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 October 29 & 30, 2024, by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, Dunmore 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 two applicable patient records reviewed.
Patient #5 was admitted to the facility on March 22,2021 and was discharged on April 26, 2024. Patient #5 transferred to another narcotic treatment facility on April 26, 2024. There was no documentation of what materials were sent to the receiving facility.
This is a repeat citation from the November 8, 2023 licensing inspection.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
The Clinical Supervisor and Clinic Director will provide a review and training on the regulation and policy which addresses the procedures for Transfer Patients to clinical staff during group supervision on 12/4/24. An addition review and training for All staff members will occur on 12/9/24. Compliance to 715.20(3) and policy 7.1.14 will occur during regular individual and group supervision, documenting supervisions accordingly. Additional compliance reviews will be conducted during Chart 2 Charge and Quality Record Reviews conducted by the Clinic Director and Clinical Supervisor, on all discharge records for patients referred out. Such reviews will be conducted monthly to ensure all appropriate documents are uploaded to the stored document library, to include fax confirmation sheets having been sent and received by accepting NTP. This information was reviewed during a scheduled all Staff Meeting on November 4, 2024 with additional follow up as noted herein.
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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 document an annual physical examination by the narcotic treatment physician within the regulatory timeframe in one out of three applicable records reviewed.
Patient #4 was admitted on April 23, 2018 and discharged on July 11, 2024. An annual physical was due no later than April 23, 2024; however, it was not completed until May 25, 2024.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
Clinic Director will review regulation 715.23 (B) (5) with medical providers and Charge Nurse during supervision on 11/20/2024. The Charge Nurse will review Services Pending a month in advance and ensure patients are scheduled accordingly. Alerts for completion will be placed on patient charts. Charge Nurse will conduct reviews weekly to ensure the scheduled and timely annual physical examination are completed. Utilizing internal Quality Chart Reviews, along with the Chart to Charge process, continued reviews will afford the ability to ensure Patient Annual Medical reviews are completed prior to a patient admission anniversary date. If patient fails to show for scheduled annual physical examination a no show medical note will be completed in the EMR. This information was reviewed during a scheduled All staff meeting on November 4, 2024 and will be reviewed with all staff on an ongoing basis as part of scheduled all staff meetings and scheduled supervisions.
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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 a review of patient records, the facility failed to document an annual evaluation of each patient ' s status and review, date and have it signed by the medical director in the regulatory timeframe in three out of three applicable patient records.
Patient #4 was admitted on April 23, 2018 and discharged on July 11, 2024. An annual evaluation was due no later than April 23, 2024; however, it was completed on June11, 2024.
Patient #5 was admitted on March 22, 2021 and discharged on April 26, 2024. An annual evaluation was due no later than March 22, 2024; however, it was completed on March 29, 2024.
Patient #6 was admitted on September 15, 2020 and discharged on September 19, 2024. An annual evaluation was due no later than September 15, 2024; however, it was completed on September 19, 2024.
These finding were reviewed with facility staff during the licensing process.
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Plan of Correction
The Clinical Supervisor will review regulation 715.23 (c1-7) with clinical staff members during group supervision on 12/4/2024. Staff members will be re-trained in the timeline for completion of Annual evaluation for patients to be completed each year prior to the patients admission anniversary date. Clinical supervisor and Clinic Director will complete monthly quality chart reviews and will utilize Chart to Charge to ensure compliance to this regulation. Clinical supervisor will review services pending each week in order to ascertain which patients are due for an annual clinical evaluation and will ensure clinical staff complete prior to due date. This information was reviewed during a scheduled all Staff Meeting on November 4, 2024 and will be reviewed on an ongoing basis during scheduled all staff meetings and scheduled weekly supervisions.
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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 document that an individual treatment and rehabilitation plan was developed with the client per the facility ' s policy and procedure manual in two out of five applicable records reviewed. The facility ' s policy and procedure manual states that the individual treatment and rehabilitation plan is developed within thirty days of admission.
Client #2 was admitted on May 7, 2024 and was still active at the time of the inspection. An individual treatment and rehabilitation plan was due no later than June 7, 2024; however, it was not completed until June 12, 2024.
Client #8 was admitted on May 20, 2024 and was still active at the time of the inspection. An individual treatment and rehabilitation plan was due no later than June 20, 2024; however, it was not completed until June 24, 2024.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Clinical Supervisor and Clinic Director will review this policy and regulation with each clinical team member during group supervision scheduled for 12/4/24. During monthly quality record reviews clinical supervisor and Clinic Director will review intial treatment plans for timeliness to ensure initial treatment plans are completed within 30 days of admission to the narcotic treatment program. Clinical Superisor will review, on a daily basis, all new admissions to ensure individual comprehensive treatment planning sessions are scheduled timely. Compliance to same will be reviewed during regular weekly individual supervision.
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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 treatment plan in three out of eight applicable records reviewed.
Client #2 was admitted on May 7, 2024 and was still active at the time of the inspection. The treatment plan dated June 12, 2024, indicated two and half hours of therapy a month, one of which would be individual therapy. In July 2024, the client only received two hours of therapy.
Client #3 was admitted on May 1, 2024 and was still active at the time of the inspection. The treatment plan dated July 1, 2024, indicated two and half hours of therapy a month, one of which would be individual therapy. In August 2024, the client only received one hour of therapy.
Client #4 was admitted on April 23, 20218 and discharged on July11, 2024. The treatment plan dated April 2, 2024, indicated one hour of individual therapy per month. In May 2024, the client only 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
The Clinical Supervisor and Clinic Director will review this policy and regulation with each clinical team member during group supervision on 12/4/24. The Clinical Supervisor and Counseling staff will monitor compliance of all patients counseling requirements according to patient's individual treatment plan during individual supervisions. Additional reviews for compliance will be conducted during monthly internal quality record reviews. In the event that a patient does not show for a scheduled individual or group session the counselor will enter "no show counseling" notes into the EMR. Engagement efforts will be taken with patients who are non-compliant with treatment hours as indicated and agreed upon within the patient treatment plan and documented within the patient's record. A 'General Contact Note' will be added at the end of each month providing an explanation as to Patient's barrier to maintain counseling compliance as per the treatment plan, should a patient remain non-compliant. Compliance to the regulation will be reviewed and documented during regular weekly individual supervision.
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709.93(a)(11) LICENSURE Client records
709.93. Client records.
(a) There shall be a complete client record on an individual which includes information relative to the client's involvement with the project. This shall include, but not be limited to, the following:
(11) Follow-up information.
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Observations
Based on a review of client records, the facility failed to provide a complete client record, which is to include follow-up information per the facility ' s policy and procedure manual in two out of three discharged records reviewed. The facility ' s policy and procedure manual states that a follow up contact occurs within thirty days after discharge.
Client #4 was admitted on April 23, 2018 and discharged on July 11, 2024. A follow up contact was due no later than August 11, 2024; however, there was no documentation that one was completed.
Client #5 was admitted on March 22, 2021 and discharged on April 26, 2024. A follow up contact was due no later than May 26, 2024; however, there was no documentation that one was completed.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
The Clinical Supervisor and Clinic Director will review regulation 709.93 (a) (11) and CTC policy and procedure with clinical team members during group supervision on 12/4/24. Clinical staff will complete follow up contact with discharged patients within 30 days of discharge and will document follow up in patient record. Clinical supervisor and Clinic Director will review discharge patient records for the prior month during monthly quality record reviews to ensure completion of necessary follow up contact to patient and documention of contact or attempt of contact in event patient is unable to be contacted. This will be reviewed on a weekly basis during scheduled individual supervision to ensure compliance to regulation and policy.
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