INITIAL COMMENTS
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This report is a result of a complaint investigation on October 10, 2019 and an on-site licensure renewal inspection and methadone monitoring inspection conducted on October 15 -16, 2019, October 18, 2019, and October 21, 2019 by staff from the Department of Drug and Alcohol Programs, Bureau of Quality Assurance for Prevention & Treatment. Based on the findings of the on-site complaint investigation and inspection, Lebanon Treatment Center was found not to be in compliance with the applicable chapters of 28 PA Code which pertain to the facility. The following deficiencies were identified during this inspection:
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Plan of Correction
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704.9(c) LICENSURE Supervised Period
704.9. Supervision of counselor assistant.
(c) Supervised period.
(1) A counselor assistant with a Master's Degree as set forth in 704.8 (a)(1) (relating to qualifications for the position of counselor assistant) may counsel clients only under the close supervision of a trained counselor or clinical supervisor for at least the first 3 months of employment.
(2) A counselor assistant with a Bachelor's Degree as set forth in 704.8 (a)(2) may counsel clients only under the close supervision of a trained counselor or clinical supervisor for at least the first 6 months of employment.
(3) A registered nurse as set forth in 704.8 (a)(3) may counsel clients only under the close supervision of a trained counselor or clinical supervisor for at least the first 6 months of employment.
(4) A counselor assistant with an Associate Degree as set forth in 704.8 (a)(4) may counsel clients only under the close supervision of a trained counselor or clinical supervisor for at least the first 9 months of employment.
(5) A counselor assistant with a high school diploma or GED equivalent as set forth in 704.8 (a)(5) may counsel clients only under the direct observation of a trained counselor or clinical supervisor for the first 3 months of employment. For the next 9 months, the counselor assistant may counsel clients only under the close supervision of a lead counselor or a clinical supervisor.
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Observations
During a licensing inspection conducted on October 15 -16, 2019, October 18, 2019, and October 21, 2019, the facility failed to provide documentation of the required close supervision/direct observation of counselor assistants.
Employee # 9 was hired as a counselor assistant on July 2, 2018 with a high school diploma. Close supervision was reduced to twice a month after January 23,2019 and there was no direct observation documented.
Employee # 10 was hired as a counselor assistant on March 10, 2019 with a high school diploma. Close supervision was reduced to twice a month after May 21, 2019 and there was no direct observation documented.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
For all counselor assistants that have a high school diploma or GED equivalent the Clinical supervisor will document Direct supervision for the first 3 months and close supervision for the next 9 months of employment according to the regulation. To ensure compliance in this area Clinical Supervision will be monitored monthly by Clinic Director and Clinical Services Coordinator. |
704.11(f)(2) LICENSURE Trng Hours Req-Coun
704.11. Staff development program.
(f) Training requirements for counselors.
(2) Each counselor shall complete at least 25 clock hours of training annually in areas such as:
(i) Client recordkeeping.
(ii) Confidentiality.
(iii) Pharmacology.
(iv) Treatment planning.
(v) Counseling techniques.
(vi) Drug and alcohol assessment.
(vii) Codependency.
(viii) Adult Children of Alcoholics (ACOA) issues.
(ix) Disease of addiction.
(x) Aftercare planning.
(xi) Principles of Alcoholics Anonymous and Narcotics Anonymous.
(xii) Ethics.
(xiii) Substance abuse trends.
(xiv) Interaction of addiction and mental illness.
(xv) Cultural awareness.
(xvi) Sexual harassment.
(xvii) Developmental psychology.
(xviii) Relapse prevention.
(3) If a counselor has been designated as lead counselor supervising other counselors, the training shall include courses appropriate to the functions of this position and a Department approved core curriculum or comparable training in supervision.
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Observations
During a licensing inspection conducted on October 15 -16, 2019, October 18, 2019, and October 21, 2019, the facility failed to provide documentation of the required training hours for employee # 7.
Employee # 7 was hired as a counselor May 2, 2016. There were only nineteen documented training hours reviewed in the personnel record.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Employee #7 was informed by clinical supervisor of the required amount of trainings and will begin the yearly training plan to ensure she is in compliance. This will be monitored monthly by the Clinical Supervisor and the Clinic Director during individual supervision monthly. The Clinical Supervisor will also track along with the counselor the amount of training hours that are required and Certificates of completion will be uploaded in the Employee HR file. |
705.26 (2) LICENSURE Heating and cooling.
