INITIAL COMMENTS
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This report is a result of an on-site provisional license follow-up inspection conducted on March 23-24, 2022 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:
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Plan of Correction
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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.
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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 #1, who was promoted to counselor on December 10, 2021, did not meet the one year of experience requirement of a person with a bachelor's degree.
Employee #2, who was promoted to counselor on December 10, 2021, did not meet the one year of experience requirement of a person with a bachelor's degree.
These findings were reviewed with facility staff during the licensing inspection.
This is a repeat citation from the November 16, 2021 annual licensing inspection.
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Plan of Correction
Dunmore CTC will ensure that any staffing additions will meet the necessary educational and experience requirements to hold the counselor position. Dunmore CTC will also ensure that the transition from the counselor assistant position to counselor position are documented thoroughly to ensure the accurate representation of experience and competency in chemical dependency treatment for regulatory bodies, including, but not limited to close supervision.
One of the staff members in question did meet the necessary requirements to be classified as a full counselor position as of 01/10/2022.
The other staff member in question has been re-classified to a counselor assistant and will meet the necessary experience requirements on 06/01/2022. This staff member is engaging in close and documented weekly supervision to date.
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 that all areas of 704.7 are met prior to the actual promotion.
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704.9(c) LICENSURE Supervised Period
704.9. Supervision of counselor assistant.
(c) Supervised period.
(1) A counselor assistant with a Master's Degree as set forth in 704.8 (a)(1) (relating to qualifications for the position of counselor assistant) may counsel clients only under the close supervision of a trained counselor or clinical supervisor for at least the first 3 months of employment.
(2) A counselor assistant with a Bachelor's Degree as set forth in 704.8 (a)(2) may counsel clients only under the close supervision of a trained counselor or clinical supervisor for at least the first 6 months of employment.
(3) A registered nurse as set forth in 704.8 (a)(3) may counsel clients only under the close supervision of a trained counselor or clinical supervisor for at least the first 6 months of employment.
(4) A counselor assistant with an Associate Degree as set forth in 704.8 (a)(4) may counsel clients only under the close supervision of a trained counselor or clinical supervisor for at least the first 9 months of employment.
(5) A counselor assistant with a high school diploma or GED equivalent as set forth in 704.8 (a)(5) may counsel clients only under the direct observation of a trained counselor or clinical supervisor for the first 3 months of employment. For the next 9 months, the counselor assistant may counsel clients only under the close supervision of a lead counselor or a clinical supervisor.
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Observations
Based on a review of personnel records, the facility failed to document required supervision by a trained counselor or clinical supervisor.
Employee #2 was reclassified as a counselor assistant following the annual licensing inspection on November 16, 2021. There was no documentation of the employee receiving close supervision as required as a counselor assistant with a bachelor's degree.
The finding was reviewed with facility staff during the licensing inspection.
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Plan of Correction
Employee #2 has been re-classified back to a counselor assistant following this provisional licensing inspection. This staff member will meet the necessary experience requirements on 06/01/2022. This staff member is engaging in close and documented weekly supervision to date. |
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.
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Observations
Based on a review of personnel records, the facility failed to document the completion of 24 clock hours of annual training required for counselors in employees #5 and 6 employee records. The facility's training year that was reviewed was from January 1, 2021 through December 31, 2021.
Employee #5 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 14 hours and 58 minutes of annual training for the training year reviewed.
Employee #6 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 16 hours and 5 minutes of annual training for the training year reviewed.
The findings were reviewed with facility staff during the licensing inspection.
This is a repeat citation from the November 16, 2021 annual licensing inspection.
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Plan of Correction
Dunmore CTC Clinical Management team will ensure that each and every clinical staff member completes the required 25 hours of annual trainings expected during the calendar year.
The Clinical Supervisor will complete a monthly review of each staff members' monthly training hours in order to be in full compliance at the close of each calendar year. Certificates of training completion are to be provided to the Office Manager so that it may be accurately represented in ones' personnel file.
This effort will remain ongoing to ensure that this is not a repeat deficiency for Dunmore CTC.
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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.
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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 #6 was hired as a counselor on March 25, 2019 and was still acting in that position. Employee #4 was reported to have 37.5 hours per week devoted to their 38 clients on their caseload.
The FTE counselor's caseload calculation is as follows: 37.5/37.5 = 1 (FTE); 38/1 = 38, which equals to a client/counselor ratio of 38:1.
