INITIAL COMMENTS
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This report is a result of an on-site licensure renewal and methadone monitoring inspection conducted on November 7-8, 2023, 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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704.11(b)(1) LICENSURE Individual training plan.
704.11. Staff development program.
(b) Individual training plan.
(1) A written individual training plan for each employee, appropriate to that employee's skill level, shall be developed annually with input from both the employee and the supervisor.
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Observations
Based on one of seven personnel records reviewed, the facility failed to provide a written individual training plan to include documentation of input from both the employee and the supervisor in employee record # 1.
Employee # 1 was hired as the Project director on April 22, 2018 and was still in this position at the time of the inspection. A training plan was acknowledged by the employee on January 4, 2023, however, there was no documentation of input from both the employee and the supervisor.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
This citation has been presented to the Project Director via the RD. The Individual Training Plan will be revised as per 704.11(b)(1) to include documented input from the Employee as well as their Supervisor and will included the additional signature line for both parties to sign and date accordingly. Such will be put into effect for the new Annual Training Plan in 2024. Ongoing monitoring of annual training plans will be the responsibility of the Clinic Director and department supervisors to ensure that all staff have individual training plans that have input from both the employee and the supervisor. These will be reviewed on a quarterly basis as an agenda item during monthly leadership meetings. |
704.11(c)(1) LICENSURE Mandatory Communicable Disease Training
704.11. Staff development program.
(c) General training requirements.
(1) Staff persons and volunteers shall receive a minimum of 6 hours of HIV/AIDS and at least 4 hours of tuberculosis, sexually transmitted diseases and other health related topics training using a Department approved curriculum. Counselors and counselor assistants shall complete the training within the first year of employment. All other staff shall complete the training within the first 2 years of employment.
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Observations
Based on a review of personnel records and the facility's Staffing Requirement Facility Summary Report (SRFSR) form, the facility failed to ensure that employee's #10, 13, 14, and #15 received the minimum of 6 hours of HIV/AIDS training and at least 4 hours of TB/STD and other health related topics within the regulatory timeframe.
Employee #10 was hired as a counselor assistant on May 9, 2022 and promoted to counselor on May 9, 2023 and was still in this position at the time of the inspection. Employee # 10 was due to have the communicable disease trainings no later than May 9, 2023. There was no documentation in the personnel file of the completion of the TB/STD training as of the date of the inspection.
Employee #13 was hired as a support staff on June 5, 2017, and was still in this position at the time of the inspection. Employee # 13 was due to have the communicable disease trainings no later than June 5, 2019. There was no documentation in the personnel file of the completion of the HIV/AIDS training and the TB/STD training as of the date of the inspection.
Employee #14 was hired as a support staff on October 5, 2020, and was still in this position at the time of the inspection. Employee # 14 was due to have the communicable disease trainings no later than October 5, 2022. There was no documentation in the personnel file of the completion of the HIV/AIDS training and the TB/STD training as of the date of the inspection.
Employee #15 was hired as a support staff on April 1, 2017, and was still in this position at the time of the inspection. Employee # 15 was due to have the communicable disease trainings no later than April 1, 2019. There was no documentation in the personnel file of the TB/STD training as of the date of the inspection.
The findings were reviewed with facility staff during the licensing process.
This is a repeat citation from the October 27, 2022, annual licensing inspection.
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Plan of Correction
All newly hired staff will complete HIV/AIDS and TB/STD training within the first year of hire, in accordance with State regulation 704.11(c)(1). The Office Manager will monitor all training requirements on a quarterly basis and report updates to the CTC Director via a quarterly training report.
As of 11/08/2023, there was a waiting list for the required HIV/AIDS and TB/STD trainings in the Northeast Region. Those staff members that were identified as needing to attend this training have been registered to attend. It is expected that completion of these mandatory trainings will be by 03/31/2024.
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709.32 (b) LICENSURE Medication control
§ 709.32. Medication control.
(b) Verbal orders for medication can be given only by a physician or other medical professional authorized by State and Federal law to prescribe medication and verbal orders may be received only by another physician or medical professional authorized by State and Federal law to receive verbal orders. When a verbal or telephone order is given, it has to be authenticated in writing by a physician or other medical professional authorized by State and Federal law to prescribe medication. In detoxification levels of care, written authentication shall occur no later than 24 hours from the time the order was given. Otherwise, written authentication shall occur within 3 business days from the time the order was given.
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Observations
Based on two of five applicable client records reviewed, the facility failed to have verbal orders authenticated in writing by a physician or other medical professional authorized by State and Federal law to prescribe medication within 3 business days from the time the order was given in client records # 3, and 9.
