INITIAL COMMENTS
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This report is a result of an on-site provisional license follow-up inspection conducted on May 17, 2023 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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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
Based on a review of client records, the facility failed have verbal orders for the client's medication dose to be ordered by a narcotic treatment physician in four out of four applicable records reviewed.
Client #3 was admitted on January 30, 2023 and was still active at the time of the inspection. A physician assistant gave verbal order for methadone on January 30, 2023.
Client #4 was admitted on April 7, 2023 and was still active at the time of the inspection. A physician assistant gave verbal order for methadone on April 19, 2023.
Client #5 was admitted on February 15, 2023 and was still active at the time of the inspection. A physician assistant gave verbal order for methadone on February 15, 2023.
Client #6 was admitted on March 8, 2023 and was still active at the time of the inspection. A physician assistant gave verbal order for methadone on March 8, 2023.
This is a repeat citation from the November 17, 2022 annual licensing inspection.
These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
709.32 (b) citation continues to present as an EMR software issue. This issue was discussed, at length, following the 11/17/2022 audit citation with continued efforts by the Software designers to correct the issue.
RD/CD continues follow up and a resolution has been implemented and appears to have resolved the issue based on follow up reviews during the week of June 19, 2023. This IT corrective measure to the EHR allows the Advanced Practitioner to gain access to the 'Verbal by' drop down in order to accurately assign the MD to the respective Verbal Order.
Advanced Practitioners notified of the corrective measure on June 19th and to commence the use and monitor all job functionality within the EHR to ensure sustained corrective measure is in place. Review and training to be provided on same on 6/26/23.
RD/CD/MD will continue to monitor this application on a daily and weekly basis to ensure continued compliance on a daily/weekly basis in order to ensure a sustained software correction has been applied.
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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 the review of patient records, the facility failed to provide 2.5 hours of psychotherapy per month, 1 hour of which shall be individual psychotherapy in two out of four applicable records reviewed.
Patient #1 was admitted on May 4, 2022 and discharged on March 13, 2023. In January 2023, the patient received one hour of individual therapy. In February 2023, the patient received 30 minutes of individual therapy with one no show appointment.
Patient #5 was admitted on February 15, 2023 and was still active at the time of the inspection. In March 2023, the patient received one hour each of group and individual therapy. In April 2023, the patient received 1.5 hours of individual therapy and no group sessions.
This is a repeat citation from the November 17, 2022 licensing inspection.
These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
RD/CD/CS created and updated the counselor end of day checklist to include services provided by counselor daily.
Continued use of the Services Due is printed out daily for each counselor and will be reviewed for compliance at the end of each day.
Training provided by RD/CD/CS to all counseling personnel on June 12, 2023 during the Staff Team Meeting with regards to Pt. compliance and No Show or cancellation to clinical sessions, to include the clear 'flow' of engagement efforts and clinical compliance to Treatment Plan recommendations being present in documentation.
Additionally, daily End of Day reviews will also ensure proper documentation of patient psychotherapy services, no show notes and or a cancelations are completed daily. This checklist will be reviewed daily by CS with counseling staff.
RD/CD and CS will review the end of day checklist weekly to ensure documentation and treatment plans are updated accordingly.
CS will continue to run SMART EMR reports to review non-compliant clients and add to MDT to review with the team.
RD/CD and CS will conduct an additional training and review using case modeling and examples on 6/26/23.
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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 the review of patient records, the facility failed to provide one hour per month of group or individual therapy during the third and fourth year of treatment in one out of two applicable records reviewed.
Patient #7 was admitted on January 20, 2022 and was still active at the time of the inspection. In March 2023, the patient received 30 minutes of individual therapy and no group sessions.
The finding was reviewed with facility staff during the licensing inspection.
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Plan of Correction
RD/CD/CS created and updated the counselor end of day checklist to include services provided by counselor daily.
Continued use of the Services Due is printed out daily for each counselor and will be reviewed for compliance at the end of each day.
Training provided by RD/CD/CS to all counseling personnel on June 12, 2023 during the Staff Team Meeting with regards to Pt. compliance and No Show or cancellation to clinical sessions, to include the clear 'flow' of engagement efforts and clinical compliance to Treatment Plan recommendations being present in documentation.
