detrimental if presented to the patient. Reasons for removing sections shall be documented in the record." The revision will be completed by 1/31/2020. The CTC Director will review policy revisions during February 21st, 2020 All Staff Meeting.
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709.34 (a) (1) LICENSURE Reporting of unusual incidents
§ 709.34. Reporting of unusual incidents.
(a) The project shall develop and implement policies and procedures to respond to the following unusual incidents:
(1) Physical assault or sexual assault by staff or a client.
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Observations
During a licensing inspection conducted on November 18, 2019 through November 19, 2019, the project failed to provide procedures for responding to physical assault or sexual assault by staff or a client.
These findings were reviewed with project staff during the licensing process.
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Plan of Correction
The CTC Director will work with the Director of Quality and Compliance to revise policy 7.1.18. Previously the policy outline how to respond to an assault but did not specify "Physical" and "sexual". The revision will be completed by 1/31/2020. The CTC Director will review all policy revisions during the February 21st, 2020 All Staff Meeting.
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709.34 (a) (2) LICENSURE Reporting of unusual incidents
§ 709.34. Reporting of unusual incidents.
(a) The project shall develop and implement policies and procedures to respond to the following unusual incidents:
(2) Selling or use of illicit drugs on the premises.
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Observations
During a licensing inspection conducted on November 18, 2019 through November 19, 2019, the project failed to develop and implement procedures in responding to selling or use of illicit drugs on the premises.
These findings were reviewed with project staff during the licensing process.
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Plan of Correction
The CTC Director will work with the Director of Quality and Compliance to develop a policy to address how the facility will respond to Selling or use of illicit drugs on the premises. The policy will be developed by 1/31/2020. The CTC Director will review all policy revisions during the February 21st, 2020 All Staff Meeting.
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709.34 (a) (3) LICENSURE Reporting of unusual incidents
§ 709.34. Reporting of unusual incidents.
(a) The project shall develop and implement policies and procedures to respond to the following unusual incidents:
(3) Death or serious injury due to trauma, suicide, medication error or unusual circumstances while in residential treatment or, when known by facility, for ambulatory services.
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Observations
During a licensing inspection conducted on November 18, 2019 through November 19, 2019, the project failed to develop and implement procedures in responding to death or serious injury due to trauma, suicide, medication error or unusual circumstances while in residential treatment or, when known by facility, for ambulatory services.
These findings were reviewed with project staff during the licensing process.
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Plan of Correction
The CTC Director will work with the Director of Quality and Compliance to revise the Sentinel Event policy (3.4.1) in the PA Operations manual to meet the requirements of the regulation. The revision will be completed by 1/31/2020. The CTC Director will review all policy revisions during the February 21st, 2020 All Staff Meeting. "
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709.34 (a) (6) LICENSURE Reporting of unusual incidents
§ 709.34. Reporting of unusual incidents.
(a) The project shall develop and implement policies and procedures to respond to the following unusual incidents:
(6) Event at the facility requiring the presence of police, fire or ambulance personnel.
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Observations
During a licensing inspection conducted on November 18, 2019 through November 19, 2019, the project failed to provide procedures in responding to an event at the facility requiring the presence of policy, fire or ambulance personnel.
These findings were reviewed with project staff during the licensing process.
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Plan of Correction
The CTC Director will work with the Director of Quality and Compliance to revise Emergency Action Plan policy (9.6) in the PA Operations manual to meet the requirements of the regulation. The revision will be completed by 1/31/2020. The CTC Director will review all policy revisions during the February 21st, 2020 All Staff Meeting.
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709.34 (a) (7) LICENSURE Reporting of unusual incidents
§ 709.34. Reporting of unusual incidents.
(a) The project shall develop and implement policies and procedures to respond to the following unusual incidents:
(7) Fire or structural damage to the facility.
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Observations
During a licensing inspection conducted November 18, 2019 through November 19, 2019, the project failed to develop and implement procedures in responding to fire or structural damage to the facility.
These findings were reviewed with project staff during the licensing process.
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Plan of Correction
The CTC Director will work with the Director of Quality and Compliance to revise the Emergency Preparedness Plan to specify procedures for responding to Fire of Structural Damage to the facility. The CTC Director will review the revised policy During the January 24th. 2020 All Staff Meeting.
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709.34 (a) (8) LICENSURE Reporting of unusual incidents
§ 709.34. Reporting of unusual incidents.