Employee #7 was hired as a counselor on June 17, 2021 and was still acting in that position. Employee #7 was reported to have 37.5 hours per week devoted to their 36 clients on their caseload.
Employee #9 was hired as a counselor on December 20, 2021 and was still acting in that position. Employee #9 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.
Employee #8 was hired as a counselor on December 20, 2021 and was still acting in that position. Employee #8 was reported to have 37.5 hours per week devoted to their 50 clients on their caseload.
The FTE counselor's caseload calculation is as follows: 37.5/37.5 = 1 (FTE); 50/1 = 50, which equals to a client/counselor ratio of 50:1.
This is a repeat citation from the November 16, 2021, November 13, 2020 and November 19, 2019 licensing inspection.
The findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
Plan of Correction:
The Clinic Director and Clinical Supervisor will hire an additional staff member, due to resignation, to correct the issue of ratio compliance. As of May 9th, 2022, a new clinical staff member will start, therefore reducing all overall caseload sizes, including those who meet the criteria of licensure alert 01-14, to that of which falls into compliance with the 35:1 requirement.
The Clinical Supervisor will monitor the weekly patient caseload ratios when assigning new admissions to counselors. The Clinic Director will monitor census weekly via EMR report to ensure compliance with this regulation and hire additional staff as needed to fall within the standards of this regulation.
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709.28 (c) 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.
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Observations
Based on an overhead conversation during the on-site inspection, the facility failed to keep confidential information private. A conversation occurred between staff and a patient regarding counseling and dose level in a common area with other patients present.
The finding was reviewed with facility staff during the licensing inspection.
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Plan of Correction
Dunmore CTC will ensure that all private, confidential patient conversations will not occur in common areas of the facility. The Clinic Director will present this information during the April 28th, 2022 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
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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 January 2-8, 2022, the patient census was 527. The facility was required to provide at least 52.7 physician hours. There were 51.5 physician hours documented.
During the week of January 9-15, 2022, the patient census was 528. The facility was required to provide at least 52.8 physician hours. There were 39.25 physician hours documented.
During the week of January 16-22, 2022, the patient census was 524. The facility was required to provide at least 52.4 physician hours. There were 46.25 physician hours documented.
During the week of January 23-29, 2022, the patient census was 521. The facility was required to provide at least 52.1 physician hours. There were 46.5 physician hours documented.
This is a repeat citation from the November 16, 2021, 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.
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Plan of Correction
Modifications have been made to existing program physician schedules to meet the necessary one hour per week onsite requirement for every ten patients. The physician schedules have and will continue to be closely monitored to ensure that there is adequate coverage for the current patient census.
As of 01/29/2022 and to date, physician hours have been met in compliance to this regulation.
Dunmore CTC will be hiring another physician to assist with those times where there is an anticipated lack of coverage to meet the necessary regulation ratio requirement. To date, this job is posted and we are actively seeking candidates. The Clinic Director will closely monitor the weekly physician coverage calendar to ensure that this regulation continues to be met.
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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.
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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.
This is a repeat citation from the November 15-16, 2021 annual licensing inspection.
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Plan of Correction
Dispensing nurses will ensure that every patient removes hats and sunglasses in order to verify identity prior to medication administration
The Charge Nurse presents this information during all monthly nursing meetings and monitors dispensing staff for continued compliance on a weekly basis. The CTC security guard will also remind all patients to remove hats and sunglasses when they are presenting for medication dispensing.
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715.14(b) LICENSURE Urine testing
(b) A narcotic treatment program shall develop and implement policies and procedures to ensure that urine collected from patients is unadulterated. These policies and procedures shall include random observation which shall be conducted professionally, ethically and in a manner which respects patient privacy.
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Observations
Based on direct observation of urinalysis collection procedures, the facility failed to follow their policy and procedures manual to ensure that urine collected from patients is unaltered. Policy 5.12.1 states the staff person will use appropriate temperature tools to ensure specimen is appropriate temperature. Temperature tools were not used during one patient's urine collection process.
The findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
Dispensing nursing staff will use appropriate temperature tools, in addition to the tactile method (hand or thermometer) to ensure that the specimen provided is of appropriate temperature. The Charge Nurse presents this information during all monthly nursing meetings and monitors 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.
