INITIAL COMMENTS
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This report is a result of an unannounced on-site licensure follow up inspection and methadone and buprenorphine monitoring 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, Pittsburgh 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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715.6(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
Based on the review of physician timesheets, the facility failed to provide at least one hour of physician time a week, onsite for every ten patients.
During the week of March 26-April 1, 2023, the patient census was 383. The facility was required to provide at least 38.3 physician hours. There were only 36 physician hours documented.
This is a repeat citation from the March 11, 2022, and November 16, 2022 licensing inspection.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
Starting July 1st we will have a full time Nurse Practitioner that will take over and Director will oversee hours. We will use our Medical Director and other per diem Nurse Practitioner as backup coverage and vacation. |
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 a review of patient records, the facility failed to complete an annual physical examination given by the narcotic treatment physician which includes an annual reevaluation by the narcotic treatment physician in one out of three applicable records.
Patient #2 was admitted on June 4, 2020 and was discharged on February 10, 2023. The annual physical examination was due no later than June 4, 2022; however, it wasn ' t completed until July 27, 2022.
This is a repeat citation from the March 11, 2022 and November 16, 2022 licensing inspections.
These findings were reviewed with the facility staff during the licensing process.
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Plan of Correction
Starting on July 1st we will have a full time Nurse Practitioner and we started to utilize telehalth again. I met with our Nurse Practitioners and will discuss in team meeting on 6/7/23.Director and Practitioner will meet monthly to ensure we are completing prior to their admission date. |
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 of each patient 's status by the patient 's counselor and reviewed, dated and signed by the medical director on the annual date of the patient 's admission in one out of three applicable records reviewed.
Patient #2 was admitted on June 4, 2020 and was discharged on February 10, 2023. The annual evaluation was due no later than June 4, 2022; however, it wasn ' t completed until June 13, 2022.
This is a repeat citation from the March 11, 2022 and November 16, 2022 licensing inspections.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Clinic Director will review this with all staff, especially clinical during team meeting on 6/7/23.
Clinical Supervisor will follow up in supervision with counselors monthly to ensure this is completed.
Counselors will work on planning out their annual clinicals and working on completing them before the admission date.
Director will check in monthly with Clinical Supervisor to see progress that the annual clinicals completed before admission date. |
709.92(a) LICENSURE Treatment and rehabilitation services
709.92. Treatment and rehabilitation services.
(a) An individual treatment and rehabilitation plan shall be developed with a client. This plan shall include, but not be limited to, written documentation of:
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Observations
Based on a review of client records, the facility failed to develop a comprehensive treatment and rehabilitation plan with the client within their policy ' s set time frame of 8-30 days of admission in two out of four applicable records.
Client #6 was admitted on February 9, 2023 and was still active at the time of the inspection. A comprehensive treatment plan was due no later than March 9, 2023; however, it was not completed until March 23, 2023.
Client #7 was admitted on February 27, 2023 and was still active at the time of the inspection. A comprehensive treatment plan was due no later than March 27, 2023; however, it was not completed until April 3, 2023.
This is a repeat citation from the March 11, 2022 and November 16, 2022 licensing inspections.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Clinic Director will review this with all staff, especially clinical during team meeting on 6/7/23. Clinical Supervisor will follow up in supervision with counselors monthly. Director and Supervisor will continue to review and approve tx plans as completed in order to have the pts sign them sooner. New staff will be trained on this item. |