INITIAL COMMENTS
|
This report is a result of an on-site licensure renewal and methadone monitoring inspection conducted on November 15-16, 2021 by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, Habit OPCO, Inc. 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
|
704.7(b) LICENSURE Counselor Qualifications
704.7. Qualifications for the position of counselor.
(a) Drug and alcohol treatment projects shall be staffed by counselors proportionate to the staff/client and counselor/client ratios listed in 704.12 (relating to full-time equivalent (FTE) maximum client/staff and client/counselor ratios).
(b) Each counselor shall meet at least one of the following groups of qualifications:
(1) Current licensure in this Commonwealth as a physician.
(2) A Master's Degree or above from an accredited college with a major in chemical dependency, psychology, social work, counseling, nursing (with a clinical specialty in the human services) or other related field which includes a practicum in a health or human service agency, preferably in a drug and alcohol setting. If the practicum did not take place in a drug and alcohol setting, the individual's written training plan shall specifically address a plan to achieve counseling competency in chemical dependency issues.
(3) A Bachelor's Degree from an accredited college with a major in chemical dependency, psychology, social work, counseling, nursing (with a clinical specialty in the human services) or other related field and 1 year of clinical experience (a minimum of 1,820 hours) in a health or human service agency, preferably in a drug and alcohol setting. If a person's experience did not take place in a drug and alcohol setting, the individual's written training plan shall specifically address a plan to achieve counseling competency in chemical dependency issues.
(4) An Associate Degree from an accredited college with a major in chemical dependency, psychology, social work, counseling, nursing (with a clinical specialty in the human services) or other related field and 2 years of clinical experience (a minimum of 3,640 hours) in a health or human service agency, preferably in a drug and alcohol setting. If a person's experience was not in a drug and alcohol setting, the individual's written training plan shall specifically address a plan to achieve counseling competency in chemical dependency issues.
(5) Current licensure in this Commonwealth as a registered nurse and a degree from an accredited school of nursing and 1 year of counseling experience (a minimum of 1,820 hours) in a health or human service agency, preferably in a drug and alcohol setting. If a person's experience was not in a drug and alcohol setting, the individual's written training plan shall specifically address a plan to achieve counseling competency in chemical dependency issues.
(6) Full certification as an addictions counselor by a statewide certification body which is a member of a National certification body or certification by another state government's substance abuse counseling certification board.
|
Observations
Based on a review of personnel records, the facility failed to document that each counselor met both the education and experiential qualifications for the position.
Employee #5, who was promoted to counselor on January 10, 2021, did not meet the experience requirements to be a counselor. At the time of the promotion, the employee did not have one year of clinical experience required to be a counselor with a bachelor's degree.
Employee #8, who was hired to be a counselor on June 1, 2021, did not meet the experience requirements to be a counselor. At the time of the hire, the employee did not have one year of clinical experience required to be a counselor with a bachelor's degree.
These findings were reviewed with facility staff during the licensing inspection.
|
Plan of Correction
Dunmore CTC will ensure that any staffing additions meet the necessary educational and experience requirements to hold the counselor position. Dunmore CTC will also ensure that transitions from the counselor assistant to counselor position are documented thoroughly to ensure the accurate representation of experience and competency in chemical dependency treatment for regulatory bodies. A review of the necessary protocols to accurately represent the same has been presented and reviewed with the clinical supervisor on December 13th, 2021. The staff members in question were re-classified to Counselor Assistants and a training plan has been developed specifically noting the plans and goals to achieve full counselor status at their 1 year of employment mark with Dunmore CTC. Any and all future promotional recommendations for clinical staff members will require the presentation of all necessary data and supporting documentation to the Clinic Director and or their designee to ensure all areas of 704.7 are met prior to the actual promotion. |
704.11(f)(2) LICENSURE Trng Hours Req-Coun
704.11. Staff development program.
(f) Training requirements for counselors.
(2) Each counselor shall complete at least 25 clock hours of training annually in areas such as:
(i) Client recordkeeping.
(ii) Confidentiality.
(iii) Pharmacology.