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Observations
Based on direct observation of medication administration procedures, 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. This citation was corrected during the on-site licensing inspection.
The finding was reviewed with facility staff during the licensing inspection.
This is a repeat citation from the November 15-16, 2021 annual licensing inspection.
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Plan of Correction
On March 24th, 2022, Dunmore CTC modified the direction of the dosing line to ensure that only patients who were at the dosing windows were in the dispensing area. Dunmore CTC staff continues to monitor patients daily. during dosing times, to ensure privacy, confidentiality, and disruption free medication dosing. |
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
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 six out of six applicable records reviewed.
Patient #3 was admitted on January 5, 2022 and was still active at the time of the inspection. The patient received one hour of therapy with one no show in February 2022.
Patient #4 was admitted on December 29, 2021 and was still active at the time of the inspection. The patient received two hours of therapy in February 2022.
Patient #5 was admitted on November 18, 2021 and was still active at the time of the inspection. The patient received zero hours of therapy in January 2022. In February 2022, the patient received one hour of therapy with one no show.
Patient #6 was admitted on July 10, 2020 and was still active at the time of the inspection. The patient received two hours of therapy in January 2022. In February 2022, the patient received one hour of therapy with one no show.
Patient #7 was admitted on November 12, 2021 and was still active at the time of the inspection. The patient received two hours of therapy in February 2022.
Patient #10 was admitted on January 21, 2021 and was still active at the time of the inspection. The patient received 1.5 hours of therapy in January 2022. In February 2022, the patient had zero therapy hours with one no show.
These findings were reviewed with facility staff during the licensing inspection.
This is a repeat citation from the November 16, 2021, November 13, 2020, November 19, 2019, November 15, 2018, November 16, 2017 and October 13, 2016 annual licensing inspections.
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Plan of Correction
All Dunmore CTC patients are informed of their 2.5 hour counseling requirement per month, during their first two years of treatment. The Clinic Director and Clinical Supervisor are responsible for ensuring compliance with psychotherapy services for all patients within this narcotic treatment program. The Clinical Supervisor reviews this regulation with each clinical team member during weekly individual and group supervision. Each counselor will enter "no show counseling" notes into the EMR when a patient does not attend a scheduled individual or group session and progressive interventions will be taken with patients who are non-compliant with treatment hours. Continued issues of counseling non-compliance after multiple intervention attempts will be brought to the Multi-Disciplinary Team for consideration of an Administrative Discharge. |
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 complete an annual evaluation within the regulatory timeframe in one out of two applicable records reviewed.
Patient #10 was admitted on January 21, 2021 and was still active at the time of the inspection. An annual clinical evaluation was due on January 21, 2022; however, it was not completed until January 28, 2022.
The finding was reviewed with facility staff during the licensing inspection.
This is a repeat citation from the November 16, 2021 licensing inspection.
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Plan of Correction
Clinic Director and Clinical Supervisor reviewed 715.23(c)(1-7) and failure to be in compliance with this regulation. Each counselor will run their Services Due report daily in the EMR to ensure that all necessary services are completed in a timely manner, by the due date noted. The Clinic Director and Clinical Supervisor will internally audit all patients charts for compliance to this regulation. |
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.
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Observations
Based on the review of patient records, the facility failed to review and update treatment plans at least every sixty days in three out of seven records reviewed.
Patient # 6 was admitted on July 10, 2020 and was still active at the time of the inspection. A treatment plan update was completed on December 9, 2021 and the next update was due no later than February 9, 20202; however, it was not completed until March 2, 2022.
Patient #7 was admitted on November 12, 2021 and was still active at the time of the inspection. A treatment plan update was completed on January 12, 2022 and the next update was due no later than March 12, 2022; however, there was no documentation a treatment plan update being completed at the time of the inspection.
Patient #9 was admitted on February 17, 2021 and was still active at the time of the inspection. A treatment plan update was completed on November 30, 2021 and the next update was due no later than January 30, 2022; however, it was not completed until February 7, 2022.
This is a repeat citation from the November 16, 2021 annual licensing inspection.
These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
The Clinic Director and Clinical Supervisor reviewed regulation 709.92(b) and the failure to comply with this regulation. A detailed review of patient charts are conducted on a weekly basis 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.
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Observations
Based on the review of patient records, the facility failed to provide counseling services according to the patient's individual treatment plan in seven out of seven applicable records reviewed.