705.26. Heating and cooling.
The nonresidential facility:
(2) May not permit in the facility heaters that are not permanently mounted or installed.
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Observations
During a physical plant inspection conducted on October 15 -16, 2019, October 18, 2019, and October 21, 2019 a space heater that was not permanently mounted or installed was observed in an administrative office.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Space Heater has since been removed from the facility and staff are aware of this policy. Compliance will be monitored monthly via health and safety drills and physical plant inspections. The Clinic Director will monitor this on a monthly basis during the monthly facility inspection. |
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.
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Observations
During a licensing inspection conducted on October 15 -16, 2019, October 18, 2019, and October 21, 2019, the facility failed to provide documentation of fire drills being conducted during normal staffing conditions. Fire drills are being documented to occur between the hours of 12:00 pm and 1:00 pm. The program's medication hours are 5:00am-12:00pm and 2:00pm-4:00pm.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Health and Safety liaisons will ensure all fire dills are completed in their entirety Randomly during normal hours of operation. This will me monitored monthly by the Clinic Director and Health and Safety Liaison. |
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 licensing inspection conducted on October 15 -16, 2019, October 18, 2019, and October 21, 2019, the facility failed to maintain a written fire drill record including the exit route used, number of persons in the facility, and whether the fire alarm or smoke detector was operative.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The program has an updated form that will be in use. This form includes number on persons on site, date, time and route used for evacuation and the test button on the alarm will be active to ensure smoke detector is working properly. This will be monitored by the Clinic Director Monthly during the Scheduled Health and Safety Meetings |
709.24 (a) (3) LICENSURE Treatment/rehabilitation management.
§ 709.24. Treatment/rehabilitation management.
(a) The governing body shall adopt a written plan for the coordination of client treatment and rehabilitation services which includes, but is not limited to:
(3) Written procedures for the management of treatment/rehabilitation services for clients.
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Observations
During a licensing inspection conducted on October 15 -16, 2019, October 18, 2019, and October 21, 2019, the facility failed to complete preliminary treatment plans and Comprehensive treatment plans according to the project ' s policy and procedure manual in 11 of 12 records reviewed. The project ' s policy and procedure manual stated preliminary treatment plans to be completed within 7 days of admission and the comprehensive treatment plan to be completed within the first thirty days of admission.
Client # 1 was admitted on March 18, 2019 and was still active at the time of the inspection. The preliminary treatment plan was not completed until April 16, 2019 and the comprehensive treatment plan was not completed until May 29, 2019.
Client # 2 was admitted on May 15, 2018 and was still active at the time of the inspection. The preliminary treatment plan was not completed until July 19, 2019 and the comprehensive treatment plan was not completed until August 1, 2018.
Client # 3 was admitted on June 3, 2019 and was still active at the time of the inspection. The preliminary treatment plan was not completed until August 29, 2019. There was no comprehensive treatment plan completed
Client # 6 was admitted on January 22, 2019 and discharged on October 4, 2019. The comprehensive treatment plan was not developed with the client until May 8, 2019.
Client # 7 was admitted on November 19, 2018 and was discharged on June 20, 2019. The preliminary treatment plan was not completed until January 16, 2019 and the comprehensive treatment plan was not completed until January 18, 2019.
Client # 8 was admitted on May 31, 2018 and was discharged on October 9, 2019. The preliminary treatment plan was not completed until June 30, 2018 and the comprehensive treatment plan was not completed until August 31, 2018.
Client # 9 was admitted on July 18, 2018 and was still active at the time of the inspection. The preliminary treatment plan was not completed until August 8, 2018 and the comprehensive treatment plan was not completed until October 1, 2018.
Client # 11 was admitted on June 9, 2019 and was still active at the time of the inspection. The preliminary treatment plan was not completed until July 3, 2019 and the comprehensive treatment plan was not completed until August 30, 2019.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Preliminary Treatment plans are being generated upon admission to be completed within 7 days of admission. To monitor compliance in the area the Clinical Supervisor will complete a quality records review weekly of all admissions and will address non compliance with all admission individually with all counselors.
The Clinical Supervisor will review all treatment plans treatment plans upon admissions and weekly during Clinical meetings and individual supervisions to ensure compliance. All Treatment plans will be reviewed by the Program Director weekly during management meetings with facility leadership. |
709.26 (a) (3) LICENSURE Personnel management.