(iv) Treatment planning.
(v) Counseling techniques.
(vi) Drug and alcohol assessment.
(vii) Codependency.
(viii) Adult Children of Alcoholics (ACOA) issues.
(ix) Disease of addiction.
(x) Aftercare planning.
(xi) Principles of Alcoholics Anonymous and Narcotics Anonymous.
(xii) Ethics.
(xiii) Substance abuse trends.
(xiv) Interaction of addiction and mental illness.
(xv) Cultural awareness.
(xvi) Sexual harassment.
(xvii) Developmental psychology.
(xviii) Relapse prevention.
(3) If a counselor has been designated as lead counselor supervising other counselors, the training shall include courses appropriate to the functions of this position and a Department approved core curriculum or comparable training in supervision.
|
Observations
Based on a review of the Staffing Requirements Facility Summary Report and personnel records, the facility failed to document the completion of 25 clock hours of annual training required for counselors in employees # 4 and 7 employee record. The facility's training year that was reviewed was from January 1, 2020 through December 31, 2020.
Employee #4 was hired as a counselor on July 23, 2018 and was still in the position as of the date of the inspection. The employee record only documented 15 hours, 1 minute of annual training for the training year reviewed.
Employee #7 was hired as a counselor on March 25, 2019 and was still in the position as of the date of the inspection. The employee record only documented 18 hours, 22 minutes of annual training for the training year reviewed.
These findings were reviewed with facility staff during the licensing inspection.
|
Plan of Correction
Dunmore CTC Clinical Management team will ensure that each and every clinical staff member completes the required number of annual trainings expected during a calendar year. A review of the staff members adherence to the appropriate amount of trainings each year was presented and reviewed during the full staff monthly meeting held on December 17th, 2021. Also discussed was that the staff ensure that certificates of completion of trainings are provided to the Office Manager so that it may be accurately represented in ones' personnel file. This effort will remain ongoing to ensure this is not a repeat deficiency for Dunmore CTC. |
704.12(a)(6) LICENSURE OutPatient Caseload
704.12. Full-time equivalent (FTE) maximum client/staff and client/counselor ratios.
(a) General requirements. Projects shall be required to comply with the client/staff and client/counselor ratios in paragraphs (1)-(6) during primary care hours. These ratios refer to the total number of clients being treated including clients with diagnoses other than drug and alcohol addiction served in other facets of the project. Family units may be counted as one client.
(6) Outpatients. FTE counselor caseload for counseling in outpatient programs may not exceed 35 active clients.
|
Observations
Based on the review of the Staffing Requirements Facility Summary Report, the facility failed to keep client/staff ratios at or below the regulation limit of 35/1.
The counselor Full Time Equivalent (FTE) is determined by dividing the total number of hours the counselor devotes to their clients by facility ' s work week. Then, in order to obtain the counselor ' s ratio, the total number of clients on the counselor ' s caseload is divided by the FTE.
Employee #4 was hired as a counselor on July 23, 2018 and was still acting in that position. Employee #4 was reported to have 37.5 hours per week devoted to their 39 clients on their caseload.
Employee #8 was hired as a counselor on June 1, 2021 and was still acting in that position. Employee #8 was reported to have 37.5 hours per week devoted to their 39 clients on their caseload.
The FTE counselor's caseload calculation is as follows: 37.5/37.5 = 1 (FTE); 39/1 = 39, which equals to a client/counselor ratio of 39:1.
Employee #5 was promoted on January 10, 2021 and was still acting in that position. Employee #5 was reported to have 37.5 hours per week devoted to their 36 clients on their caseload.
Employee #6 was promoted on September 27, 2018 and was still in that position. Employee #6 was reported to have 37.5 hours per week devoted to their 36 clients on their caseload.
The FTE counselor's caseload calculation is as follows: 37.5/37.5 = 1 (FTE); 36/1= 36, which equals to a client/counselor ratio of 36:1.
This is a repeat citation from the November 13, 2020 and November 19, 2019 licensing inspections.
