INITIAL COMMENTS
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This report is a result of an on-site licensure renewal and methadone monitoring inspection conducted on October 26-27, 2023, by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, Cranberry Township 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:
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Plan of Correction
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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.
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Observations
Based on one of seven 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.
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Plan of Correction
To ensure Cranberry CTC meets the regulation to document input from both employee and supervisor on training plans, effective 1/31/24, all personnel training plans be granted a space for input from both the trainee and their respective supervisor. A signature line will be included for both parties to sign. The director and quality team are responsible for monitoring this regulation. |
715.16(a)(3) LICENSURE Take-home privileges
(a) A narcotic treatment program shall determine whether a patient may be provided take-home medications.
(3) The narcotic treatment physician shall document in the patient record the rationale for permitting take-home medication.
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Observations
Based on three of five applicable patient records reviewed, the facility failed to document the rational prior to permitting take-home medication in patient records # 1, 3, and 4.
Patient # 1 was admitted on July 6, 2023, and was still active at the time of the inspection. Patient # 1 was permitted 2 day take-homes, however, there was no documentation of the rationale for permitting take home medication in the patient record.
Patient # 3 was admitted on May 11, 2023, and was still active at the time of the inspection. Patient # 2 was permitted 2 day take-homes, however, there was no documentation of the rationale for permitting take home medication in the patient record.
Patient # 4 was admitted on March 7, 2023, and was still active at the time of the inspection. Patient # 4 was permitted 2 day take-homes, there was no documentation of the rationale for permitting take home medication in the patient record.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
In order to meet this regulation, Cranberry CTC will conduct an audit of all patient files. Patient files that are missing rational for take home status will have documentation of rational added by medical director. Moving forward, any patients obtaining take home medication will have clear documentation in the patient's file identifying the rationale for the status. Clinical supervisor will review and audit, Medical Director will approve, and Clinic Director will monitor and oversee. |
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.
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Observations
Based on three of three applicable client records reviewed, the facility failed to provide an aftercare plan according to the facility ' s policies and procedures. The policy and procedures indicate that as soon as discussion of discharge or transition to another program begins, a transition/aftercare plan is developed with input and participation of the patient, family, and concerned persons, and the patient receives a copy of their plan prior to discharge.
Client # 9 was admitted on December 8, 2020, and successfully discharged on June 22, 2023. There was not documentation of an aftercare plan in the client record.
Client # 10 was admitted on April 17, 2023, and was discharged on August 3, 2023. The client was transferred to another treatment facility and there was not documentation of an aftercare plan in the client record.
Client # 11 was admitted on August 1, 2013, and successfully discharged on April 11, 2023. There was not documentation of an aftercare plan in the client record.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
To meet this regulation, Cranberry CTC will complete a discharge plan with the patient upon admission. The discharge plan will be reviewed and updated yearly and when a patient is planning a medically supervised withdrawal from methadone. The EHR has been updated to provide service prompts to ensure this task is completed when policy identifies. The counselor will prepare a discharge plan when the patient begins planning a medically supervised withdrawal. Clinical supervisor will monitor in supervision and Clinic director will oversee to ensure regulation is met. |