INITIAL COMMENTS
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This report is a result of an on-site licensure renewal and methadone monitoring inspection conducted on October 19-20, 2023, by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, Duncansville 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 nine 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
Effective 1/31/2024 all personnel training plans be granted a space for input from both the trainee and their respective supervisor. A signature line will be included for both parties to sign. The director and quality team are responsible for monitoring this regulation.
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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 review of The Staffing Requirements Facility Summary Report, the full-time equivalent (FTE) maximum counselor caseload in the outpatient program exceeded 35 active clients for employee # 3.
Employee # 3 was hired as a Clinical Supervisor on November 9, 2020, and was still in this position at the time of the inspection. Employee #3 was reported to have 8 hours per week devoted to their 8 clients on their caseload.
The FTE counselor ' s caseload calculation is as follows: 8/40 = .2(FTE); 8/.2 = 40, which equals to a client/counselor ratio of 40:1.
The counselor Full Time Equivalent (FTE) is determined by dividing the total number of hours the counselor devotes to their clients by the facilities hours of operation 37.5. Then, in order to obtain the counselor ' s ratio, the total number of clients on the counselor ' s caseload is divided by the FTE.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
All counselor caseloads were reviewed and all the counselor caseloads for active patients do not exceed 35 active patients. The review was completed by the clinic director and clinical supervisor on 11/10/2023. The clinical supervisor is responsible for compliance with this standard and reviewed on an on-going basis. |
705.24 (4) LICENSURE Bathrooms.
705.24. Bathrooms.
The nonresidential facility shall:
(4) Provide privacy in toilets by doors.
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Observations
Based on a physical plant inspection, the facility failed to provide privacy in the female staff restroom as the door on the smaller stall did not close or lock.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Clinic director met with landlord/contractor on 11/8/2023 to review female restroom, the contractor will install a lock on the stall door, to replace the existing lock. The changes will be completed by 12/4/2023. The clinic director is responsible for compliance for this standard. |
705.24 (5) LICENSURE Bathrooms.
705.24. Bathrooms.
The nonresidential facility shall:
(5) Ventilate bathrooms by exhaust fan or window.
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Observations
Based on a physical plant inspection, the female client restroom did not provide ventilation by window or an operable exhaust fan.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Clinic Director met with landlord/contractor on 11/8/2023 to review the female restroom, the contractor will install a new exhaust fan in the women's rest room. The changes will be completed by 12/4/2023. The clinic director is responsible for compliance for this standard. |
705.24 (7) LICENSURE Bathrooms.
705.24. Bathrooms.
The nonresidential facility shall:
(7) Maintain each bathroom in a functional, clean and sanitary manner at all times.
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Observations
Based on a physical plant inspection, the facility failed to maintain the female staff restroom in a functional manner at all times as the lock on the larger stall door did not unlock without difficulty.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Clinic director met with landlord/contractor on 11/8/2023 to review female restroom, the contractor will install a lock on the stall door, to replace the existing lock. The changes will be completed by 12/4/2023. The clinic director is responsible for compliance for this standard. |
705.28 (d) (6) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(6) Conduct fire drills on different days of the week, at different times of the day and on different staffing shifts.
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Observations
Based on a review of the facility fire drill log for the months of January 2023 through September 2023, the facility failed to conduct fire drills at different times of the day or night and on different shifts in seven of the nine months reviewed. Fire drills times were between 11:30 am and 12:30 pm the months of January, March, April, May, June, July, and August 2023.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The clinic will conduct fire drills on different days of the week, at different times of the day and on different staffing shifts. This will be reviewed during the supervisor staff meeting on November 6, 2023. The clinic director is responsible for monitoring this standard on an on-going basis.
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709.28 (b) LICENSURE Confidentiality
§ 709.28. Confidentiality.
(b) The project shall secure hard copy client records within locked storage containers. Electronic records must be stored on secure, password protected data bases.
