INITIAL COMMENTS
|
This report is a result of an on-site licensure renewal inspection and methadone monitoring inspection conducted on November 16, 2023, by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, New Castle 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:
|
Plan of Correction
|
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.
|
Observations
Based on one of nine personnel records reviewed, the facility failed to provide a written individual training plan to include documentation of input from both the employee and the supervisor in employee record # 1.
Employee # 1 was hired as the Project director on April 22, 2018, and was still in this position at the time of the inspection. A training plan was acknowledged by the employee on January 4, 2023, however, there was no documentation of input from both the employee and the supervisor.
These findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
In the future, All Acadian Healthcare staff members will have a written individual training plan to include documentation of input from the employee and the Supervisor. This issue will be closely monitored by supervisors and managers. |
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.
|
Observations
Based on a review of the facility fire drill log for the months of December 2022 through October 2023, the facility failed to conduct fire drills the months of August and October 2023.
These findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
Clinic's Health and Safety coordinator will conduct fire drills monthly. This Clinic Director will inspect the drill to ensure it is indeed a fire drill, rather than another type of drill. This inspection by the Clinic Director will be completed each month. The Clinic Director will review the Health and Safety Manual to see if the fire drill has been documented in the Health and Safety Manual. |
705.28 (d) (2) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(2) Conduct fire drills during normal staffing conditions.
|
Observations
Based on a review of the facility fire drill log for the months of December 2022 through October 2023, the facility failed to conduct fire drills during normal staffing conditions. All documented fire drills occurred after 11:00 am which is after dosing hours.
These findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
The clinic's Health and Safety coordinator will complete fire drills during normal staffing conditions. This Clinic Director will note when the fire drill is conducted to determine the time of day and if the drill is conducted during normal staffing conditions. If the drill is not conducted during normal staffing conditions, another fire drill will be conducted that meet the requirements during that month. This Clinic Director will note the time of day and clinic situations for every fire drill. The time and date of the fire drill will be documented in the Health and Safety Manual. |
705.28 (d) (6) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(6) Conduct fire drills on different days of the week, at different times of the day and on different staffing shifts.
|
Observations
Based on a review of the facility fire drill log for the months of December 2022 through October 2023, the facility failed to conduct fire drills at different times of the day or night and on different shifts. Fire drills times were between 11:30 am and 12:30 pm the months of December 2022, January, February, March, April, May, June, July, and September 2023.
These findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
The Health and Safety Coordinator will conduct fire drills at various times while staff and patients are in the building. The fire drills will be conducted between 5:00 am and 1:30 pm. The fire drills will not be conducted at the same time as in the past. This Clinic Director will note the time of day when the fire drills are taking place. This Clinic Director will document the times of the other monthly drills and ensure the drills are at various times. If the drills are at the same times as prior months, the drill will be cancelled and another drill will be completed in that month. |
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.
|
Observations
Based on four of twelve of 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 in client records # 2, 3, 9 and 11.
Client # 2 was admitted on September 8, 2023, and was still active at the time of the inspection. A review of client records and discussion with facility administration indicated funding was being provided to the client. There was not an informed and voluntary consent from the client for the disclosure of information in the client record to a funding source.
Client # 3 was admitted on March 13, 2023, and was still active at the time of the inspection. A review of client records and discussion with facility administration indicated funding was being provided to the client. There was not an informed and voluntary consent from the client for the disclosure of information in the client record to a funding source.
Client # 9 was admitted on December 12, 2022, and was discharged January 26, 2023. Information was disclosed to a treatment facility on December 12, 2022, without an informed and voluntary consent from the client for the disclosure of information.
Client # 11 was admitted on May 8, 2023, and was discharged August 2, 2023. Information was disclosed to multiple treatment facilities on June 20, 2023, without an informed and voluntary consent from the client for the disclosure of information.
These findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
The Clinic Director, Clinical Supervisor and Lead Counselor will instruct all staff to obtain informed and voluntary consent from the client before disclosing information contained in the patient records. The CD, CS, and Lead Counselor will monitor this issue by performing routine audits of the patient's records. |
709.34 (c) (2) LICENSURE Reporting of unusual incidents
§ 709.34. Reporting of unusual incidents.
(c) To the extent permitted by State and Federal confidentiality laws, the project shall file a written unusual incident report with the Department within 3 business days following an unusual incident involving:
(2) Death or serious injury due to trauma, suicide, medication error or unusual circumstances.
|
Observations
Based on a review of the facility unusual incident logbook, the facility failed to report to the Department within 3 business days an unusual incident involving death or serious injury due to trauma, suicide, medication error or unusual circumstances.
Incidents involving death occurred on May 2, July 5, July 19, August 29, and August 31, 2023. There was no documentation a report was filed with the Department.
These findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
This Clinic Director has bi weekly meetings (supervision) with the Regional Director. The Clinic Director will address all patient deaths with the Regional Director. The reports and documentation sent to the Department of Drug and Alcohol will be reviewed by the Regional Director to ensure all deaths are documented in a timely manner. |
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.
|
Observations
Based on two of twelve patient records reviewed, the facility failed to provide documentation of a random drug-screening urinalysis for each patient at least monthly in patient records # 1 and 11.