(a) The project shall develop and implement policies and procedures to respond to the following unusual incidents:
(8) Outbreak of a contagious disease requiring Centers for Disease Control (CDC) notification.
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Observations
During a licensing inspection conducted November 18, 2019 through November 19, 2019, the project failed to develop and implement procedures in responding to an outbreak of a contagious disease requiring Centers for Disease Control (CDC) notification.
These findings were reviewed with project staff during the licensing process.
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Plan of Correction
The Dunmore Comprehensive Treatment Center (CTC) has policies and procedures for responding to an outbreak of a contagious disease requiring Centers for Disease Control (CDC) notification which is located in the Pennsylvania Operations Manual in Policy 9.7 "INFECTION PREVENTION AND CONTROL PLAN". The policy will be reviewed by the Director of Quality and Compliance and revised if necessary to meet the requirements of the regulation. The CTC Director will review the policy with all staff members during the February 21st, 2020 All Staff Meeting.
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709.34 (b) (1) LICENSURE Reporting of unusual incidents
§ 709.34. Reporting of unusual incidents.
(b) Policies and procedures must include the following:
(1) Documentation of the unusual incident.
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Observations
During a licensing inspection conducted on November 18, 2019 through November 19, 2019, the project ' s policy and procedure manual did not provide a procedure on documenting unusual incidents.
These findings were reviewed with project staff during the licensing process.
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Plan of Correction
The Habit Opco - Dunmore Comprehensive Treatment Center has policies and procedures for Documentation of Unusual incidents including: Unusual Incident policy (3.4) and the Sentinel Event Policy (3.4.1) which are located in the PA Operations manual as well as Incident Reporting policy in the Risk Management manual. The CTC Director is responsible for ensuring compliance with these policies.
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709.34 (b) (2) LICENSURE Reporting of unusual incidents
§ 709.34. Reporting of unusual incidents.
(b) Policies and procedures must include the following:
(2) Prompt review and identification of the causes directly or indirectly responsible for the unusual incident.
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Observations
During a licensing inspection conducted on November 18, 2019 through November 19, 2019, the project ' s policy and procedure manual did not provide a procedure on the prompt review and identification of the cause directly or indirectly responsible unusual incidents.
These findings were reviewed with project staff during the licensing process.
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Plan of Correction
The Habit Opco - Dunmore Comprehensive Treatment Center Director will work with the Director of Quality and Compliance to revise the Unusual incident policy (3.4) to clarify the procedure for prompt review and identification of the causes directly or indirectly responsible for the unusual incident. The revision will be completed by 1/31/2020. The CTC Director will review all policy revisions during the February 21st, 2020 All Staff Meeting.
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709.34 (b) (3) LICENSURE Reporting of unusual incidents
§ 709.34. Reporting of unusual incidents.
(b) Policies and procedures must include the following:
(3) Implementation of a timely and appropriate corrective action plan, when indicated.
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Observations
During a licensing inspection conducted on November 18, 2019 through November 19, 2019, the project ' s policy and procedure manual did not provide a procedure on the implementation of a timely and appropriate corrective action plan for an unusual incident, when indicated.
These findings were reviewed with project staff during the licensing process.
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Plan of Correction
The Habit Opco - Dunmore Comprehensive Treatment Center Director will work with the Director of Quality and Compliance to revise the Unusual incident policy (3.4) to clarify the procedure on the implementation of a timely and appropriate corrective action plan for an unusual incident, when indicated. The revision will be completed by 1/31/2020. The CTC Director will review all policy revisions during the February 21st, 2020 All Staff Meeting.
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709.34 (b) (4) LICENSURE Reporting of unusual incidents
§ 709.34. Reporting of unusual incidents.
(b) Policies and procedures must include the following:
(4) Ongoing monitoring of the corrective action plan.
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Observations
During a licensing inspection conducted on November 18, 2019 through November 19, 2019, the project ' s policy and procedure manual did not provide a procedure on the ongoing monitoring of the corrective action plan for an unusual incident.
These findings were reviewed with project staff during the licensing process.
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Plan of Correction
The Habit Opco - Dunmore Comprehensive Treatment Center Director will work with the Director of Quality and Compliance to revise the Unusual incident policy (3.4) to clarify the procedure for ongoing monitoring of the corrective action plan for an unusual incident. The revision will be completed by 1/31/2020. The CTC Director will review all policy revisions during the February 21st, 2020 All Staff Meeting.