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Observations
Based on a physical plant inspection, the facility failed to ensure client identifying information was secured in locked storage containers. Counselor offices were left open and unlocked with no one in the offices.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Counselors were instructed on proper procedures for securing patient information in their offices including no patient information should be left on their desk it should be placed in their desk drawer when they are not using it. Counselor doors should be closed and locked when the counselor is not in their office. This training took place on November 20, 2023. The Clinical Supervisor is responsible for monitoring. |
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 five of twelve 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. The facility policy and procedure manual also indicates the physician will sign within three business days.
Client # 1 was admitted on October 4, 2023, and was still active at the time of the inspection. A verbal order for medication was given by the physician on October 4 and October 9, 2023, but there was no documentation the verbal order was authenticated in writing.
Client # 2 was admitted on November 21, 2022, and was still active at the time of the inspection. A verbal order for medication was given by the physician on February 13, 2023, but was not authenticated in writing until March 1, 2023. A verbal order for medication was given by the physician on February 13, 2023, but was not authenticated in writing until March 1, 2023. A verbal order for medication was given by the physician on April 28, 2023, and June 29, 2023, but was not authenticated in writing until July 7, 2023. A verbal order for medication was given by the physician on August 18 and September 5, 2023, but there was no documentation the verbal order was authenticated in writing.
Client # 3 was admitted on June 6, 2023, and was still active at the time of the inspection. A verbal order for medication was given by the physician on June 7, 2023, but was not authenticated in writing until June 13, 2023.
Client # 4 was admitted on February 3, 2023, and was still active at the time of the inspection. A verbal order for medication was given by the physician on May 30, 2023, but was not authenticated in writing until July 7, 2023.
Client # 6 was admitted on September 25, 2017, and was still active at the time of the inspection. A verbal order for medication was given by the physician on March 9, 2023, but was not authenticated in writing until April 11, 2023.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The PA-C will request a verbal order from the physician for the client. The verbal order will be authenticated in writing by the physician or other medical professional authorized by State and Federal law to prescribe medication within three (3) business days from the time the order was given. This will be addressed with the physician and PA-C in the medical staff meeting on 11/15/2023. The clinic director is responsible for compliance with this standard. Implementation will begin immediately and reviewed on an on-going basis. |
715.6(e) LICENSURE Physician Staffing
(e) A physician assistant or certified registered nurse practitioner may perform functions of a narcotic treatment physician in a narcotic treatment program if authorized by Federal, State and local laws and regulations, and if these functions are delegated to the physician assistant or certified registered nurse practitioner by the medical director, and records are properly countersigned by the medical director or a narcotic treatment physician. One-third of all required narcotic treatment physician time shall be provided by a narcotic treatment physician. Time provided by a physician assistant or certified registered nurse practitioner may not exceed two-thirds of the required narcotic treatment physician time.
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Observations
Based on the facility ' s weekly census and physicians ' hours, the facility failed to provide documentation of the narcotic treatment physician providing at least one-third of the required narcotic treatment physician time.
The census for the week of May 28-June 3, 2023, was 367. The required narcotic treatment physician time was 36.7. One-third of the required narcotic treatment physician time to be provided by the narcotic treatment physician was 12.22; however, there were only 11 hours documented.
The census for the week of June 4-10, 2023, was 370. The required narcotic treatment physician time was 37.0. One-third of the required narcotic treatment physician time to be provided by the narcotic treatment physician was 12.33; however, there were only 11 hours documented.
The census for the week of June 11-17, 2023, was 369. The required narcotic treatment physician time was 36.9. One-third of the required narcotic treatment physician time to be provided by the narcotic treatment physician was 12.3. There were only 7.5 hours documented.
The census for week June 18-24, 2023, was 371. The required narcotic treatment physician time was 37.1. One-third of the required narcotic treatment physician time to be provided by the narcotic treatment physician was 12.36. There were only 7.5 hours documented.
The census for week June 25-July 1, 2023, was 377. The required narcotic treatment physician time is 37.7. One-third of the required narcotic treatment physician time to be provided by the narcotic treatment physician was 12.56. There were only 11 hours documented.
The census for week July 9-15, 2023, was 379. The required narcotic treatment physician time is 37.9. One-third of the required narcotic treatment physician time to be provided by the narcotic treatment physician was 12.63. There were only 11 hours documented.