These findings were reviewed with facility staff during the licensing inspection.
|
Plan of Correction
By January 2021, the Clinic Director will hire two additional staff to correct the issue of ratio compliance. Based on the current census and those who meet the criteria of licensure alert 01-14, the facility will meet the 35:1 requirement with the addition of (2) clinical staff members. The Clinical Supervisor will monitor the ratio weekly when assigning new admissions to counselors. The CTC Director will monitor census weekly to ensure compliance with this regulation and hire additional staff as needed. To be noted, Dunmore CTC has had a very difficult time hiring new employees during the pandemic. During this audit period, the Clinic Director and Clinical Supervisor were actively engaged in the process of scheduling and completing interviews to replace staff who resigned.
Subsequent to the date of this audit, a new clinician has been identified and offered the position on site in Dunmore with a start date of November 19th, 2021. Dunmore CTC is still recruiting for another additional staff member - once identified, this hire will place Dunmore CTC back into compliance with this regulation. |
705.28 (d) (4) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(4) Maintain a written fire drill record including the date, time, the amount of time it took for evacuation, the exit route used, the number of persons in the facility at the time of the drill, problems encountered and whether the fire alarm or smoke detector was operative.
|
Observations
Based on the review of fire drill logs from December 2020 through October 2021, the facility failed to document a complete fire drill log. The January 27, 2021 fire drill log did not include time of the drill, amount of time it took for evacuation and whether the fire alarm or smoke detector was operative.
This is a repeat citation from the November 13, 2020 and November 19, 2019 annual licensing inspections.
The findings were reviewed with facility staff during the licensing inspection.
|
Plan of Correction
The Health and Safety Liaison will conduct at minimum, one fire drill per month and document the drill using the designated Emergency drill form, which notes the time the fire drill took place, the time it took to evacuate, the exit route used, the number of people in the facility at the time of the fire drill, and any problems that may have been encountered during the drill. The CTC Director will monitor compliance in this area by inspecting the extinguishers and reviewing the Health and Safety documentation monthly. |
709.28 (c) (3) LICENSURE Confidentiality
§ 709.28. Confidentiality.
(c) The project shall obtain an informed and voluntary consent from the client for the disclosure of information contained in the client record. The consent must be in writing and include, but not be limited to:
(3) Purpose of disclosure.
|
Observations
Based on the review of patient records, the facility failed to document a complete informed and voluntary consent to release of information form which includes a purpose of disclosure in one in seven records reviewed.
Patient # 2 was admitted on February 18, 2021 and was discharged on September 30, 2021. A release form dated July 29, 2021 to a family member stated the purpose as "see above".
The findings were reviewed with facility staff during the licensing inspection.
|
Plan of Correction
Dunmore CTC Clinic Director and Office Manager will ensure that all release of information forms will indicate a specific purpose of the disclosure to named parties within the ROI. All releases of information will be reviewed for accuracy and that these releases of information are completed in its entirety on a monthly basis. This information was presented during the December 17th, 2021 all staff meeting to ensure compliance to this regulation. |
709.28 (c) (4) LICENSURE Confidentiality
§ 709.28. Confidentiality.
(c) The project shall obtain an informed and voluntary consent from the client for the disclosure of information contained in the client record. The consent must be in writing and include, but not be limited to:
(4) Dated signature of client or guardian as provided for under 42 CFR 2.14(a) and (b) and 2.15 (relating to minor patients; and incompetent and deceased patients).
|
Observations
Based on the review of patient records, the facility failed to document a complete informed and voluntary consent to release information form which includes a dated client signature in one out of seven records reviewed.
Patient #1 was admitted on October 25, 2016 and was still active at the time of the inspection. A consent form stated, "signature not required, already on file", referring to a previous consent form that expired on December 4, 2016.
The findings were reviewed with facility staff during the licensing inspection.
|
Plan of Correction
Dunmore CTC Clinic Director and Office Manager will ensure that all release of information forms are signed by the patient that is requesting the release of their confidential information to external parties. All releases of information will be reviewed for accuracy and that these releases of information are completed in its entirety, including patient signature, on a monthly basis. This information was presented during the December 17th, 2021 all staff meeting to ensure compliance to this regulation. |
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
|
Observations
Based on a review of physician timesheets and census reports, the facility failed to provide physician services at least one hour per week onsite for every ten patients.