Client # 3 was admitted on August 15, 2023, and was still active at the time of the inspection. A verbal order for medication was given by the physician on August 15, 2023, but was not authenticated in writing until August 21, 2023.
Client # 9 was admitted on December 14, 2022, and was discharged on June 12, 2023. A verbal order for medication was given by the physician on December 14, 2022, but was not authenticated in writing until December 20, 2022.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
All verbal orders for medication will be authenticated in writing within 3 business days in accordance with regulation 709.32(b). The Medical Director and Charge Nurse will review all medical documentation in the EMR for admission and interim charts via the quality record review process to ensure that verbal medication orders have been signed within the appropriate timeframe. |
715.14(a) LICENSURE Urine testing
(a) A narcotic treatment program shall complete an initial drug-screening urinalysis for each prospective patient and a random urinalysis at least monthly thereafter.
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Observations
Based on three of twelve patient records reviewed, the facility failed to provide documentation of a random drug-screening urinalysis for each patient at least monthly in patient records # 8, 10, and 12.
Patient # 8 was admitted on June 12, 2019, and was discharged on September 20, 2023. A random drug-screening urinalysis was not completed for the month of May, June, July, and August 2023.
Patient # 10 was admitted on November 4, 2014, and was discharged on May 2, 2023. A random drug-screening urinalysis was not completed for the month of April 2023.
Patient # 12 was admitted on May 24, 2021, and was discharged on February 1, 2023. A random drug-screening urinalysis was not completed for the months of December 2022 and January 2023.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Patients provide random monthly drug screening samples as per 715.14(a). Dunmore CTC uses an EMR to randomly generate a monthly urinalysis screening for all patients. The Charge Nurse reviews SMART records the final week of the month and place hard holds on all patients who require a DSA for the last day of month. In order to ensure that clients are receiving monthly random drug screen urinalysis the Charge Nurse will as part of chart reviews review all suspended status patients and ensure to document an Unable to Obtain (UTO) notification in the Pt. record to support compliance to 715.14(a) and noting suspended Pt.'s non-presence at the time, and inability to obtain a random urinalysis sample, within the Pt. record/EMR. |
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 six of seven applicable patient records reviewed, the narcotic treatment program failed to provide 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 in patient records # 1, 2, 3, 4, 9, and # 12.
Patient # 1 was admitted on December 12, 2022, and was still active at the time of the inspection. There were zero hours documented for January and February 2023; one hour in April and May 2023; zero hours in June 2023 and only 30 minutes documents in August 2023.
Patient # 2 was admitted on June 30, 2021, and was still active at the time of the inspection. There were zero hours documented in January and February 2023; one hour in March 2023, and only 30 minutes of individual psychotherapy and one hour of group psychotherapy in May 2023.
Patient # 3 was admitted on August 15, 2023, and was still active at the time of the inspection. There were zero hours documented in September 2023.
Patient # 4 was admitted on March 9, 2023, and was still active at the time of the inspection. There were only 30 minutes of individual psychotherapy documented in July 2023, only one hour of individual psychotherapy documented in September 2023, and zero hours of individual psychotherapy documented in October 2023.
Patient # 9 was admitted on December 14, 2022, and was discharged June 12, 2023. There were only 30 minutes documented in January 2023, one hour documented in February 2023 and zero hours documented in March and May 2023.
Patient # 12 was admitted on May 24, 2021, and was discharged February 1, 2023. There was one hour documented in December 2022, 30 minutes documented in January 2023, and zero minutes documented in February 2023.
These findings were reviewed with facility staff during the licensing process.
This is a repeat citation from the October 27, 2022 annual licensing inspection.
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Plan of Correction
The Clinic Director and Clinical Supervisor are responsible for ensuring compliance with psychotherapy services for all patients within this narcotic treatment program. At the time of admission, all Patients are educated as to the counseling requirements. 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 ensure progressive interventions are noted, and taken, with patients who are non-compliant with treatment hours; all of which will be documented within the Pt. Record/EMR. Continued issues of counseling non-compliance after multiple intervention attempts will be brought to the Multi-Disciplinary Team for consideration of next steps. The Clinical Supervisor and Counseling staff will monitor compliance of all patients counseling requirements during weekly individual supervision as well as internal quality record reviews. A 'General Contact Note' will be added at the end of each month providing an explanation as to Pt.'s barrier to maintain counseling compliance, should a Pt. remain non-compliant. |
715.19(2) LICENSURE Psychotherapy services
A narcotic treatment program shall provide individualized psychotherapy services and shall meet the following requirements:
(2) A narcotic treatment program shall provide each patient at least 1 hour per month of group or individual psychotherapy during the third and fourth year of treatment. Additional psychotherapy shall be provided as dictated by ongoing assessment of the patient.
