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 5, 2020 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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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
Based on a review of fire drills on November 5, 2020, the facility failed to maintain a fire drill record that included whether the fire alarm or smoke detector was operative on the fire drill dated July 31, 2020.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Health and Safety Liaison will continue to conduct, at minimum, one fire drill per month. The fire drills will be documented using the designated emergency drill form which includes all required elements specified in the regulation including whether the fire alarm and smoke detector were operative.
The CTC Director will monitor compliance in this area by reviewing and signing each drill report monthly and reviewing Health and Safety documentation in its entirety quarterly.
This process will be reviewed during the December 9, 2020 Monthly Staff meeting to ensure all staff are duly notified and for an effective roll out.
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705.28 (d) (7) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(7) Set off a fire alarm or smoke detector during each fire drill.
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Observations
Based on a review of fire drills on November 5, 2020, the facility failed to maintain a fire drill record that included whether the facility set off a fire alarm or smoke detector during each fire drill.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Health and Safety Liaison will continue to conduct, at minimum, one fire drill per month. The fire drills will be documented using the designated emergency drill form which includes all required elements specified in the regulation including whether the fire alarm or smoke detector were set off during each fire drill.
The CTC Director will monitor compliance in this area by reviewing and signing each drill report monthly and reviewing Health and Safety documentation in its entirety quarterly.
This process will be reviewed during the December 9, 2020 Monthly Staff meeting to ensure all staff are duly notified and for an effective roll out.
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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 5,2020 the narcotic treatment program failed to provide narcotic treatment physician services at least 1 hour per week onsite for every ten patients.
From September 6-12, 2020 the program had a census of 240 which required 24.0 physician hours, only 10 were provided.
From September 13-19, 2020 the program had a census of 241 which required 24.1 physician hours, only 7 were provided.
From September 20-26, 2020 the program had a census of 238 which required 23.8 physician hours, only 8 were provided.
From September 27- October 3, 2020 the program had a census of 237 which required 23.7 physician hours, only 19 were provided.
From October 4-10, 2020 the program had a census of 237 which required 23.7 physician hours, only 7.75 were provided.
From October 11-17, 2020 the program had a census of 239 which required 23.9 physician hours, only 8 were provided.
From October 18-24, 2020 the program had a census of 230 which required 23.0 physician hours, only 5.25 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 26, 2019 and November 28, 2018.
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Plan of Correction
A suggested alternative:
The CTC Director, in concert with the Regional Director, will ensure that the Program Physician provides at least 1 hour per week onsite for every ten patients. A Physician schedule has been developed as of 12/08/2020 and will be submitted to the medical staff monthly to ensure there is adequate coverage of PA/CRNP and MD per census requirements. The CTC Director will monitor the monthly calendar to ensure there is adequate coverage between MDs and PA/CRNP.
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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
Based on a review of 11 patient records on November 5, 2020, the narcotic treatment program failed to provide 5 out of 11 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 #1 was admitted on May 27, 2020 and was current at the time of the inspection. Patient #1 had 30 minutes of individual and 0 hours of group psychotherapy in September 2020.
Patient #2 was admitted on September 3, 2020 and was discharged on November 5, 2020. Patient #2 had 30 minutes of individual therapy and 3 hours of group therapy in October 2020.
Patient #3 was admitted on August 14, 2020 and was current at the time of the inspection. Patient #3 had no individual or group therapy in September 2020. Patient #3 had 1.5 hours of individual therapy and no group therapy in October 2020.
Patient #8 was admitted on January 11, 2019 and was current at the time of the inspection. Patient #8 had 0 hours of individual and 3 hours of group therapy in August 2020. Patient #8 had 30 minutes of individual and 3 hours of group therapy in October of 2020.
Patient #9 was admitted on January 3, 2020 and was current at the time of the inspection. Patient #9 had 2 hours of individual and 0 hours of group therapy in September 2020.
These findings were reviewed with the program staff during the licensing process.
This was a repeat citation from the licensing inspection that took place on November 26, 2019.
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Plan of Correction
Amidst the current pandemic (COVID-19) it proves essential for the Clinical Supervisor and their team to maintain strict monitoring to patient compliance and adherence to psychotherapy services. The clinical supervisor will continue with weekly review(s) with each counselor to include the requirements for counseling services needed for each staff member's case load. Reports in Smart are run regularly and will be reviewed during each of these weekly meetings, noting the number of hours for both individual and group counseling that each patient is receiving, or required to receive, for the period in question.
Telehealth individual and group counseling will be increased, as needed, due to pandemic, to ensure Pt. adherence to clinical requirements under 715.19(1). This plan will be reviewed with the clinical supervisor on Wednesday, December 9, 2020 with immediate and sustained implementation as of that date. The clinical supervisor will attend to weekly meetings with the Clinic Director, part of which will provide updates as to the corrective measures being conducted and maintenance to same.
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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
Based on a review of 11 patient records on November 5, 2020, the narcotic treatment program failed to provide one out of four patients with at least 1 hour per month of group or individual psychotherapy during the third and fourth year of treatment. Additional psychotherapy shall be provided as dictated by ongoing assessment of the patient.
Patient #5 was admitted on September 29, 2017 and was discharged on April 10, 2020. Patient #5 had only 30 minutes of individual psychotherapy in January 2020, February 2020 and March 2020.
Patient #6 was admitted on October 4, 2017 and was discharged on April 27, 2020. Patient #6 had no documented psychotherapy for January 2020 and February 2020. Patient #6 had 30 minutes of individual psychotherapy in March 2020.
Patient #7 was admitted on October 21, 2016 and was discharged on October 30, 2020. Patient #7 had 30 minutes of individual psychotherapy in August 2020 and 30 minutes of individual psychotherapy in September 2020.
Patient #10 was admitted on January 25, 2018 and was still current at the time of the inspection. Patient #10 had 30 minutes of individual psychotherapy in August 2020.
These findings were reviewed with program staff during the licensing process.
This was a repeat citation from the licensing inspection on November 26, 2020.
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Plan of Correction
Amidst the current pandemic (COVID-19) it proves essential for the Clinical Supervisor and their team to maintain strict monitoring to patient compliance and adherence to psychotherapy services. The clinical supervisor will continue with weekly review(s) with each counselor to include the requirements for counseling services needed for each staff members case load. Reports in Smart are run regularly and will be reviewed during each of these weekly meetings, noting the number of hours for both individual and group counseling that each patient is receiving, or required to receive, for the period in question.
Telehealth individual and group counseling will be increased, as needed, due to pandemic, to ensure Pt. adherence to clinical requirements under 715.19(2). This plan will be reviewed with the clinical supervisor on Wednesday, December 9, 2020 with immediate and sustained implementation as of that date. The clinical supervisor will attend to weekly meetings with the Clinic Director, part of which will provide updates as to the corrective measures being conducted and maintenance to same.
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