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709.34 (b) (5) LICENSURE Reporting of unusual incidents
§ 709.34. Reporting of unusual incidents.
(b) Policies and procedures must include the following:
(5) Reporting mechanism to ensure that reporting of an unusual incident to an entity is in compliance with State and Federal confidentiality laws.
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Observations
During a licensing inspection conducted on November 18, 2019 through November 19, 2019, the project ' s policy and procedure manual did not provide a procedure on the reporting mechanism to ensure that reporting of an unusual incident to an entity is in compliance with State and Federal confidentiality laws.
These findings were reviewed with project staff during the licensing process.
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Plan of Correction
The Habit Opco - Dunmore Comprehensive Treatment Center Director will work with the Director of Quality and Compliance to revise the Unusual incident policy (3.4) to clarify that reporting of unusual incidents to external agencies is to be in compliance with State and Federal confidentiality laws. The revision will be completed by 1/31/2020. The CTC Director will review all policy revisions during the February 21st, 2020 All Staff Meeting.
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715.6(d) LICENSURE Physician Staffing
(d) A narcotic treatment program shall provide narcotic treatment physician services at least 1 hour per week onsite for every ten patients
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Observations
During a review of physician ' s hours on November 18-19, 2019, the narcotic treatment program failed to provide narcotic treatment physician services at least 1 hour per week onsite for every ten patients.
From August 4-10, 2019 the program had a census of 542 which required 54.2 physician hours, only 29.5 were provided.
From August 11-17, 2019 the program had a census of 543 which required 54.3 physician hours, only 15.0 were provided.
From August 18-24, 2019 the program had a census of 544 which required 54.4 physician hours, only 52.15 were provided.
From September 1-7, 2019 the program had a census of 543 which required 54.3 physician hours, only 45.0 were provided.
From September 8-14, 2019 the program had a census of 551 which required 55.1 physician hours, only 44.30 were provided.
From September 15-21, 2019 the program had a census of 553 which required 55.3 physician hours, only 42.0 were provided.
From September 22-28, 2019, the program had a census of 553 which required 55.3 physician hours, only 50.45 were provided.
From September 20- October 5, 2019, the program had a census of 553 which required 55.3 physician hours, only 53 were provided.
From October 6- 12, 2019, the program had a census of 554 which required 55.4 physician hours, only 39 were provided.
These findings were reviewed with the program staff during the licensing process.
This is a repeat citation from the licensing inspection conducted on November 15, 2018.
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Plan of Correction
The CTC Director will ensure that the Program Physician(s) provide at least 1 hour per week onsite for every ten patients. A Physician schedule has been developed as of 01/01/2020 and will be submitted to the medical staff monthly to ensure there is adequate coverage. The CTC Director will monitor the monthly calendar to ensure there is adequate coverage.
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715.8(1)(vi) LICENSURE Psychosocial Staffing
A narcotic treatment program shall comply with the following staffing ratios as established in Chapter 704 (relating to staffing requirements for drug and alcohol treatment activities):
(vi) Outpatients. The counseling caseload for one FTE counselor in an outpatient narcotic treatment program may not exceed 35 active patients.
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Observations
During a review of the Staffing Requirement Facility Summary Report Form, the counseling caseload for one FTE counselor in an outpatient narcotic treatment program exceeded more than 35 active patients (35:1).
The FTE for the counseling caseload in the outpatient narcotic treatment program was 40 patients (40:1).
These findings were reviewed with program staff during the licensing process.
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Plan of Correction
By March 15th, 2020, Facility Director will hire two additional staff to correct the issue of ratio compliance. Based on the current census and those who meet the criteria of licensure alert 01-14, the facility will meet the 35:1 requirement. The Clinical Supervisor will monitor ratio weekly, when assigning new admissions to counselors. The CTC Director will monitor census weekly to ensure compliance with this regulation and hire additional staff as needed.
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715.11 LICENSURE Confidentiality of patient records
A narcotic treatment program shall physically secure and maintain the confidentiality of all patient records in accordance with 42 CFR 2.22 (relating to notice to patients of Federal confidentiality requirements) and § 709.28 (relating to confidentiality).
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Observations
During a review of client records on November 18-19, 2019, the narcotic treatment program did not physically secure and maintain the confidentiality of all patient records in accordance with 42 CFR 2.22 (relating to notice to patients of Federal confidentiality requirements) and 709.28 (relating to confidentiality).