§ 709.26. Personnel management.
(a) The governing body shall adopt and have implemented written project personnel policies and procedures in compliance with State and Federal employment laws. In addition, the written policies and procedures must specifically include, but are not limited to:
(3) Supervision of staff.
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Observations
During a licensing inspection conducted on October 15 -16, 2019, October 18, 2019, and October 21, 2019, the governing body failed to adopt and implement written policies and procedures in compliance with State and Federal employment laws with written policies and procedures that must specifically include the supervision of project staff.
These findings were reviewed with project staff during the licensing process.
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Plan of Correction
The program does have a written policy and procedures for the supervision of all staff. These policies were provided during the onsite inspection. Reference policy # 7.2 located in the Pa Operations Manual. HR policy 172 located in the HR Policy Manual. The Clinic Director will make sure all of the staff have supervision weekly or as required by the regulations and will review Supervision records with Clinical Services Coordinator monthly to ensure compliance. The Director will also have weekly documented supervision with all program
Supervisors, admin. support staff and the Nursing Supervisor will hold supervision with The Nurses weekly The Medical Director will have monthly supervision with Acadia's National Medical Director. The Program director will continue to have weekly supervision with the Regional Director |
709.28 (c) (2) 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:
(2) Specific information disclosed.
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Observations
During a licensing inspection conducted on October 15 -16, 2019, October 18, 2019, and October 21, 2019, the project failed to document a completed informed and voluntary consent to disclose information in two records that included the specific information disclosed.
Client #10 was admitted on August 12, 2019 and was still active at the time of the inspection. There was an informed and voluntary consent signed and dated on August 12, 2019 to an emergency contact, but the informed and voluntary consent form did not include the specific information to be disclosed.
Client #11 was admitted on June 19, 2019 and was still active at the time of the inspection. There was an informed and voluntary consent signed and dated on June 19, 2019 to an emergency contact, but the informed and voluntary consent form did not include the specific information to be disclosed.
The findings were reviewed with project staff during the licensing process.
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Plan of Correction
Client #10 and #11:
The program will review all consents during the quality records review process to ensure continued compliance in this area. The Clinical Supervisor will provide training on completing a release of information completely to make sure the program remains in compliance.
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709.31 (a) LICENSURE Data collection system
§ 709.31. Data collection system.
(a) A data collection and recordkeeping system shall be developed that allows for the efficient retrieval of data needed to measure the project ' s performance in relationship to its stated goals and objectives.
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Observations
During a licensing inspection conducted on October 15-16, October 18 and 21, 2019, the facility was unable to provide documentation requested in a timely manner. The Staffing Requirement Facility Summary Report, requested prior to the inspection date, Physician's hours, and client census had to be requested and re-requested several times. After receiving the requested items, they were both not complete or in the manner at which they were requested. The inability to provide the client census and physician hours until the last day of the inspection resulted in the addition of another day to be added to the inspection.
These findings were reviewed with project staff during the licensing process.
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Plan of Correction
The program has developed a tracking system with the medical team to monitor all of the physician hours. The Medical staff will record all hours into the posted login sheet to be reviewed and adjusted as needed by the Director daily to ensure compliance. The program has 3 medical providers to make sure we continue to adhere to the state required doctor to patient ratio. The census is recorded into the programs EHR and printed out daily for review and signature by the Director. It is then placed on a shared drive for easy access cataloged by date. The Staffing requirements for Counselors is cataloged and updated weekly by the Clinical Supervisor and shared with the Director weekly at the Management meetings. |
709.32 (b) LICENSURE Medication control
§ 709.32. Medication control.
(b) Verbal orders for medication can be given only by a physician or other medical professional authorized by State and Federal law to prescribe medication and verbal orders may be received only by another physician or medical professional authorized by State and Federal law to receive verbal orders. When a verbal or telephone order is given, it has to be authenticated in writing by a physician or other medical professional authorized by State and Federal law to prescribe medication. In detoxification levels of care, written authentication shall occur no later than 24 hours from the time the order was given. Otherwise, written authentication shall occur within 3 business days from the time the order was given.
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Observations
During a licensing inspection conducted on October 15 -16, 2019, October 18, 2019, and October 21, 2019, the facility failed to provide a policy and procedure implementing written authentication shall occur within three business days from the time a verbal or telephone order is given by a physician or other medical professional authorized by State and Federal law to prescribe medication.