During the week of July 4-10, 2021, the patient census was 507. The facility was required to provide at least 50.7 physician hours. There were 41 physician hours documented.
During the week of July 11-17, 2021, the patient census was 508. The facility was required to provide at least 50.8 physician hours. There were 36.5 physician hours documented.
During the week of July 18-24, 2021, the patient census was 512. The facility was required to provide at least 51.2 physician hours. There were 39.25 physician hours documented.
During the week of July 25-31, 2021, the patient census was 512. The facility was required to provide at least 51.2 physician hours. There were 48.75 physician hours documented.
During the week of August 1-7, 2021, the patient census was 512. The facility was required to provide at least 51.2 physician hours. There were 37 physician hours documented.
During the week of August 8 - 14, 2021, the patient census was 511. The facility was required to provide at least 51.1 physician hours. There were 38 physician hours documented.
During the week of August 15-21, 2021, the patient census was 509. The facility was required to provide at least 50.9 physician hours. There were 50 physician hours documented.
During the week of August 29-September 4, 2021, the patient census was 511. The facility was required to provide at least 51.1 physician hours. There were 44 physician hours documented.
During the week of September 5-11, 2021, the patient census was 510. The facility was required to provide at least 51 physician hours. There were 36 physician hours documented.
During the week of September 12-18, 2021, the patient census was 519. The facility was required to provide at least 51.9 physician hours. There were 50.5 physician hours documented.
During the week of September 26-October 2, 2021, the patient census was 512. The facility was required to provide at least 51.2 physician hours. There were 50.25 physician hours documented.
During the week of October 3-9, 2021, the patient census was 512. The facility was required to provide at least 51.2 physician hours. There were 48.5 physician hours documented.
During the week of October 10-16, 2021, the patient census was 510. The facility was required to provide at least 51 physician hours. There were 35.5 physician hours documented.
During the week of October 17-23, 2021, the patient census was 504. The facility was required to provide at least 50.4 physician hours. There were 37 physician hours documented.
During the week of October 24-30, 2021, the patient census was 503. The facility was required to provide at least 50.3 physician hours. There were 49 physician hours documented.
This is a repeat citation from the November 13, 2020, November 19, 2019, November 15, 2018, November 16, 2017 and October 13, 2016 annual licensing inspections.
These findings were reviewed with facility staff during the licensing inspection.
|
Plan of Correction
The CTC Director will ensure that the Program Physician(s) provide at least 1 hour per week onsite for every ten patients. A Physician schedule has been developed as of 01/01/2022 and will be submitted to the medical staff monthly to ensure there is adequate coverage. There is consideration of hiring another physician to assist with those times where there is an anticipated lack of coverage to meet the necessary regulation ratio requirement. The CTC Director will monitor the monthly calendar to ensure there is adequate coverage. |
715.9(a)(2) LICENSURE Intake
(a) Prior to administration of an agent, a narcotic treatment program shall screen each individual to determine eligibility for admission. The narcotic treatment program shall:
(2) Verify the individual 's identity, including name, address, date of birth, emergency contact and other identifying data.
|
Observations
Based on the review of patient records, the facility failed to verify the individual's identity in one out of four applicable patient records.
Patient #4 was admitted on July 23, 2021 and was still active at the time of the inspection. There was no documented identification in the patient's record.
The findings were reviewed with facility staff during the licensing inspection.
|
Plan of Correction
Dunmore CTC will obtain a copy of each patients identity in the form of a state issued photo ID, driver's license, and/or birth certificate and social security card prior to the initial administration of medication. The office manager will monitor each patients chart on a weekly basis to ensure that patient identification is present. This information was presented during an all staff meeting on December 17th, 2021. |
715.13(a) LICENSURE Patient identification
(a) A narcotic treatment program shall use a system for patient identification for the purpose of verifying the correct identity of a patient prior to administration of an agent.
|
Observations
Based on the observation of medication administration, the facility failed to properly verify the correct identity of a patient prior to administration of an agent. Section 6.1.1, #7d of the facility's policy and procedures manual states "patients will present at the dispensing window without hats or sunglasses. There were two observed occurrences where the patient was not asked to remove their hat prior to dosing.
