INITIAL COMMENTS
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This report is a result of an on-site licensure renewal and a Methadone monitoring inspection conducted on November 25-26, 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-Watsontown 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 staff files on November 25-26, 2019, the facility failed to ensure 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. All support staff shall complete the training within the first 2 years of employment.
Staff #8 was hired on January 30, 2017 as Security. The facility failed to have Staff #8 trained in the subjects of HIV/AIDS and TB/STD within two years.
These 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 support staff will complete HIV/AIDS training within the first 2 years of hire, in accordance with the State regulation. The Clinic Director will monitor all training requirements on a quarterly basis and monitor progress via a quarterly training report.
As of 12/12/2019, Employee #8 has completed the required HIV/AIDS and is scheduled for TB/STD on February 13, 2020 ."
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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 the fire drill record on November 25-26, 2019, the facility failed to conduct unannounced fire drills at least once a month.
The facility failed to conduct fire drills for the months of March, May and July 2019.
These findings were reviewed with the 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 in this area by reviewing the Health and Safety documentation monthly and compialing data quarterly.
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709.28 (c) (3) 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. The consent must be in writing and include, but not be limited to:
(3) Purpose of disclosure.
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Observations
During a review client records on November 25-26, 2019, the project failed to document a completed informed and voluntary consent to disclose form including the purpose of disclosure in one of fourteen records reviewed.
Client #5 was admitted on March 19, 2019 and was still current at the time of the inspection. An informed and voluntary consent to disclose information form, dated June 11, 2019, to a county agency, did not include the purpose of disclosure.
These findings were reviewed with the project staff during the licensing process.
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Plan of Correction
The Clinical Supervisor will provide training on completing a release of information completely to make sure the program is in compliance with this regulation. The training will be conducted on 1/13/2020 during the monthly Clinical Meeting. The Clinical Supervisor will review all consents during the quality records review process to ensure continued compliance in this area.
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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 25-26, 2019, the project failed to inform clients that the reason for removing sections from a client's record, was to 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 26,2020 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 25-26, 2019, the project failed to provide procedures for responding to the following unusual incidents: 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 to include responding to assault and sexual assault. The revision will be completed by 1/31/2020. The CTC Director will review all policy revisions during the February 26, 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 25-26, 2019, the project failed to provide procedures for responding to the following unusual incidents: 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 26, 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 25-26, 2019, the project failed to provide procedures for responding to the following unusual incidents: 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
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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 26,2020 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 25-26, 2019, the project failed to provide procedures for responding to the following unusual incidents: 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 26,2020 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 on November 25-26, 2019, the project failed to develop and implement procedures in responding to the following unusual incidents: 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 or Structural Damage to the facility. The CTC Director will review the revised policy During the February 26,2020 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 on November 25-26, 2019, the project failed to develop and implement procedures in responding to the following unusual incidents: 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 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 "9.7 INFECTION PREVENTION AND CONTROL PLAN". The CTC Director is responsible for ensuring compliance with these policies.
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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 25-26, 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 CTC 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 25-26, 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 CTC 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 26,2020 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 25-26, 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 CTC 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 26,2020 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 25-26, 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 CTC 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 26,2020 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 25-26, 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 CTC 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 26,2020 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 25-26, 2019, the narcotic treatment program failed to provide narcotic treatment physician services at least 1 hour per week onsite for every ten patients.
From July 7-13, 2019 the program had a census of 255 which required 25.5 physician hours, only 21.5 were provided.
From July 28- August 3, 2019 the program had a census of 256 which required physician hours, only 24.25 were provided.
From September 1-7, 2029 the program had a census of 246 which required 24.6 physician hours, only 16.45 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 28, 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 1/31/2020 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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715.9(a)(4) LICENSURE Intake
(a) Prior to administration of an agent, a narcotic treatment program shall screen each individual to determine eligibility for admission. The narcotic treatment program shall:
(4) Have a narcotic treatment physician make a face-to-face determination of whether an individual is currently physiologically dependent upon a narcotic drug and has been physiologically dependent for at least 1 year prior to admission for maintenance treatment. The narcotic treatment physician shall document in the patient 's record the basis for the determination of current dependency and evidence of a 1 year history of addiction.
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Observations
Prior to administration of an agent, the narcotic treatment program shall screen each individual to determine eligibility for admission. The narcotic treatment program failed to have a narcotic treatment physician make a face-to-face determination of whether an individual was currently physiologically dependent upon a narcotic drug and had been physiologically dependent for at least 1 year prior to admission for maintenance treatment. The narcotic treatment physician failed to document in the patient's record the basis for the determination of current dependency and evidence of a 1 year history of addiction.
Patient #5 was admitted on March 19, 2019 and was still current at the time of the inspection. Patient #5 was dosed 40 mg of Methadone on March 19, 2019. The narcotic treatment physician did not sign that the individual was currently physiologically dependent upon a narcotic drug and had been physiologically dependent for at least 1 year prior on June 25, 2019.