The census for week July 16-22, 2023, was 381. The required narcotic treatment physician time is 38.1. One-third of the required narcotic treatment physician time to be provided by the narcotic treatment physician was 12.7. There were only 11 hours documented.
The census for week July 23-29, 2023, was 366. The required narcotic treatment physician time is 36.6. One-third of the required narcotic treatment physician time to be provided by the narcotic treatment physician was 12.2. There were only 11 hours documented.
The census for week July 30-August 5, 2023, was 365. The required narcotic treatment physician time is 36.5. One-third of the required narcotic treatment physician time to be provided by the narcotic treatment physician was 12.16. There were only 11 hours documented.
The census for week August 6-12, 2023, was 368. The required narcotic treatment physician time is 36.8. One-third of the required narcotic treatment physician time to be provided by the narcotic treatment physician was 12.26. There were only 11 hours documented.
The census for week August 13-19, 2023, was 370. The required narcotic treatment physician time is 37.0. One-third of the required narcotic treatment physician time to be provided by the narcotic treatment physician was 12.33. There were only 11 hours documented.
The census for week August 20-26, 2023, was 373. The required narcotic treatment physician time is 37.3. One-third of the required narcotic treatment physician time in 12.43. There were only 11 hours documented.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The physician will provide the required on-site hours. The physician is responsible for providing one-third of all required narcotic treatment time. Time provided by the PA-C may not exceed two-thirds of the required narcotic treatment physician time. This will be reviewed at the staff meeting November 15, 2023. The clinic director is responsible for monitoring and approving the hours spent on-site by the physician and PA-C. This will be implemented immediately and monitored on an on-going basis. |
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.
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Observations
Based on one of twelve patient records reviewed, the facility failed to document an emergency contact prior to the administration of an agent.
Patient # 7 was admitted on July 15, 2021, and was discharged on July 26, 2023. There was no documentation of an emergency contact in the patient record.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
During intake the counselor will verify the individual's identity, including name, address, date of birth, emergency contact and other identifying data. This will be addressed at the counselor meeting on November 20, 2023. The clinical supervisor is responsible for compliance and it will be reviewed during the monthly record review. |
715.15(b) LICENSURE Medication dosage
(b) The narcotic treatment physician shall determine the proper dosage level for a patient, except as otherwise provided in this section. If the narcotic treatment physician determining the initial dose is not the narcotic treatment physician who conducted the patient examination, the narcotic treatment physician shall consult with the narcotic treatment physician who performed the examination before determining the patient 's initial dose and schedule.
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Observations
Based on three of four applicable patients reviewed, the facility failed to have a narcotic treatment physician determine the proper dosage level prior to the administration of medication.
Patient # 1 was admitted on October 4, 2023, and was still active at the time of the inspection. The initial dose was determined by the physician assistant during the physical exam on October 4, 2023.
Patient # 2 was admitted on November 21, 2022, and was still active at the time of the inspection. The initial dose was determined by the physician assistant during the physical exam on November 21, 2022.
Patient # 3 was admitted on June 6, 2023, and was still active at the time of the inspection. The initial dose was determined by the physician assistant during the physical exam on June 6, 2023.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The narcotic treatment physician shall determine the proper dosage level for a patient. The narcotic treatment physician shall consult with the narcotic treatment provider who performed the examination before determining the patient's initial dose and schedule. This will be addressed with the physician and PA-C in the medical staff meeting on 11/15/2023. The clinic director is responsible for compliance with this standard. Implementation will begin immediately and reviewed on an on-going basis. |
715.16(a)(3) LICENSURE Take-home privileges
(a) A narcotic treatment program shall determine whether a patient may be provided take-home medications.
(3) The narcotic treatment physician shall document in the patient record the rationale for permitting take-home medication.
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Observations
Based on five of five applicable patient records reviewed, the facility failed to document in the patient record the rationale for permitting take-home medication.
Patient # 1 was admitted on October 4, 2023, and was still active at the time of the inspection. Patient # 1 was permitted 2 day take-homes, however, the documentation required by the narcotic physician was not provided in the patient record.