The findings were reviewed with facility staff during the licensing inspection.
|
Plan of Correction
Dispensing nurses will ensure that every patient removes hats and/or sunglasses in order to verify identity prior to medication administration. The charge nurse will present this information during the monthly nursing meeting. The charge nurse will monitor dispensing staff for continued compliance on a weekly basis. |
715.17(c)(1)(i-vi)) LICENSURE Medication control
(c) A narcotic treatment program shall develop and implement written policies and procedures regarding the medications used by patients which shall include, at a minimum:
(1) Administration of medication.
(i) A narcotic treatment physician shall determine the patient 's initial and subsequent dose and schedule. The physician shall communicate the initial and subsequent dose and schedule to the person responsible for the administration of medication. Each medication order and dosage change shall be written and signed by the narcotic treatment physician.
(ii) An agent shall be administered or dispensed only by a practitioner licensed under the appropriate Federal and State laws to dispense agents to patients.
(iii) Only authorized staff and patients who are receiving medication shall be permitted in the dispensing area.
(iv) There shall be only one patient permitted at a dispensing station at any given time.
(v) Each patient shall be observed when ingesting the agent.
(vi) Administering and dispensing shall be conducted in a manner that protects the patient from disruption or annoyance from other individuals.
|
Observations
Based on direct observation of medication administration, the facility failed to ensure medication was properly administered by asking the patient to speak following dosing. Two patients were not required to speak. In addition, the facility failed to permit only patients and authorized staff in the dispensing area. The line of patients waiting to be dosed was observed to be directly behind the patient receiving their medication.
These findings were reviewed with facility staff during the licensing inspection.
|
Plan of Correction
Dosage shall be verified by the patient to the nurse and confirmed with the current dose order before preparing. The patient will ingest the medication in front of the dispensing nurse and will speak with the dispensing nurse prior to leaving the dispensing areas to minimize the possibility of medication diversion. This process was reviewed for consistency with dispensing nurse staff during the monthly nursing supervision meeting. The charge nurse will monitor dispensing staff for continued compliance on a weekly basis. |
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.
|
Observations
Based on the review of patient records, the facility failed to provide patient with 2.5 hours of psychotherapy a month during the patient's first two years of treatment in three out of four applicable patient records.
Patient #2 was admitted on February 18, 2021 and discharged on September 30, 2021. The patient received 1.5 hours of therapy in June 2021, zero hours in July 2021 and 30 minutes in August 2021.
Patient #3 was admitted on December 2, 2020 and discharged on June 1, 2021. The patient received 30 minutes in February and April 2021 and zero hours in March 2021.
Patient #4 was admitted on July 23, 2021 and was still active at the time of the inspection. The patient received one hour of therapy in August and October 2021 and two hours of therapy in September 2021.
This is a repeat citation from the November 13, 2020, November 19, 2019, November 15, 2018, November 16, 2017 and October 13, 2016 annual licensing inspections.
These findings were reviewed with facility staff during the licensing inspection.
|
Plan of Correction
Dunmore CTC Clinic Director and Clinical Supervisor are responsible for ensuring compliance with psychotherapy services for all patients within this narcotic treatment program. The Clinical Supervisor reviewed the requirements for counseling services with all counselors on December 16th, 2021. As of December 20th, 2021, each counselor will run their Direct Services Analysis reports in the EMR and turn into the Clinical Supervisor for verification of patient compliance to psychotherapy. The Clinical Supervisor will review the reports in individual and group supervision.
Patients that missed counseling will be held to meet with a member of the clinical team prior to medicating to address issues of counseling non-compliance. Continued issues of counseling non-compliance after multiple intervention attempts will be brought to the team for consideration of an A |
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.
|
Observations
Based on the review of patient records, the facility failed to complete an annual evaluation within the regulatory timeframe in two out of three applicable records reviewed.