A consent form for patient #1 to a county agency signed and dated for July 8, 2019 released the methadone dose and dosing history for the patient.
These findings were reviewed with the program staff during the licensing process.
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Plan of Correction
The Clinical Supervisor will provide training on 01/29/2020 to address completing a release of information completely to make sure the program remains in compliance. The Clinical Supervisor will review all consents during the quality records review process, monthly, to ensure continued compliance in this area.
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715.15(a) LICENSURE Medication Dosage
(a) The narcotic treatment physician shall review the dosage levels at least twice a year, with each review occurring at least 2 months apart, to determine a patient 's therapeutic dosage.
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Observations
The narcotic treatment physician failed to review the dosage levels of two out of four Buprenorphine clients at least twice a year, with each review occurring at least 2 months apart, to determine a patient 's therapeutic dosage.
Client #9 was admitted on February 27, 2019 and was current at the time of the inspection. The narcotic treatment physician failed to review Client #9 's dosage levels since prescribing Buprenorphine on February 27, 2019.
Client #13 was admitted on October 24, 2018 and was discharged on July 16, 2019. The narcotic treatment physician failed to review Client #13's dosage levels between October 24, 2018 and July 16, 2019.
These findings were reviewed with program staff during the licensing process.
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Plan of Correction
The Habit Opco - Dunmore Comprehensive Treatment Center will ensure that the dosage levels of all patients are reviewed at least twice per year with each review occurring at least 2 months apart to determine a patient's therapeutic dosage. The Charge Nurse and Medical Director will review compliance in this area during interim quality records reviews.
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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
During a review of client records on November 18-19, 2019, the narcotic treatment physician failed to document in the patient record the rationale for permitting take-home medication.
Patient #4 was granted take home status on March 23, 2019 however the treatment physician failed to document in the patient record the rationale for permitting take-home medications.
These findings were reviewed with program staff during the licensing process.
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Plan of Correction
The CTC Clinical Supervisor, Charge Nurse, and Medical Director will ensure that a patient is eligible for take-homes based on clinical and medical compliance. Take-home committee will meet weekly to review take-home applications and complete the necessary documentation to show the rationale for permitting take-home medication. Charge nurse/Medical Director will run reports monthly to ensure that documentation is complete for take-home justification.
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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
During a review of client records on November 18-19, 2019, the narcotic treatment program failed to 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.
Patient #2 was admitted on December 12, 2018 and transferred out on February 15, 2019. Patient #2 had 2 hours of individual psychotherapy for January 2019.
Patient #8 was admitted on February 11, 2019 and was current at the time of the inspection. Patient #8 had 1.5 hours of individual psychotherapy for July 2019 and 1.5 hours of individual therapy for August 2019.
Patient #9 was admitted on February 27, 2019 and was current at the time of the inspection. Patient #9 had 30 minutes of individual psychotherapy and 1.5 hours of group therapy for August 2019.
Patient #13 was admitted on October 24, 2018 and was discharged on July 16, 2019. Patient #13 had no group counseling since January 31, 2019 and no individual psychotherapy since February 12, 2019 until being discharged on July 16, 2019.
Patient #14 was admitted on January 26, 2017 and was discharged on April 19, 2019. Patient #14 had no psychotherapy since December 29, 2018 until being discharged on April 19, 2019.
These findings were reviewed with program staff during the licensing process.
This was a repeat citation from the inspection conducted on November 15, 2018.
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Plan of Correction
"The CTC Director and Clinical Supervisor are responsible for ensuring compliance with psychotherapy services. The Clinical Supervisor reviewed the requirements for counseling services with all counselors on 12/11/2019. As of 12/18/2019 each counselor will run their Direct Services Analysis reports in SMART and turn into the Clinical Supervisor. Additionally the Clinical Supervisor will run the report monthly and send results to the CTC Director and the Director of Quality and Compliance with a plan of action for overall results below the benchmark of 96%. The Clinical Supervisor will review the reports in individual and group supervision. Ongoing non-compliance in meeting the Direct Services requirement will be addressed by the Clinical Supervisor individually utilizing the Employee Improvement Plan process.
Patients that missed counseling will be held to meet with a member of the clinical team prior to medicating to address issues of counseling non-compliance. Continued issues of counseling non-compliance after multiple intervention attempts will be brought to the team for consideration of an Administrative Medically Supervised Withdrawal."