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Additionally, daily End of Day reviews will also ensure proper documentation of patient psychotherapy services, no show notes and or a cancelations are completed daily. This checklist will be reviewed daily by CS with counseling staff.
RD/CD and CS will review the end of day checklist weekly to ensure documentation and treatment plans are updated accordingly.
CS will continue to run SMART EMR reports to review non-compliant clients and add to MDT to review with the team.
RD/CD and CS will conduct an additional training and review using case modeling and examples on 6/26/23.
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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
Based on the review of patient records, the facility failed to conduct an annual physical examination within the regulatory timeframe in one out of three applicable records.
Patient #8 was admitted on January 25, 2022 and was still active at the time of the inspection. The annual physical exam was due on January 25, 2023; however, it was completed on March 2, 2023.
This is a repeat citation from the March 25, 2022 and November 17, 2022 licensing inspections.
The finding was reviewed with facility staff during the licensing inspection.
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Plan of Correction
RD/CD/CS will review citation §715.23(b)(5) with SMART analyst in effort to achieve a sustained corrective EHR - SMART software fix to readmission cycled service dates.
RD/CD/CS will provide training on 6/26/2023 to all staff to present the need to monitor all annual services 'readmission' dates to ensure 'annual services' are provided on the readmission date as opposed to the original admission date.
RD/CD/CS/CN will monitor all readmissions on a Weekly basis to ensure annual dates of services are manually modified according to the actual readmission date.
RD/CD/CS/CN will provide training to ALL staff during the 6/26/2023 training date. All Mgmt. personnel will continue with weekly monitoring of same to ensure the manual date entries have been completed and compliance to §715.23(b)(5) is maintained.
CN and Providers to continue to run services due SMART report monthly to ensure patients complete the Annual Physical examination on or before annual due date.
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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 the review of patient records, the facility failed to document an annual evaluation within the regulatory timeframe in one out of three applicable records reviewed.
Patient #8 was admitted on January 25, 2022 and was still active at the time of the inspection. The annual evaluation was due on January 25, 2023; however, it was not completed until March 2, 2023.
This is a repeat citation from the November 18, 2022, March 25, 2022 and November 17, 2022 licensing inspection.
The finding was reviewed with facility staff during the licensing inspection.
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Plan of Correction
RD/CD/CS will review citation §715.23(c) with SMART analyst in effort to achieve a sustained corrective EHR - SMART software fix to readmission cycled service dates.
RD/CD/CS will provide training on 6/26/2023 to all staff to present the need to monitor all annual services 'readmission' dates to ensure 'annual services' are provided on the readmission date as opposed to the original admission date.
RD/CD/CS/CN will monitor all readmissions on a Weekly basis to ensure annual dates of services are manually modified according to the actual readmission date.
RD/CD/CS/CN will provide training to ALL staff during the 6/26/2023 training date. All Mgmt. personnel will continue with weekly monitoring of same to ensure the manual date entries have been completed and compliance to §715.23(c)is maintained.
CS and counseling staff to continue to run services due SMART report monthly to ensure patients complete the Annual evaluation on or before annual due date.
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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 three out of six applicable records reviewed.
Client #7 was admitted on January 20, 2022 and was still active at the time of the inspection. A treatment plan update was completed on February 14, 2023 and the next update was due no later than April 14, 2023; however, it was not completed until May 2, 2023.
Client #8 was admitted on January 25, 2022 and was still active at the time of the inspection. A treatment plan update was completed on March 1, 2023 and the next update was due no later than May 1, 2023; however, it was not completed until May 2, 2023.
Client #9 was admitted on February 8, 2022 and was still active at the time of the inspection. A treatment plan update was completed on March 1, 2023 and the next update was due no later than May 1, 2023; however, there were no additional updates in the client's record at the time of the inspection.
This is a repeat citation from the November 17, 2022 annual licensing inspection.
These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
RD/CD/CS created and updated the counselor end of day checklist to include services provided by counselor daily to review all treatment plan updates that are due and ensure are completed by end of day. This checklist will be reviewed daily by CS with counseling staff.
RD/CD and CS will review the end of day checklist weekly to ensure documentation and treatment plans are updated accordingly.