In two of seven patient records reviewed, there was not written authentication within three business days from the time a verbal or telephone order was given by a physician or other medical professional authorized by State and Federal law to prescribe medication.
Patient # 2 was admitted on May 15, 2018 and was still an active patient at the time of the inspection. A verbal order for a dose increase were given on September 6, 2018 but was not signed by the physician until September 13, 2019.
Patient # 7 was admitted on November 19, 2018 and discharged on June 20, 2019. A verbal order to taper was given on May 23, 2019 but was not signed by the physician until June 5, 2019.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Clinic will work with Clinical Services Coordinator to revise the policy 4.2 to state all verbal orders will be signed by the prescriber within 3 days. The Program Management will review policy revisions during November 2019 All Staff Meeting. The Clinic Director will monitor and the Nursing supervisor will monitor ongoing compliance in the area via quality records reviews monthly. |
709.33 (a) LICENSURE Notification of termination.
§ 709.33. Notification of termination.
(a) Project staff shall notify the client, in writing, of a decision to involuntarily terminate the client ' s treatment at the project. The notice shall include the reason for termination.
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Observations
During a licensing inspection conducted on October 15 -16, 2019, October 18, 2019, and October 21, 2019 the project failed to notify clients, in writing, of the project ' s decision to involuntarily terminate the client ' s treatment at the project in two applicable records reviewed.
Client # 5 was admitted on February 11, 2015 and involuntarily terminated on July 1, 2019, according to the discharge summary. No documentation was present that the project staff notified the client in writing of the decision to involuntarily terminate the client ' s treatment at the project.
Client # 8 was admitted on May 31, 2018 and involuntarily terminated for non-compliance on October 9, 2019, according to the discharge summary. No documentation was present that the project staff notified the client in writing of the decision to involuntarily terminate the client ' s treatment at the project.
The findings were reviewed with project staff during the licensing process.
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Plan of Correction
The Program will ensure all patient that are involuntarily discharged will be informed in writing using the Notification of Treatment Termination letters located in the EHR. Patient # 5 was notified of his termination via certified mail and program has signed receipt on file for delivery on July 12th 2019.The Program will issues letters to all patients during the weekly medical team. The Clinical Supervisor , Nursing Supervisor and Clinic Director will review all discharges and ensure all letters are uploaded in the Medical record. |
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 October 15 -16, 2019, October 18, 2019, and October 21, 2019, the project failed to provide procedures for responding to a 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 Clinical Services Department to revise the 7.1.18 to include responding to sexual assault. The Clinic Director will review Policy revisions with staff in the January 2019 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 October 15 -16, 2019, October 18, 2019, and October 21, 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 Clinical Services Department to develop a policy to address how the facility will respond to Selling or use of illicit drugs on the premises. The CTC Director will review Policy revisions with staff in the January 2019 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 October 15 -16, 2019, October 18, 2019, and October 21, 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 has a Sentinel Event policy (3.4.1) in the PA Operations manual which addresses the requirements in 709.34. The CTC Director is responsible for ensuring that the policy is followed. This will be reviewed in the November All Staff Meeting.
The Program Director has requested a policy update form the corporate office to address. The program will become compliant with a policy to address serious injury due to trauma, Suicide medication errors and unusual Circumstances. This will be completed within the next 30days and staff will be educated in the December All Staff Meeting. |
709.34 (a) (4) 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:
(4) Significant disruption of services due to disaster such as fire, storm, flood or other occurrence which closes the facility for more than 1 day.
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Observations
During a licensing inspection conducted on October 15 -16, 2019, October 18, 2019, and October 21, 2019, the project failed to develop and implement procedures in responding to significant disruption of services due to disaster such as fire, storm, flood or other occurrence which closes the facility for more than 1 day.
These findings were reviewed with project staff during the licensing process.
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Plan of Correction
The CTC has a Emergency Action Plan policy (9.6)and the usage of alternative treatment site policy (9.4) in the PA Operations manual which addresses the requirements in 709.34. The CTC Director is responsible for ensuring that the policy is followed. This will be reviewed in the November All Staff Meeting.
The Director will request a policy update from the corporate office to address emergency situations such as fire, storm, flood or any other occurrences in which it will be closed for more than 1 day. This policy will be in place within the next 30 days and Staff will be educated in the December All Staff Meeting |
709.34 (a) (5) 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:
(5) Theft, burglary, break-in or similar incident at the facility.