Patient #6 was admitted on February 23, 2015 and was current at the time of the inspection. Patient #6 was dosed 30 mg of Methadone on August 29, 2019. The narcotic treatment physician did not sign that the individual was currently physiologically dependent upon a narcotic drug and had been physiologically dependent for at least 1 year prior on September 10, 2019.
These findings were reviewed with program staff during the licensing process.
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Plan of Correction
The CTC Director will review the admission documentation requirements with the CTC Physician. The Clinic Director will review every admission chart to ensure that all required documentation is in the EHR. The CTC director will also monitor compliance weekly and address non-compliance with the Physician as needed.
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715.12(1-5) LICENSURE Informed patient consent
A narcotic treatment program shall obtain an informed, voluntary, written consent before an agent may be administered to the patient for either maintenance or detoxification treatment. The following shall appear on the patient consent form:
(1) That methadone and LAAM are narcotic drugs which can be harmful if taken without medical supervision.
(2) That methadone and LAAM are addictive medications and may, like other drugs used in medical practices, produce adverse results.
(3) That alternative methods of treatment exist.
(4) That the possible risks and complications of treatment have been explained to the patient.
(5) That methadone is transmitted to the unborn child and will cause physical dependence.
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Observations
The narcotic treatment program failed to obtain an informed, voluntary, written consent before an agent was administered to the patient for either maintenance or detoxification treatment in one of seven records reviewed.
Patient # 2 was admitted on April 30, 2019 and was discharged on October 9, 2019. There was no documentation that patient # 2 signed an informed, voluntary, written consent before methadone was administered on April 30, 2019.
These findings were reviewed with the program staff during the licensing process.
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Plan of Correction
The admitting prescriber will review the appropriate Informed Consent with the patient and answer any questions. Patient and prescriber will sign the consent. The Clinic Director will review each chart for compliance prior to admission. The CTC director will also monitor compliance weekly and address non-compliance with the Physician as needed.
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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 14 patient records on November 25-26, 2019, the narcotic treatment program failed to provide 7 out of 14 patients 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 April 30, 2019 and was discharged on October 9, 2019. Patient #2 had 1 hour of individual psychotherapy in May 2019, 0 hours of psychotherapy in June 2019, 0 hours of psychotherapy in July 2019, 0.5 hours of individual psychotherapy in August 2019 and 1 hour of individual psychotherapy in September 2019. Patient #2 had no group therapy.
Patient #3 was admitted on April 5, 2018 and was current at the time of the inspection. Patient #3 had 0 hours of individual psychotherapy in the months of July, August, September and October 2019.
Patient #7 was admitted on August 7, 2018 and was discharged on August 21, 2019. Patient #7 had 0.5 hours of individual psychotherapy in January 2019, 0 hours of individual psychotherapy in February and March 2019, 0.5 hours of individual psychotherapy in April 2019, 1 hour of individual psychotherapy in May 2019, 0.5 hours of individual psychotherapy in June 2019 and 1.5 hours of individual psychotherapy in July 2019. Patient #7 had no group therapy.
Patient #11 was admitted on July 18, 2019 and was current at the time of inspection. Patient #11 had 2 hours of individual psychotherapy in August 2019, 1 hour of individual psychotherapy in September 2019 and 1.5 hours in October of 2019. Patient # 11 had no group therapy.
Patient #12 was admitted on August 1, 2019 and was current at the time of the inspection. Patient #12 had 2 hours of individual psychotherapy in September 2019 and no group therapy.
Patient #13 was admitted on April 11, 2018 and was discharged on March 1, 2019. Patient #13 had 2 hours of individual psychotherapy in October 2019, 1 hour of individual psychotherapy in November 2019, 1 hour of group therapy in December 2019, no therapy in January 2019 and 30 minutes of individual psychotherapy in February 2019.
Patient #14 was admitted on June 27, 2019 and was discharged on August 26, 2019. Patient #14 had 1 hour of individual psychotherapy in July 2019 and no group therapy.
These findings were reviewed with program staff during the licensing process.
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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 1/13/2020. As of 1/1/2020 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 14 patient records on November 25-26, 2019, the narcotic treatment program failed to provide 1 out of 14 patients 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 was admitted on December 22, 2016 and was discharged on June 6, 2019. Patient #4 only had 30 minutes of individual psychotherapy in December 2018 and 30 minutes of individual psychotherapy in March 2019.
These findings were reviewed with program staff during the licensing process.
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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 1/13/2020. As of 1/1/2020 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(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
The transferring narcotic treatment program failed to transfer patient files to 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.
Client #2 was admitted on April 30, 2019 and was transferred on October 9, 2019. The transferring narcotic treatment program failed to transfer admission date and medical and psychosocial summaries. They also failed to have the written consent of 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 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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715.28(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 25-26, 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 26,2020 All Staff Meeting.
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