INITIAL COMMENTS
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This report is a result of an on-site licensure renewal and methadone monitoring inspection conducted on July 9 - 11, 2019 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, Charleroi Treatment Services LLC 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
The facility failed to provide documentation of HIV/AIDS and TB/STD training in one of two personnel records reviewed on July 9, 2019.Employee # 8 was hired for the position of counselor assistant on March 5, 2018. There was no documentation of HIV/AIDS and TB/STD training in employee record # 8.The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Employee #8 will complete HIV/AIDS and TB/STD training's. Executive director is responsible for monitoring training's. Executive Director will develop spreadsheet listing all staff whom which are required to receive HIV/AIDS and TB/STD training will completed required time frames. Executive Director will explore in house and off-site training options and schedule. Expected date to be completed by October 2019. |
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
The facility failed to provide documentation that written unusual incident reports were filed with the Department within 3 business days of the death of a client based on a review of client record lists and unusual incident reports on July 9, 2019.The death of two clients occurred on January 25, 2019 and April 15, 2019.The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Executive Director will notify the Department in writing within 3 business days of all unusual incidents that are required to be reported.
Executive director will submit the 2 unusual reports that happen previously to Department for filing.
Any and all unusual incident reports will be reported to Executive Director, binder will be kept and all parties will be notified.
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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
The narcotic treatment program failed to provide documentation of narcotic treatment physician services at least one hour per week onsite for every ten patients based on a review of the patient weekly census and physician's work schedule on July 9, 2019.The facility's patient census was 218 on June 17, 2019 and the physician only worked 20 hours.The facility's patient census was 217 on June 24, 2019 and the physician only worked 20 hours.The facility's patient census was 221 on July 1, 2019 and the physician only worked 20 hours.The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Executive Director will ensure that it is at least one physician hour weekly per 10 patients. Executive Director will review the census weekly to ensure there will be a sufficient number of physician hours provided. |
715.14(a) LICENSURE Urine testing
(a) A narcotic treatment program shall complete an initial drug-screening urinalysis for each prospective patient and a random urinalysis at least monthly thereafter.
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Observations
The facility failed to document a random drug screening urinalysis at least monthly in one of twelve patient records reviewed on July 9 - 11, 2019.Patient # 10 was admitted April 12, 2018. There was no documentation of drug screening urinalysis testing for the following months: August 2018, September 2018, March 2019 and May 2019. Oral swab testing was instead completed for these months. The facility does not have an exception for oral swab testing.The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Executive Director will hold monthly chart audits to ensure compliance with random, monthly urinalysis testing. Executive Director has submitted a request for waiver to administer oral swab testing on 7/9/2019, awaiting certificate to be posted in laboratory. |
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
The narcotic treatment program failed to document an average of 2.5 hours of psychotherapy per month in three of nine patient records reviewed on July 9 - 11, 2019.Patient # 1 was admitted January 15, 2019. The following psychotherapy hours were documented: February 2019 - 1.25, March 2019 - 2.5, April 2019 - 2.25, May 2019 - 1.25 and June 2019 - 2.25. Only an average of 1.9 psychotherapy hours per month were documented in patient record # 1.Patient # 11 was admitted August 7, 2018. The following psychotherapy hours were documented: October 2018 - 1.25, November 2018 - 2.5, December 2018 - 1.25, January 2019 - 2.5, February 2019 - 1.75, March 2019 - 2.5, April 2019 - 1.25 and May 2019 - 1.25 hours. Only an average of 1.78 psychotherapy hours per month were documented in patient record # 11.Patient # 12 was admitted July 17, 2018. The following psychotherapy hours were documented: : August 2018 - .75, September 2018 - 1.5, October 2018 - 1.25, November 2018 - 2, December 2018 - 1.25, January 2019 - 1.25, February 2019 - 2.5, March 2019 - 2.5, April 2019 - 2.5 and May 2019 - 0 hours. Only an average of 1.55 psychotherapy hours per month were documented in patient record # 12. The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Executive Director is responsible for overseeing counseling requirements per patient and per patient caseloads. Executive Director will monitor staff caseloads weekly to ensure that 2.5 hours of therapy will be provided to patients monthly.
Beginning week of 7/15/19 Executive Director held clinical treatment team staff meeting to make evaluate insufficient counseling hours and what corrective actions need to be taken, to ensure hours are being met. |
715.19(3) LICENSURE Psychotherapy services
A narcotic treatment program shall provide individualized psychotherapy services and shall meet the following requirements:
(3) After 4 years of treatment, a narcotic treatment program shall provide each patient with at least 1 hour of group or individual psychotherapy every 2 months. Additional psychotherapy shall be provided as dictated by ongoing assessment of the patient.
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Observations
The narcotic treatment program failed to provide documentation of at least 1 hour of group or individual psychotherapy every two months in two of two patient records reviewed on July 9 - 11, 2019.Patient # 9 was admitted December 4, 2017. No psychotherapy hours were documented for patient # 9 between May 7, 2018 and April 4, 2019.The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Executive Director is responsible for monitoring quantity of services are met per patient. Executive Director will monitor staff caseloads monthly, and ensure that one hour of psychotherapy is being met. Beginning week of 7/15/19 Executive Director composed clinical treatment staff meeting to make aware of insufficient counseling hours, and what corrective actions to be taken to ensure completion. |