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Observations
During a licensing inspection conducted on October 15 -16, 2019, October 18, 2019, and October 21, 2019, the project failed to develop and implement procedures in responding to theft, burglary, break-in or similar incident at the facility.
These findings were reviewed with project staff during the licensing process.
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Plan of Correction
The CTC has a policy Unwanted intruder and Robbery (9.6.10) in the PA Operations Manual which addresses the requirements in 709.34. The CTC Director is responsible for ensuring that the policy is followed. This will be reviewed in the November All Staff Meeting.
The Program will request a revision to the policy from the corporate office. This policy will be in place within the next 30 days. Staff we be educated of the policy revision during the December 2019 All Staff Meeting. |
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 October 15 -16, 2019, October 18, 2019, and October 21, 2019, the project failed to develop and implement procedures in responding to event at the facility requiring the presence of police, fire or ambulance personnel.
These findings were reviewed with project staff during the licensing process.
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Plan of Correction
The CTC has an Emergency Action Plan policy (9.6) in the PA Operations manual which addresses the requirements in 709.34. The CTC Director is responsible for ensuring that the policy is followed. This will be reviewed in the November All Staff Meeting. The plan will include an Incident report submitted to the Licensing agency as required by Sate Regulations. The report will also be sent to the Corporate Risk Management Office, and the SCA. The incident report will also include a level of severity and if necessary the corrective action developed to avoid this type of incident from reoccurring The revision will also include procedures to address if the police, fire, or ambulance personnel respond to an event at the facility which could include anything from a medical need, violent behavior, false fire alarm the fire department responds to, a person being arrested etc. The revision that will be in be in place within the next 30 days and the Staff will be educated in the December 2019 All Staff Meeting. |
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 October 15 -16, 2019, October 18, 2019, and October 21, 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 Clinical Services Coordinator 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 2020 All Staff Meeting. |
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 October 15 -16, 2019, October 18, 2019, and October 21, 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 CTC had a Certified OSHA Training today (11/22/2019) by an independent contractor which provided training to addressing this issue. The CTC also has a policy in the Operations Manual. The CTC addresses the Policy in the infectious control plan(9.7). The CTC Director will be responsible for insurance with the policy. The CTC Director will request a Policy revision from the corporate office to identify procedures for notification and procedures for staff, patients and other stakeholders in such an event. This plan will be in place within the next 30 days and the staff will be notified of the policy revision and trained on the procedure in the December 2019 All Staff Meeting. The CTC Director will request a policy to address if a contagious disease outbreak occurs at the facility. This policy will be in place within the next 30 days. The Staff will be informed and educated on the ne policy in the December All Staff meeting. |
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 October 15 -16, 2019, October 18, 2019, and October 21, 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 Director is responsible for ensuring compliance with these policies regarding incidents.
All incident reports will be completed and submitted to CTC Director upon each incident occurring or by COB daily |
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 October 15 -16, 2019, October 18, 2019, and October 21, 2019, the project's policy and procedure manual did not provide a procedure on the prompt review and identification of the causes 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 Clinical Services Department 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. Program Management will review Policy revisions with staff in the January 2019 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 October 15 -16, 2019, October 18, 2019, and October 21, 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 Clinical Services Department 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.
Program Management will review Policy revisions with staff in the January 2019 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 October 15 -16, 2019, October 18, 2019, and October 21, 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 Clinical Services Department to revise the Unusual incident policy (3.4) to clarify the procedure for ongoing monitoring of the corrective action plan for an unusual incident. Program Management9CTC Director) will review Policy revisions with staff in the January 2019 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 October 15 -16, 2019, October 18, 2019, and October 21, 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 Clinical Services Department to revise the Unusual incident policy (3.4) to clarify that reporting of unusual incidents to external agencies is in compliance with State and Federal confidentiality laws. The CTC Director will review the revised policy with the Staff at the January All Staff meeting to insure compliance. |
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 licensing inspection conducted on October 15 -16, 2019, October 18, 2019, and October 21, 2019, the narcotic treatment program was unable to provide documentation that the narcotic treatment physician provided services at least 1 hour per week onsite for every ten patients.
The week of September 8-15, 2019 the program census was 398. The documented narcotic treatment physician hours were 35.5 rather than the required 39.8.
