INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection and methadone monitoring inspection conducted on October 15 & 16, 2024 by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, Harrisburg 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(c)(1) LICENSURE Mandatory Communicable Disease Training
704.11. Staff development program.
(c) General training requirements.
(1) Staff persons and volunteers shall receive a minimum of 6 hours of HIV/AIDS and at least 4 hours of tuberculosis, sexually transmitted diseases and other health related topics training using a Department approved curriculum. Counselors and counselor assistants shall complete the training within the first year of employment. All other staff shall complete the training within the first 2 years of employment.
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Observations
Based on a review of personnel records and the facility's Staffing Requirement Facility Summary Report form, the facility failed to ensure that employees received the minimum of six hours of HIV/AIDS training and at least four hours of TB/STD and other health related topics within the regulatory timeframe in one out of seven personnel records reviewed. Employee #4 was hired as a counselor on February 27, 2023 and was due to have the communicable disease trainings no later than February 27, 2024. Employee #4 completed the HIV/AIDS training on October 10, 2024, and there is no documentation in the personnel file of the completion of the TB/STD training as of the date of the inspection.This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
Director met with counselor and scheduled BTHEN -Behavioral Health Training & Education Network
https://www.bhten.com ? ce_type ? ddap.
TB virtual training for 11/20 training from 9-1 PM. DDAP approved 4 hours training. Clinical Supervisor will be responsible to audit training logs monthly and report to director standing of counselors. |
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
Based on a review of client records, the facility failed to follow their written procedures for the management of treatment/rehabilitation services for follow up contacts in one out of two applicable client records reviewed. The facility ' s policy and procedures manual states that follow up contacts occur at thirty and sixty days after discharge. Client #7 was admitted on March 31, 2021 and discharged on March 26, 2024. A sixty day follow up contact was due no later than May 26, 2024; however, there is no documentation that one was completed. This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
Clinical Supervisor was retrained 10/17/20254 and will complete random audits of all discharges for within 30 days of patient discharge to ensure compliance. The director will be responsible for completing a random rereview of discharges monthly for the next 5 months to ensure compliance. |
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.
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Observations
Based on a review of facility records, the facility failed to file a written unusual incident report with the Department within 3 business days following an unusual incident involving the death or serious injury due to trauma, suicide, medication error or unusual circumstances.The facility was notified on May 7, 2024 that an active client was deceased. Upon review of unusual incidents submitted to the Department, it was found that this incident had not been reported at the time of the inspection. This finding was reviewed with the facility staff during the licensing process.
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Plan of Correction
Clinical Supervisor will ensure that all reports of death or serious injury due to trauma, suicide, medication error or unusual circumstances are reported to Clinic Director immediately and Director will be responsible to file the report within 3 days on Unusual Incident Electronic Reporting system and ensuring that all incidents are reported in a timely fashion through EMR discharge reporting measures. |
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 records. Patient #9 was admitted on May 20, 2015 and was still active at the time of the inspection. An annual evaluation was completed on May 14, 2024; however, the medical director did not review and sign until May 20, 2024. This is a repeat citation from the October 26, 2023 licensing inspection. This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
The medical director will review all annuals twice a week. Nursing supervisor will audit medical charts weekly for compliance for the next 6 months to ensure compliance. |
709.92(b) LICENSURE Treatment and rehabilitation services
709.92. Treatment and rehabilitation services.
(b) Treatment and rehabilitation plans shall be reviewed and updated at least every 60 days.
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Observations
Based on a review of client records, the facility failed to document treatment plan updates within the regulatory timeframe in four out of nine applicable records reviewed.Client #1 was admitted on January 23, 2024 and was still active at the time of the inspection. A treatment plan update was completed on March 21, 2024, and the next update was due no later than May 21, 2024; however, it was completed on May 23, 2024. A treatment plan update was due no later than July 23, 2024; however, it was completed on July 25, 2024. Client #4 was admitted on September 24, 2021 and was still active at the time of the inspection. A treatment plan update was completed on May 20, 2024, and the next update was due no later than September 20, 2024, due to an exception; however, it was completed on September 24, 2024. Client #5 was admitted on December 4, 2023 and was still active at the time of the inspection. A treatment plan was completed on April 2, 2024, and the next update was due no later than August 2, 2024, due to an exception; however, it was completed on August 13, 2024. Client #9 was admitted on May 20, 2015 and was still active at the time of the inspection. A treatment plan was completed on May 6, 2024, and the next update was due no later than September 6, 2024, due to an exception; however, it was completed on September 30, 2024. These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Director and Clinical supervisor met to discuss treatment plan updates with staff. Counselors will update treatment plans one week early for review and Clinical supervisor complete random biweekly chart audits to ensure that the treatment plans are updated as required |
709.92(c) LICENSURE Treatment and rehabilitation services
709.92. Treatment and rehabilitation services.
(c) The project shall assure that counseling services are provided according to the individual treatment and rehabilitation plan.
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Observations
Based on a review of client records, the facility failed to ensure that the clients received counseling services according to their individual treatment plan in three out of nine applicable records reviewed.Client #1 was admitted on January 23, 2024 and was still active at the time of the inspection. The treatment plan dated July 25, 2024, indicated two and half hours per month with one hour of individual therapy. In August and September of 2024, the client received half an hour of individual therapy and two hours of group therapy in September and one hour of group therapy in August. Client #2 was admitted on March 5, 2024 and was still active at the time of the inspection. The treatment plan dated April 8, 2024, indicated one and half hours of group and one hour of individual therapy a month. In July and September 2024, the client received half an hour of individual therapy. Client #9 was admitted on May 20, 2015 and was still active at the time of the inspection. The treatment plan dated May 6, 2024, indicated one hour of individual therapy per month. In June and August 2024, the client received half an hour of individual therapy. These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Clinic Director met with staff to retrain on updating the required training hours with care level changes to reflect necessary counseling hours. Clinical supervisor will review all requests for level of care changes to ensure there is an updated treatment plan to reflect the change. Clinical supervisor will complete biweekly audits for the next 6 months to ensure compliance. |