Patient #1 was admitted on October 25, 2016 and was still active at the time of the inspection. An annual clinical evaluation was due on October 25, 2021; however, it was not completed until November 12, 2021.
Patient #7 was admitted on March 7, 2019 and discharged on October 22, 2021. An annual clinical evaluation was due on March 7, 2021; however, it was not completed until March 25, 2021.
These findings were reviewed with facility staff during the licensing inspection.
|
Plan of Correction
Clinic director and Clinical Supervisor reviewed 715.23(c)(1-7) and failure to be in compliance with this regulation on December 13th, 2021. Dunmore CTC will ensure that all documentation required for patients files will be completed in a timely manner and will be reviewed by the Clinical Supervisor. 5% of patient charts will be internally audited for completion on a monthly basis.
The clinic director will meet with the Medical Director in order to review the necessity for the Medical Director to review and sign off on all clinical annual evaluations completed by the primary clinicians. |
709.91(b)(6) LICENSURE Intake and admission
709.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(6) Psychosocial evaluation.
|
Observations
Based on a review of patient records, the facility failed to document a psychosocial evaluation in two out of four applicable patient records.
Patient #4 was admitted on July 23, 2021 and was still active at the time of the inspection.
Patient #5 was admitted on February 15, 2021 and was still active at the time of the inspection.
These findings were reviewed with facility staff during the licensing inspection.
|
Plan of Correction
Facility director and Clinical Supervisor reviewed regulation 709.91(b)(6). It has been identified that the patients charts in question did indeed have biopsychosocial assessments completed - Patient #4 had a biopsychosocial assessment completed on July 23rd, 2021 and Patient #5 had a biopsychosocial assessment completed on February 12th, 2021. Within these biopsychosocial assessments, the clinician will include their clinical impression of the patient. The clinical supervisor will present this information to the clinical team in the weekly group supervision. The Clinical Supervisor will monitor compliance to this regulation on a weekly basis. |
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 the review of patient records, the facility failed to develop an individual treatment plan within the regulatory timeframe in two out of four applicable records. The facility's policy procedure manual states in section 7.1.4 that the comprehensive treatment plan must be completed between days 8-30.
Patient #2 was admitted on February 18, 2021 and discharged on September 30, 2021. A comprehensive treatment plan was due on March 18, 2021; however, it was not completed until May 27, 2021.
Patient #3 was admitted on December 2, 2021 and discharged on June 1, 2021. A comprehensive treatment plan was due on January 2, 2021; however, it was not completed until January 13, 2021.
These findings were reviewed with facility staff during the licensing inspection.
|
Plan of Correction
The Clinic Director met with the Clinical Supervisor to review regulation 709.92(b) on December 13th, 2021. A more thorough review of patient files will be conducted to ensure that counseling staff are completing necessary paperwork and documentation in a timely manner. The continued utilization of the EMR will ensure that all documentation is met within allotted time frames necessary to meet this regulation.
During the December 16th, 2021 clinical staff meeting, the clinical supervisor reviewed this regulation and required that all counseling staff complete internal audits of patient electronic records on a weekly basis. |
709.92(a)(2) 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:
(2) Type and frequency of treatment and rehabilitation services.
|
Observations
Based on the review of patient records, the facility failed to document specific type of counseling services in the patient's individual treatment plan in two out of four applicable records reviewed.
Patient #2 was admitted on February 18, 2021 and discharged on September 30, 2021. The treatment plan was dated May 27, 2021.
Patient #5 was admitted on February 15, 20201 and was still active at the time of the inspection. The treatment plan was dated March 10, 2021.