Such was presented and reviewed with all staff on June 12, 2023 providing a training to same.
CS will continue to run SMART EMR reports to review treatment plans that are due to ensure are completed within timeframe.
RD/CD and CS will conduct an additional training on 6/26/23 to follow up with staff education and compliance.
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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 comprehensive treatment plan in six out of six applicable records reviewed.
Client #1 was admitted on May 4, 2022 and discharged on March 13, 2023. A treatment plan update indicated 2.5 hours of individual therapy per month. In January 2023, the client received one hour of individual therapy. In February 2023, the client received 30 minutes of individual therapy with one no show appointment.
Client #3 was admitted on January 30, 2023 and was still active at the time of the inspection. The comprehensive treatment plan dated February 23, 2023 indicated 2.5 hours of therapy per month of which one hour will be individual. In March 2023, the client received 30 minutes of individual therapy with one no show appointment.
Client #5 was admitted on February 15, 2023 and was still active at the time of the inspection. The comprehensive treatment plan dated February 28, 2023 indicated individual therapy 2.5 hours a month and group therapy twice a month. In March 2023, the client received one hour each of individual and group therapy. In April 2023, the client received 1.5 hours of individual therapy and no group sessions.
Client #7 was admitted on January 20, 2022 and was still active at the time of the inspection. A treatment plan update dated February 14, 2023 indicated one hour of individual therapy per month. In March and April 2023, the client received 30 minutes of individual therapy each month.
Client #8 was admitted on January 25, 2022 and was still active at the time of the inspection. Two treatment plan updates dates December 29, 2022 and March 1, 2023 indicated 2.5 hours of individual therapy per month. In February 2023, the client received one hour of individual therapy. In April 2023, the client received 1.5 hours of individual therapy with one no show appointment.
Client #9 was admitted on February 8, 2022 and was still active at the time of the inspection. Two treatment plan updates dated November 9, 2022 and January 11, 2023 indicated 2.5 hours per month individual and group sessions twice a month. In January 2023, the client received 30 minutes of individual therapy. In February 2023, the client did not have any group sessions.
This is a repeat citation from the November 18, 2021, March 25, 2022 and November 17, 2022 licensing inspection.
These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
RD/CD/CS created and updated the counselor end of day checklist to include services provided by counselor daily to ensure patient counseling services are completed according to treatment plan or proper documentation of no show and or cancelations are completed by end of day. This checklist will be reviewed daily by CS with counseling staff.
Such was presented and reviewed with all staff on June 12, 2023 providing a training to same.
RD/CD and CS will review the end of day checklist weekly to ensure counseling services are documented appropriately according to the treatment plan.
RD/CD and CS will conduct an additional training on 6/26/23.
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709.17(a)(3) LICENSURE Subchapter B.Licensing Procedures.Refusal/rev
709.17. Refusal or revocation of license.
(a) The Department may revoke or refuse to issue a license for any of the following reasons:
(3) Failure to comply with a plan of correction approved by the Department, unless the Department approves an extension or modification of the plan of correction.
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Observations
Based on the review of patient records, the facility failed to comply with plans of correction approved by the Department.
A plan of correction was submitted to the Department for inspections occurring on November 18, 2021, March 25, 2022, and November 17, 2022, addressing the requirement to provide counseling services according to the individual's treatment plan.
A plan of correction was submitted to the Department for inspections occurring on November 18, 2021, March 25, 2022 and November 17, 2022, addressing the requirement to document an annual reevaluation within the regulatory timeframe.
A plan of correction was submitted to the Department for inspections occurring on March 25, 2022 and November 17, 2022, addressing the requirement to document an annual physical exam within the regulatory timeframe.
This is a repeat citation from the November 17, 2022 licensing inspection.
These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
RVP, RD/CD, CS and CN will be meeting weekly and monthly to review the aforementioned plan of correction and ensure follow-up and compliance according to noted plans.
Per the above RD/CD, CS, CN will ensure that if any adjustments or edits to plans are needed, update to this submitted POC will be provided to Licensing via the email portal.
The technical training provided by the auditor on 6/8/23 has proven helpful to plan development and training/roll out of action steps to the POC.
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