Patient #3 was admitted on January 5, 2022 and was still active at the time of the inspection. A treatment plan dated January 25, 2022 stated 2.5 hours of group and individual therapy per month. In February 2022, the client received one hour of individual therapy and had one no show.
Patient #4 was admitted on December 29, 2021 and was still active at the time of the inspection. A treatment plan dated January 8, 2022 stated 2.5 hours of therapy per month. In February 2022, the patient received two hours of therapy.
Patient #5 was admitted on November 18, 2021 and was still active at the time of the inspection. Treatment plans dated December 11, 2021 and February 7, 2022 stated 2.5 hours of therapy per month. In January 2022, the patient had zero documented time in therapy and in February 2022, the patient had one hour of therapy and one no show.
Patient #6 was admitted on July 10, 2020 and was still active at the time of the inspection. A treatment plan dated December 9, 2021 indicated 2.5 hours of therapy per month. In January 2022, the patient received two hours of therapy. In February 2022, the patient received one hour of therapy and had one no show.
Patient #7 was admitted on November 12, 2021 and was still active at the time of the inspection. A treatment plan dated December 15, 2021 indicated 2.5 hours of therapy per month. In February 2022, the patient had two hours of therapy.
Patient #9 was admitted on February 17, 2021 and was still active at the time of the inspection. A treatment plan dated November 30, 2021 indicated 1 hour per month of therapy. In January 2022, the patient had zero documented time in therapy.
Patient #10 was admitted on January 21, 2021 and was still active at the time of the inspection. A treatment plan dated December 1, 2021 indicated 2.5 hours of therapy per month. In January 2022, the patient received 1.5 hours of therapy. In February 2022, there were no sessions documented with one no show.
This is a repeat citation from the November 15-16, 2021 annual licensing inspection.
These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
All Dunmore CTC patients are informed of their 2.5 hour counseling requirement per month, during their first two years of treatment and 1 hour monthly for those meeting regulation 01-14. The Clinic Director and Clinical Supervisor are responsible for ensuring compliance with psychotherapy services for all patients within this narcotic treatment program, including that of goals, objectives, and interventions listed within the treatment plan. The Clinical Supervisor reviews this regulation with each clinical team member during weekly individual and group supervision. Each counselor will enter "no show counseling" notes into the EMR when a patient does not attend a scheduled individual or group session and progressive interventions will be taken with patients who are non-compliant with treatment hours. Continued issues of counseling non-compliance after multiple intervention attempts will be brought to the Multi-Disciplinary Team for consideration of an Administrative Discharge. |
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 the review of patient records, the facility failed to document follow-up information in two out of three applicable records reviewed.
Patient #11 was admitted on November 30, 2021 and discharged on March 2, 2022.
Patient #13 was admitted on October 10, 2019 and discharged on February 3, 2022.
These findings were reviewed with facility staff during the licensing inspection.
This is a repeat citation from the November 16, 2021 annual licensing inspection.
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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.
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Observations
Based on a review of Staffing Requirements Facility Summary Report, physician timesheets, and patient records, the facility failed to comply with three plans of correction approved by the Department. Plans of correction were submitted to the Department for inspections occurring on November 16, 2021, 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 16, 2021, 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 16, 2021, 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 inspection.
This is a repeat citation from the November 16, 2021 annual licensing inspection.
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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 will be closely monitored for compliance to each regulation noted to be deficient.
Physician Ratio: As of 01/29/2022 and to date, physician hours have been met in compliance to this regulation.
Dunmore CTC is actively pursuing Physician candidates to assist with those times where there is an anticipated lack of coverage to meet the necessary regulation ratio requirement. The Clinic Director will closely monitor the weekly physician coverage calendar to ensure that this regulation continues to be met.
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. Each counselor will enter "no show counseling" notes into the EMR when a patient does not attend a scheduled individual or group session. 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: As of May 9th, 2022, a new clinical staff member will start, therefore reducing all overall caseload sizes, including those who meet the criteria of licensure alert 01-14, to that of which falls into compliance with the 35:1 requirement.
The Clinical Supervisor will monitor the weekly patient caseload ratios when assigning new admissions to counselors. The Clinic Director will monitor census weekly to ensure compliance with this regulation and hire additional staff as needed to fall within the standards of this regulation.
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