These findings were reviewed with facility staff during the licensing inspection.
|
Plan of Correction
The Clinic Director met with the Clinical Supervisor to review regulation 709.92(b) on December 13th, 2021. A thorough review of patient treatment plans will be conducted to ensure that counseling staff are completing necessary paperwork and documentation in a timely manner, and that treatment plans are specifically addressing the type and frequency of treatment services. All treatment plans are reviewed by the Clinic Director and Clinical Supervisor for accuracy on a monthly basis. The Clinical Supervisor discussed this regulation on December 16th, 2021 with all clinical staff members. |
709.92(a)(3) 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:
(3) Proposed type of support service.
|
Observations
Based on the review of patient records, the facility failed to document support services in the patient's individual treatment plan in three out of four applicable records.
Patient #3 was admitted on December 2, 2020 and discharged on June 1, 2021. The treatment plan was dated January 13, 2021.
Patient #4 was admitted on July 23, 2021 and was still active at the time of the inspection. The treatment plan was dated June 30, 2021.
Patient #5 was admitted on February 15, 2021 and was still active at the time of the inspection. The treatment plan was dated March 10, 2021.
These findings were reviewed with facility staff during the licensing inspection.
|
Plan of Correction
The Clinic Director met with the Clinical Supervisor to review regulation 709.92(a)(3) on December 13th, 2021. A thorough review of patient treatment plans will be conducted to ensure that counseling staff are completing necessary paperwork and documentation in a timely manner, and that treatment plans are noting proposed support services with goals and objectives to meet this regulation. All treatment plans are reviewed by the Clinic Director and Clinical Supervisor for accuracy on a monthly basis. The Clinical Supervisor discussed this regulation on December 16th, 2021 with all clinical staff members. |
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.
|
Observations
Based on the review of patient records, the facility failed to review and update treatment plans at least every sixty days in four out of seven records reviewed.
Patient #3 was admitted on December 2, 2020 and discharged on January 1, 2021. A treatment plan update was completed on February 25, 2021 and the next update was due no later than April 25, 2021; however, it was not completed until May 24, 2021.
Patient #4 was admitted on July 23, 2021 and was still active at the time of the inspection. A treatment plan update was completed on August 26, 2021 and the next update was due no later than October 26, 2021; however, it was not completed until November 5, 2021.
Patient #5 was admitted on February 15, 2021 and was still active at the time of the inspection. A treatment plan update was completed on April 2, 2021 and the next update was due no later than June 2, 2021; however, it was not completed until July 15, 2021.
Patient #7 was admitted on March 7, 2019 and discharged on October 22, 2021. A treatment plan update was completed on March 2, 2021 and the next update was due no later than May 2, 2021; however, it was not completed until May 28, 2021.
These findings were reviewed with facility staff during the licensing inspection.
|
Plan of Correction
The Clinic Director met with the Clinical Supervisor to review regulation 709.92(b) on December 13th, 2021. A detailed review of patient charts will be conducted to ensure that clinical staff are completing necessary paperwork and documentation in a timely manner. The continued utilization of the EMR will ensure that all documentation is met within allotted time frames necessary to meet this regulation. All clinical staff will be required to complete internal audits of patient electronic records on a weekly basis. |
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.
|
Observations
Based on the review of patient records, the facility failed to provide counseling services according to the patient's individual treatment plan in five out of seven patient records.
Patient #2 was admitted on February 18, 2021 and was discharged on September 30, 2021. The treatment plan dated May 27, 2021 stated "2.5 hours group/individual every month". The patient received 1.5 hours of counseling in June 2021, zero counseling hours in July 2021 and 30 minutes of counseling in August 2021.
Patient #3 was admitted on December 2, 2021 and discharged on June 1, 2021. The treatment plan dated January 13, 2021 indicated weekly individual counseling sessions. The patient did not receive any individual counseling from February 11 - March 31, 2021.
Patient #4 was admitted on July 23, 2021 and was still active at the time of the inspection. A treatment plan dated July 30, 2021 indicated one hour of individual therapy per month and 1.5 hours of group therapy per month. In August and October 2021, the patient did not receive any group therapy sessions. In September 2021, the patient received one hour of group therapy.
Patient #6 was admitted on April 13, 2017 and discharged on June 14, 2021. A treatment plan dated February 27, 2021 stated one hour of counseling per month. In March 2021 and May 2021, the patient did not receive any counseling services.