The week of September 16-22, 2019 the program census was 397. The documented narcotic treatment physician hours were 34.5 rather than the required 39.7.
The findings were reviewed with program staff during the licensing process.
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Plan of Correction
The CTC has hired and additional Medical Provider to insure compliance with the required hours.Director will continue to monitor census to ensure compliance with the regulation and adjust physician/physician assistant hours appropriately.
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715.9(a)(2) 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:
(2) Verify the individual 's identity, including name, address, date of birth, emergency contact and other identifying data.
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Observations
During a licensing inspection conducted on October 15 -16, 2019, October 18, 2019, and October 21, 2019, the program failed to provide documentation verifying the ID or age of the patient in records # 9 and 10.
The findings were reviewed with program staff during the licensing process.
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Plan of Correction
he CTC Director will Educate all staff on policy (4.4.4)to address the verification of an individuals identity. This will be monitored by Clinical Supervisor and reviewed weekly with the CTC Director |
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
During a licensing inspection conducted on October 15 -16, 2019, October 18, 2019, and October 21, 2019, the program failed to provide an informed, voluntary, written consent before an agent was administered to the patient for either maintenance or detoxification treatment for Patient # 10.
Patient # 10 was admitted on August 12, 2019 and was still active at the time of the inspection. There was no documentation of an informed, voluntary, written consent before an agent was administered to the patient.
These findings were reviewed with 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. CTC Director and Clinical Supervisor will review each chart for compliance prior to admission.
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715.14(a) LICENSURE Urine testing
(a) A narcotic treatment program shall complete an initial drug-screening urinalysis for each prospective patient and a random urinalysis at least monthly thereafter.
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Observations
During a licensing inspection conducted on October 15 -16, 2019, October 18, 2019, and October 21, 2019, the program failed to complete an initial drug-screening urinalysis for each prospective patient and a random urinalysis at least monthly thereafter.
Patient # 5 was admitted on February 11, 2015 and discharged on July 1, 2019. There was no documentation of a random urinalysis at least monthly in the last four months of treatment in the patient record.
Patient # 6 was readmitted on October 12, 2019 and the only document urinalysis conducted was on January 18, 2019.
Patient # 8 was admitted on May 31, 2018 and was discharged on October 9, 2019. The program failed to complete an initial drug-screening urinalysis and random urinalysis at least monthly after May 2019.
The findings were reviewed with program staff during the licensing process.
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Plan of Correction
It is the policy of the CTC to Provide monthly random drug screens for all patients enrolled in the program. Each patient will have at least 1 monthly UDS test or more if the treatment plan, counselor or Medical Director determines more are needed.
The Clinical Supervisor and Nursing Supervisor will review all records monthly to ensure proper compliance with UDS testing requirements moving forward. This report will be monitored by the Director during weekly Leadership meetings. |
715.23(b)(5) LICENSURE Patient records
(b) Each patient file shall include the following information:
(5) The results of all annual physical examinations given by the narcotic treatment program which includes an annual reevaluation by the narcotic treatment physician.
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Observations
During a licensing inspection conducted on October 15 -16, 2019, October 18, 2019, and October 21, 2019, the program failed to provide documentation of an annual physical for patient # 2.
Patient # 2 was admitted on May 15, 2018 and was still active at the time of the inspection. An annual physical was due on May 15, 2019 but was not received until July 24, 2019.
The findings were reviewed with program staff during the licensing process.
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Plan of Correction
The Nursing Supervisor will pull the services due report in the EHR for the upcoming month and schedule annual physicals with the physicians. CTC director will also monitor compliance weekly of this report |
715.23(b)(15) LICENSURE Patient records
(b) Each patient file shall include the following information:
(15) Psychosocial evaluations of the patient.
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Observations
During a licensing inspection conducted on October 15 -16, 2019, October 18, 2019, and October 21, 2019, the program failed to provide documentation of a psychosocial assessment in patient record # 3.
Patient # 3 was admitted on June 3, 2019 and was still an active patient at the time of the inspection.
The findings were reviewed with program staff during the licensing process.
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Plan of Correction
The Clinical Supervisor will train staff on timely completion of the Biopsy social during the next Clinical meeting. She will also document during individual supervision that staff are completing timely. The ongoing compliance in the area will be monitored via Clinical Services Coordinator upon submission of monthly report. |