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Observations
Based on one of two applicable patient records reviewed, the narcotic treatment program failed to provide an average of 1 hour of group or individual psychotherapy per month during the patient 's third and fourth years in patient record # 11.
Patient # 11 was admitted August 12, 2020, and was discharged May 30, 2023. There were no hours documented of group or individual psychotherapy the months of December 2022, January 2023, February 2023, and April 2023.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Dunmore CTC patients that have been active in treatment for over 2 years are informed of their 1 hour counseling requirement per month. 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 progressive therapeutic intervention. The Clinical Supervisor and Counseling staff will monitor compliance of all patients counseling requirements during weekly individual supervision as well as internal quality record reviews. The Clinical Supervisor and Counseling staff will monitor compliance of all patients counseling requirements during weekly individual supervision as well as internal quality record reviews. A 'General Contact Note' will be added at the end of each month providing an explanation as to Pt.'s barrier to maintain counseling compliance, should a Pt. remain non-compliant. |
715.19(3) LICENSURE Psychotherapy services
A narcotic treatment program shall provide individualized psychotherapy services and shall meet the following requirements:
(3) After 4 years of treatment, a narcotic treatment program shall provide each patient with at least 1 hour of group or individual psychotherapy every 2 months. Additional psychotherapy shall be provided as dictated by ongoing assessment of the patient.
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Observations
Based on one of four applicable patient records reviewed, the narcotic treatment program failed to provide an average of 1 hour of group or individual psychotherapy every 2 months month after four years in treatment.
Patient # 8 was admitted June 12, 2019, and was discharged September 20, 2023. There were zero hours documented of group or individual psychotherapy per month in March 2023, April 2023, May 2023 and June 2023.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Dunmore CTC patients that have been active in treatment for over 2 years are informed of their 1 hour counseling requirement per month. 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 progressive therapeutic intervention. The Clinical Supervisor and Counseling staff will monitor compliance of all patients counseling requirements during weekly individual supervision as well as internal quality record reviews. The Clinical Supervisor and Counseling staff will monitor compliance of all patients counseling requirements during weekly individual supervision as well as internal quality record reviews. A 'General Contact Note' will be added at the end of each month providing an explanation as to Pt.'s barrier to maintain counseling compliance, should a Pt. remain non-compliant. |
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 two of two applicable patient record reviewed, the facility failed to provide documentation of what transfer paperwork materials were sent to the receiving narcotic treatment program.
Patient # 11 was admitted August 12, 2020, and was discharged May 30, 2023. Patient # 11 was transferred to another facility and the transfer paperwork was not documented in the patient record.
Patient # 12 was admitted May 24, 2021, and was discharged February 1, 2023. Patient # 12 was transferred to another facility and the transfer paperwork was not documented in the patient record.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Clinical Supervisor will review policy 7.1.14 which addresses the procedures for Transfer Patients. To monitor compliance in this area the Clinical Supervisor will conduct a Quality Record review on all admission records that include patient transfers into this facility. During the quality record review of all transferring patients, the reviewer will ensure that there is documentation in the patient record of the information that was sent to the receiving narcotic treatment program. This information will be discussed during a scheduled all Staff Meeting in December 2023. |
709.93(a)(9) 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:
(9) Aftercare plan, if applicable.
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Observations
Based on four of four applicable client records reviewed, the facility failed to provide an aftercare plan in accordance with facility policy and procedure manual. The policy and procedure manual indicates a transition plan be developed approximately thirty days prior to transition/discharge and provided to the client at discharge.
Client # 8 was admitted on June 12, 2019, and was successfully discharged on September 20, 2023. There was no documentation of an aftercare plan in the client record.
Client # 10 was admitted on November 4, 2014, and was successfully discharged on May 2, 2023. There was no documentation of an aftercare plan in the client record.
Client # 11 was admitted on August 12, 2020, and was transferred on May 30, 2023. There was no documentation of an aftercare plan in the client record.
Client # 12 was admitted on May 24, 2021, and was transferred on March 1, 2023. There was no documentation of an aftercare plan in the client record.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Clinical Supervisor will continue to conduct daily, weekly, and monthly reviews of all services required utilizing the services due report in the EMR; including post treatment documentation such as, discharge summaries, after care planning, and follow-up contacts on both successful and unsuccessful discharges. Follow up contacts will be assigned by the Clinical Supervisor to either the primary counselor and/or the Case mgmt. or admissions team. All such contacts will be documented within the EMR to ensure regulatory compliance. Aftercare planning will begin during patient's acclimation and admission to treatment and care. A review and roll-out of this process will be revisited during the December All Staff meeting. Clinical Supervisor in concert with Clinic Director will be responsible for ensuring ongoing compliance and monitoring of this process on a monthly basis. |