INITIAL COMMENTS
|
This report is a result of an on-site licensure renewal inspection and methadone and buprenorphine monitoring inspection conducted on February 20 & 21, 2025 by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, Center for Behavioral Health-HA, LLC dba Lewistown 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:
|
Plan of Correction
|
715.20(1) 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.
(1) The transferring narcotic treatment program shall transfer patient files which include admission date, medical and psychosocial summaries, dosage level, urinalysis reports or summary, exception requests, and current status of the patient, and shall contain the written consent of the patient.
|
Observations
Based on a review of patient records, the facility failed to document the transfer of patient files to include the required documents to the patient's new treatment facility in one out of one applicable record. Patient #3 was admitted on October 23, 2024 and transferred to another treatment facility on January 7, 2025. The record did not contain documentation that the required paperwork was sent to the receiving facility. This finding was reviewed with facility staff during the licensing process.
|
Plan of Correction
1. All staff will be 're'-educated on transfer policy and procedures to ensure all communications and documentation is completed accurately. Training will be completed during the Monthly Staff meeting on 3/10/25; with weekly reviews during clinical group and individual supervision.
2. Clinic Director/Supervisor and Charge nurse will audit transfer records at the date of the known transfer and monthly, thereafter, via the Quality Record Review Process to ensure sustained compliance verifying the receiving treatment facility are provided: admission date, medical and psychosocial summaries, dosing history, 3 months of UA results, along with any other requested documents, with the signed written consent of the patient.
|
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:
|
Observations
Based on a review of client records, the facility failed to document a comprehensive treatment plan within guidelines established by the facility's policy and procedures manual in four out of six applicable records reviewed. The facility ' s policy and procedures manual states that the comprehensive treatment plan is completed within 30 days of admission. Client #4 was admitted on September 12, 2024 and was still active at the time of the inspection. A comprehensive treatment plan was due no later than October 12, 2024; however, it was not completed until November 21, 2024. Client #6 was admitted on December 19, 2024 and was still active at the time of the inspection. A comprehensive treatment plan was due no later than January 19, 2025; however, it was not completed until January 28, 2025.Client #7 was admitted on October 21, 2024 and discharged on January 31, 2025. A comprehensive treatment plan was due no later than November 21, 2024; however, it was not completed until November 27, 2024. Client #8 was admitted on October 16, 2024 and was still active at the time of the inspection. A comprehensive treatment plan was due no later than November 16, 2024; however, it was not completed until November 20, 2024. These findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
1. Staff will be educated on policy and procedure of writing treatment plans within 30 days on or before 3/10/25.
2. As part of the trainings, counselors will print out the monthly services due report, make notations as to due dates and ensure patients are scheduled timely for the individual treatment plan to be completed.
3. Clinic director/supervisor will review service due list and audit all intake charts in accordance with the Quality Record Review Process which will monitor initial treatment plans for date compliance, reviewing with each counselor during individual supervision.
4. Staff will ensure proper documentation is in the chart when a patient is not attending sessions to participate in the initial treatment plan, including but not limited to General contact and No show notes and MDTC notes when appropriate.
Counselors compliance will be reviewed during group supervision to ensure sustained performance to same.
|