Patient # 1 was admitted on January 18, 2023, and was still active at the time of the inspection. There was no documentation of a random drug-screening urinalysis for the months of February, March, April, and May 2023.
Patient # 11 was admitted on May 8, 2023, and was discharged August 2, 2023. There was no documentation of a random drug-screening urinalysis for the month July 2023.
These findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
This Clinic Director and the Nurse Supervisor will ensure all patients will have a random drug-screen the month prior to leaving treatment. We will monitor the patient AWOL list so that the patient will be discharged in a timely manner. This will allow the patient to have a random UA screening prior to leaving treatment. |
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.
|
Observations
Based on four of four applicable patient records reviewed, the facility failed to document the rational prior to permitting take-home medication in patient records # 1, 2, 5, and 7.
Patient # 1 was admitted on January 18, 2023, and was still active at the time of the inspection. Patient # 1 was permitted 2 day take-homes on June 17, 2023, however, the documentation required by the narcotic physician was not provided in the patient record until November 7, 2023.
Patient # 2 was admitted on September 8, 2023, and was still active at the time of the inspection. Patient # 2 was permitted 2 day take-homes on September 9, 2023, however, the documentation required by the narcotic physician was not provided in the patient record until November 7, 2023.
Patient # 5 was admitted on May 26, 2020, and was still active at the time of the inspection. Patient # 5 was permitted 2 day take-homes on June 17, 2023, however, the documentation required by the narcotic physician was not provided in the patient record.
Patient # 7 was admitted on April 10, 2023, and was discharged July 18, 2023. Patient # 7 was permitted 2 day take-homes beginning June 17, 2023, however, the documentation required by the narcotic physician was not provided in the patient record.
These findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
In the future this Clinic Director will ensure that patients who are obtaining take-home medication and who do not have take-home status will have documentation from the medical director in their chart. Step 1: This Director will submit an exception request to the Department of Drug and Alcohol of Pa for permission to be closed on a particular day.
Step 2: The Clinical Supervisor and Lead Counselor will give a list to the medical of patient who do not have take-home status.
Step 3: The medical director will determine if a patient without take-home status is appropriate and stable enough to receive medication at home.
Step 4: The medical director will document the patient's appropriateness to have the take-home medication in the chart (prior) to the patient receiving the medication.
Step 5: This Clinic Director, Clinical Supervisor, Nursing Supervisor and Lead Counselor will review all charts to ensure the notation is in each of the charts. |
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.
|
Observations
Based on one of six applicable patient records reviewed, the narcotic treatment program failed to provide an average of 2.5 hours of psychotherapy per month during the patient 's first 2 years, 1 hour of which shall be individual psychotherapy in patient record # 1.
Patient # 1 was admitted on January 18, 2023, and was still active at the time of the inspection. There was only one hour of psychotherapy documented in June; the required one hour of individual psychotherapy was not documented in July, and only thirty minutes of individual psychotherapy was documented in October 2023.
These findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
The Clinical Supervisor and the Lead Counselor will inform all clinical staff that each patient in treatment under two years is required to have 2.5 hours of therapy. Each patient will have at least one hour of individual therapy. The Clinical Supervisor and Lead Counselor will audit charts to see that this is being carried out. |
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.
|
Observations
Based on two of two applicable patient records reviewed, the facility failed to provide documentation of transferring patient files to include admission date, medical and psychosocial summaries, dosage level, urinalysis reports or summary, exception requests, and current status of the patient which contains the written consent of the patient for patients # 9 and 11.
Patient # 9 was admitted on December 12, 2022, and was discharged on January 26, 2023. The medical and psychosocial summary were not included in the transfer paperwork.
Patient # 11 was admitted on May 8, 2023, and was discharged on August 2, 2023. The transfer paperwork was not sent to the receiving facility.
These findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
The Clinical Supervisor and Lead Counselor will instruct all clinical staff on the appropriate information that needs to be transferred. They will ensure that when a patient is transferring they will need to include the admission date, medical and psychosocial summaries, dosage level, urinalysis reports or summary, exception requests, and current status of the patient which is contained in the written consent. The Clinical Supervisor and Lead Counselor will complete chart audits to ensure this procedure is being followed. |
709.93(a)(9) LICENSURE Client records
709.93. Client records.
(a) There shall be a complete client record on an individual which includes information relative to the client's involvement with the project. This shall include, but not be limited to, the following:
(9) Aftercare plan, if applicable.
|
Observations
Based on three of three applicable client records reviewed, the facility failed to provide an aftercare plan in accordance with facility policy and procedure manual. The policy and procedure manual indicates a transition plan be developed approximately thirty days prior to transition/discharge and provided to the client at discharge.
Client # 9 was admitted on December 12, 2022, and was discharged January 26, 2023. There was no transition plan documented in the client record.
Client # 10 was admitted on May 10, 2017, and discharged on August 8, 2023. There was no transition plan documented in the client record.
Client # 11 was admitted on May 8, 2023, and was discharged August 2, 2023. There was no transition plan documented in the client record.
These findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
The Clinical Supervisor and Lead counselor will ensure that all patients in their various phases of treatment will have a transition plan. Each patient will have a transition plan upon discharge from treatment. The Clinical Supervisor and Lead Counselor will complete chart audits to ensure that 30 days prior to leaving treatment a transition/discharge plan is completed. |