INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection and methadone and buprenorphine monitoring inspection conducted on November 5 & 6, 2024 by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, Watsontown 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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715.20(3) 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.
(3) The transferring narcotic treatment program shall document what materials were sent to the receiving narcotic treatment program.
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Observations
Based on a review of patient records, the facility failed to provide documentation of what materials were sent to the receiving narcotic treatment program in one out of one applicable patient records reviewed.
Patient #6 was admitted to the facility on July 23, 2019 and discharged on March 12, 2024. Patient #6 transferred to another narcotic treatment facility on March 7, 2024. There is no documentation of what materials were sent to the receiving facility.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
In order to ensure compliance to §715.20(3) and adherence to policy 7.1.14 the primary counselor will review each scheduled and/or planned transfer with the Clinical Supervisor prior to the transfer to review that all required expectations to regulation and policy are adhered to. Following each scheduled and/or planned transfer the paperwork will be reviewed during individual supervision with the clinical supervisor to ensure compliance. The Clinic Director will add the review of regulation §715.20(3) and policy 7.1.14 to the Monthly All Staff meeting scheduled for November 20, 2024. The Clinical Supervisor will include regular discussions during weekly group and individual supervision sessions as well. |
715.23(c)(1-7) LICENSURE Patient records
(c) An annual evaluation of each patient 's status shall be completed by the patient 's counselor and shall be reviewed, dated and signed by the medical director. The annual evaluation period shall start on the date of the patient 's admission to a narcotic treatment program and shall address the following areas:
(1) Employment, education and training.
(2) Legal standing.
(3) Substance abuse.
(4) Financial management abilities.
(5) Physical and emotional health.
(6) Fulfillment of treatment objectives.
(7) Family and community supports.
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Observations
Based on a review of patient records, the facility failed to document an annual evaluation of each patient ' s status and have it reviewed, dated and signed by the medical director in the regulatory timeframe in one out of three applicable patient records.
Patient #9 was admitted on July 31, 2023 and was still active at the time of the inspection. An annual evaluation was due no later than July 23, 2024; however, it was completed on August 5, 2024.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
The Clinic Director and clinical supervisor will review regulation §715.23 (c1-7) with clinical staff members during group supervision on November 18, 2024. A review of Annual Evaluation due dates recurrence on the date of a patient's admission anniversary will be conducted. A print out from the facility EHR of Services Due for the up-coming week will be expected allowing the counseling staff to prepare for annual evaluation timely completion. The clinical supervisor will complete monthly quality chart reviews while also utilizing chart to charge, chart reviews, to ensure sustained compliance to this regulation. This process will be reviewed by the Clinic Director during supervision sessions with the clinical supervisor as well as during Chart to Charge reviews and approvals. |
709.91(b)(7) LICENSURE Intake and admission
709.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(7) Preliminary treatment and rehabilitation plan.
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Observations
Based on a review of client records, the facility failed to document a preliminary treatment plan within the timeline established by the facility ' s policy and procedure manual in one out of three applicable records reviewed. The facility's policy and procedures manual states that the preliminary treatment plan is due within seven days of admission.
Client #1 was admitted on September 9, 2024 and was still active at the time of the inspection. A preliminary treatment plan was due no later than September 16, 2024; however, it was completed on September 17, 2024.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
The Clinic Director and clinical supervisor will review regulation §709.91(b)(7) along with policy 7.1.3 with clinical staff members during group supervision on November 18, 2024. The specific focus will be on the review of Initial Treatment Plan due date and timely submission to same. Counseling staff members will be expected to print out weekly from the facility EHR of Services Due and attend to Initial Treatment Plan completion in a timely fashion. The primary counselor will review during individual supervision, each week, all new admissions and paperwork completions with the clinical supervisor. The clinical supervisor will complete monthly quality chart reviews while also utilizing chart to charge, chart reviews, to ensure sustained compliance to this regulation. This process will be reviewed by the Clinic Director during supervision sessions with the clinical supervisor as well as during Chart to Charge reviews and approvals. |