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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
During a review of client charts on November 18-19, 2019, the narcotic treatment program failed to provide each patient with 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.
Patient #4 transferred in on March 7, 2019 and was still current at the time of licensing. Patient #4 had 30 minutes of psychotherapy documented in April 2019, 30 minutes of psychotherapy documented in May 2019, 30 minutes of psychotherapy documented in June 2019 and no psychotherapy documented in September 2019.
These findings were reviewed with program staff during the licensing process.
This was a repeat citation from the inspection conducted on November 15, 2018.
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Plan of Correction
"The CTC Director and Clinical Supervisor are responsible for ensuring compliance with psychotherapy services. The Clinical Supervisor reviewed the requirements for counseling services with all counselors on 12/11/19. As of 12/18/2019 each counselor will run their Direct Services Analysis reports in SMART and turn into the Clinical Supervisor. Additionally the Clinical Supervisor will run the report monthly and send results to the CTC Director and the Director of Quality and Compliance with a plan of action for overall results below the benchmark of 96%. The Clinical Supervisor will review the reports in individual and group supervision. Ongoing non-compliance in meeting the Direct Services requirement will be addressed by the Clinical Supervisor individually utilizing the Employee Improvement Plan process.
Patients that missed counseling will be held to meet with a member of the clinical team prior to medicating to address issues of counseling non-compliance. Continued issues of counseling non-compliance after multiple intervention attempts will be brought to the team for consideration of an Administrative Medically Supervised Withdrawal."
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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
When reviewing client files on November 18-19, 2019, the narcotic treatment program failed to document what materials were sent to a receiving narcotic treatment program.
Patient #2 transferred out of the program on September 17, 2019. The narcotic treatment program failed to document that the client ' s admission date, medical history and psychosocial history were sent to the receiving narcotic treatment program.
These findings were reviewed with program staff during the licensing process.
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Plan of Correction
The Clinical Supervisor will review policy 7.1.14 which addresses the procedures for Transfer Patients. To monitor compliance in this area the Clinical Supervisor will conduct a Quality Record review on all discharge records including patient transfers. During the quality record review of all transferred patients the reviewer will ensure that there is documentation in the patient record that the patients transfer documents including admission date, medical and psychosocial summaries, dosage level, urinalysis reports or summary, exception requests, current status of the patient, and the written consent of the patient was sent to the receiving Program.
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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
During the review of client records on November 18-19, 2019, the receiving narcotic treatment program failed to document in writing to the transferring narcotic treatment program, the admission of the patient and the date of the initial dose given to the patient by the receiving narcotic treatment program.
Patient # 2 was transferred to the narcotic treatment program on December 12, 2018 and was transferred out on September 17, 2019. The program failed to inform the transferring narcotic treatment program in December 2018 of the admission of the patient and the initial dose that was given.
These findings were reviewed with program staff during the licensing process.
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Plan of Correction
The Clinical Supervisor will review policy 7.1.14 which addresses the procedures for Transfer Patients. To monitor compliance in this area the Clinical Supervisor will conduct a Quality Record review on all discharge records including patient transfers. During the quality record review of all transferred patients the reviewer will ensure that there is documentation in the patient record that the patients transfer documents including admission date, medical and psychosocial summaries, dosage level, urinalysis reports or summary, exception requests, current status of the patient, and the written consent of the patient was sent to the receiving Program.
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715.23(b)(4) LICENSURE Patient records
(b) Each patient file shall include the following information:
(4) The results of an initial intake physical examination.
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Observations
During a review of patient records on November 18-19, 2019, the program failed to ensure each patient file included the results of an initial intake physical examination.
Patient #6 was admitted on January 31, 2019 and was discharged on April 16, 2019. Patient #6 had no initial physical documented in their file.
These findings were reviewed with program staff during the licensing process.
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Plan of Correction
It is the policy of Dunmore Comprehensive Treatment Center to complete an initial physical on the day of admission and to document such in the Electronic Medical Record. The Director will review the Admission documentation policies with the Medical Staff on 1/31/2020. To ensure compliance in this area the Nurse Supervisor and Clinical Supervisor will review all admission patient records within 14 days of admission to ensure that all required documentation is in the patient record. Issues of non-compliance in meeting documentation requirements will be addressed by the CTC Director, Clinical Supervisor, or Nurse Supervisor individually utilizing the Employee Improvement Plan process.