Patient #7 was admitted on March 7, 2019 and discharged on October 22, 2021. The treatment plan dated January 15, 2021 stated 2.5 hours of counseling. In June 2021, the patient received two hours of counseling. In July 2021, the patient received one hour of counseling.
These findings were reviewed with facility staff during the licensing inspection.
|
Plan of Correction
The Clinic Director met with the Clinical Supervisor to review regulation 709.92(c) on December 13th, 2021. A detailed review of patient treatment plans will be conducted to ensure that counseling staff are completing necessary paperwork and documentation in a timely manner, and ensure that appropriate documentation is maintained and specifically noting patient compliance to Treatment plan expectations and counseling session attendance. All treatment plans are reviewed by the Clinic Director and Clinical Supervisor for accuracy on a monthly basis. The Clinical Supervisor discussed this regulation on December 16th, 2021 with all clinical staff members. |
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.
|
Observations
Based on the review of patient records, the facility failed to document follow-up information in one out of two records reviewed.
Patient #6 was admitted on April 13, 2017 and discharged on June 14, 2021.
The finding was reviewed with facility staff during the licensing inspection.
|
Plan of Correction
The Clinical Supervisor will continue to conduct weekly and monthly reviews of all services necessary, including that of post treatment documentation such as discharge summaries and follow-up contacts on both successful and unsuccessful discharges. Follow up contacts will be assigned by the Clinical Supervisor to either the primary clinician and/or the Admissions team and these contacts will be documented within the EMR in order to meet this regulation. |
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.
|
Observations
Based on a review of Staffing Requirements Facility Summary Report, physician timesheets, fire drill logs and patient records, the facility failed to comply with four plans of correction approved by the Department. Plans of correction were submitted to the Department for inspections occurring on November 13, 2020 and November 19, 2019, addressing incomplete information on fire drill logs. Plans of correction were submitted to the Department for inspections occurring on November 13, 2020, November 19, 2019, November 15, 2018, November 16, 2017 and October 13, 2016, addressing the requirement to provide physician services at least one hour per week onsite for every ten patients. Plans of correction were submitted to the Department for inspections occurring on November 13, 2020, November 19, 2019, November 15, 2018, November 16, 2017 and October 13, 2016, addressing the requirement to provide 2.5 of counseling services per month to patients in their first two years of treatment. Plans of correction were submitted to the Department for inspections occurring on November 13, 2020 and November 19, 2019, addressing the requirement to keep client/staff ratios for outpatient clients at or below the ratio of 35:1.
These findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
Dunmore CTC will identify issues with proposed plans of correction as they present and formulate protocols to ensure that repeat citations are avoided in the future. The current plans of correction for this audit period are believed to be attained and maintained with current staffing and policies in place.
Fire Drills: There has been a new Health and Safety Liaison appointed at Dunmore CTC and a thorough review of the expectations of fire drill and fire drill logs has occurred on December 16th, 2021.
Physician Ratio: An increase in physician hours has occurred at the time of this plan of correction and adding an additional physician has been proposed to meet the physician ratio requirement.
Counseling Requirements: If a patient does not meet the minimum counseling requirement during the month, the reason for such will be documented in the patient file. Counselors will continue to attempt to contact patients who are not meeting the minimum monthly counseling requirement immediately following a missed appointment, or after 4 weeks have passed without a clinical session. Patients who continue to refuse to meet minimum counseling requirements are placed on a Treatment Contract. A treatment team meeting is be held to review therapeutic interventions and strategies to increase session attendance. Approved interventions are incorporated into a Treatment Contract that is presented to and signed by the patient. CTC staff will determine, when a non-compliant patient may be eligible for Administrative Discharge due to counseling non-compliance. This decision will be made at a treatment team meeting, with agreement of the CTC physician, and the patient must be placed on an appropriate administrative detoxification schedule.
Patient/Staff Ratios: Dunmore CTC has experienced clinical staffing difficulties throughout the COVID pandemic. Immediately following this audit period, a new clinical staff member was hired and recruiting for an additional staff member has occurred to address the need to meet this regulation. |