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715.28(a)(1-10) LICENSURE Unusual incidents
(a) A narcotic treatment program shall develop and implement policies and procedures to respond to the following unusual incidents:
(1) Physical assault by a patient.
(2) Inappropriate behavior by a patient causing disruption to the narcotic treatment program.
(3) Selling of drugs on the premises.
(4) Complaints of patient abuse (physical, verbal, sexual and emotional).
(5) Death or serious injury due to trauma, suicide, medication error or unusual circumstances.
(6) Significant disruption of services due to disaster such as fire, storm, flood or other occurrence.
(7) Incident with potential for negative community reaction or which the facility director believes may lead to community concern.
(8) Theft, burglary, break-in or similar incident at the facility.
(9) Drug related hospitalization of a patient.
(10) Other unusual incidents the narcotic treatment program believes should be documented.
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Observations
During a review of the policy and procedure manual on November 18-19, 2019, the program failed to develop and implement policies and procedures to respond to the following unusual incidents:
-Inappropriate behavior by a patient causing disruption to the narcotic treatment program
-Incident with potential for negative community reaction or which the facility director believes may lead to community concern.
-Drug related hospitalization of a patient.
These findings were reviewed with program staff during the licensing process.
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Plan of Correction
The CTC Director will work with the Director of Quality and Compliance to develop a policy to address how the facility will respond to the following: 1.) inappropriate behavior by a patient causing disruption to the narcotic treatment program, 2.) Incident with potential for negative community reaction or which the facility director believes may lead to community concern. 3.) Drug related hospitalization of a patient. The policy will be developed by 1/31/2020. The CTC Director will review all policy revisions during the February 21st, 2020 All Staff Meeting.
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709.92(b) LICENSURE Treatment and rehabilitation services
709.92. Treatment and rehabilitation services.
(b) Treatment and rehabilitation plans shall be reviewed and updated at least every 60 days.
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Observations
During an inspection of client records on November 18-19, 2019, the facility failed to review, and update treatment and rehabilitation plans every 60 days in four out of seven records.
Client #8 was admitted on February 11, 2019 and was current at the time of inspection. They had a preliminary treatment and rehabilitation plan on February 28, 2019 and should have had a comprehensive treatment and rehabilitation plan completed by March 28, 2019 but was not completed until June 28, 2019. The next treatment and rehabilitation plan update should have been completed by August 28, 2019 but was not completed until September 8, 2019.
Client #9 was admitted on February 27, 2019 and was current at the time of the inspection. They had a preliminary treatment and rehabilitation plan on February 26, 2019 and a comprehensive treatment and rehabilitation plan on March 24, 2019. The next treatment and rehabilitation plan update should have been completed by May 24, 2019 but was not completed until August 15, 2019. The following treatment and rehabilitation plan should have been completed by October 15, 2019 but was not completed until November 1, 2019.
Client #13 was admitted on October 24, 2018 and was discharged on July 16, 2019. They had a treatment and rehabilitation plan update on November 5, 2018. The next treatment and rehabilitation plan update should have been completed by January 5, 2019 but was not completed until February 4, 2019. There should have been treatment and rehabilitation plan updates completed on April 4, 2019 and June 4, 2019, but neither were completed. Client #13 was discharged on July 16, 2019.
Client #14 was admitted on January 26, 2017 and was discharged on April 19, 2019. They had a treatment and rehabilitation plan update on October 22, 2018. The next treatment and rehabilitation plan updates should have been completed on December 22, 2018 and February 22, 2019, but neither were ever completed. Client #14 was discharged on April 19, 2019.
These findings were reviewed with facility staff during the licensing process.
This was a repeat citation from the inspection conducted on November 15, 2018.
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Plan of Correction
The Clinical Supervisor reviewed the requirements for treatment planning with all counselors on 12/11/19. As of 12/18/2019 each counselor will run their Services Due by type report for treatment plans weekly and turn into the CTC Director for review. Additionally the CTC Director will run the report monthly and send the results to the Director of Quality and Compliance with a plan of action for overall results below the benchmark of 98%. The CTC Director and Lead Counselor will review the reports in individual and group supervision. Ongoing non-compliance in completing treatment plans timely will be addressed by the CTC Director individually utilizing the Employee Improvement Plan process.
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