Patient # 3 was admitted on June 6, 2023, and was still active at the time of the inspection. Patient # 3 was permitted 2 day take-homes, however, the documentation required by the narcotic physician was not provided in the patient record.
Patient # 4 was admitted on February 3, 2023, and was still active at the time of the inspection. Patient # 4 was permitted 2 day take-homes, however, the documentation required by the narcotic physician was not provided in the patient record.
Patient # 7 was admitted on July 15, 2023, and was discharged July 26, 2023. Patient # 7 was permitted 2 day take-homes, however, the documentation required by the narcotic physician was not provided in the patient record.
Patient # 11 was admitted on December 27, 2022, and was discharged March 13, 2023. Patient # 11 was permitted 2 day take-homes, however, the documentation required by the narcotic physician was not provided in the patient record.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The narcotic treatment physician will document in the patient record the rationale for permitting take-home medication for clients. This will be addressed with the physician and PA-C in the medical staff meeting on 11/15/2023. The clinic director is responsible for compliance with this standard. Implementation will begin immediately and reviewed on an on-going 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.
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Observations
Based on four of four 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.
Patient # 2 was admitted on November 21, 2022, and was still active at the time of the inspection. There was not at least 2.5 hours of psychotherapy documented the months of December 2022, January, February, and March, April, May, June, July, and August 2023.
Patient # 3 was admitted on June 6, 2023, and was still active at the time of the inspection. There was not at least 2.5 hours of psychotherapy documented the months of July and September 2023.
Patient # 4 was admitted on February 3, 2023, and was still active at the time of the inspection. There was not at least 2.5 hours of psychotherapy documented the months of June, July, August, and September 2023.
Patient # 7 was admitted on July 15, 2021, and was discharged July 26, 2023. There was not at least 2.5 hours of psychotherapy documented the months of March, April, and June 2023.
The findings were reviewed with facility staff during the licensing process.
This is a repeat citation from the November 3, 2022 and December 3, 2021 annual licensing inspections.
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Plan of Correction
All patients for the first two (2) years will do the required 2.5 hours of counseling, one (1) hour of which will be individual psychotherapy. Counselors will make every effort to have the counseling completed each month. If the patient does not show a no-show note will be placed in the EMR to show attempts to get the required hours. This will be addressed at the November 20, 2023 counselor staff meeting. The clinical supervisor is responsible for compliance and it will be reviewed during the monthly record review. |
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 two of three applicable patient record reviewed, the narcotic treatment program failed to provide an average of 1 hour per month of group or individual psychotherapy during the third and fourth year of treatment in patient record # 8 and 9.
Patient # 8 was admitted on March 26, 2020, and was discharged August 14, 2023. There was not at least 1 hour of psychotherapy documented the months of April, May, June, and July 2023.
Patient # 9 was admitted on May 21, 2019, and was discharged March 6, 2023. There was not at least 1 hour of psychotherapy documented the months of December 2022 and January, February 2023.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
All patients during the third and fourth year will do the required one (1) hour per month of group or individual psychotherapy. Counselors will make every effort to have the counseling completed each month. If the patient does not show a no-show note will be placed in the EMR to show attempts to get the required hours. This will be addressed at the November 20, 2023, counselor staff meeting. The clinical supervisor is responsible for compliance and it will be reviewed during the monthly record review.
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715.20(3) LICENSURE Patient transfers
A narcotic treatment program shall develop written transfer policies and procedures which shall require that the narcotic treatment program transfer a patient to another narcotic treatment program for continued maintenance, detoxification or another treatment activity within 7 days of the request of the patient.
(3) The transferring narcotic treatment program shall document what materials were sent to the receiving narcotic treatment program.
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Observations
Based on two of two applicable patient records reviewed, the facility failed to provide documentation of what materials were sent to the receiving narcotic treatment program in patient records # 8 and 10.
Patient # 8 was admitted on March 26, 2020, and discharged August 14, 2023. There was no documentation of the transfer paperwork in the patient record.
Patient # 10 was admitted on March 7, 2017, and discharged April 26, 2023. There was no documentation of the transfer paperwork in the patient record.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Patients requesting a transfer to another narcotic treatment program for continued maintenance, detoxification or another treatment activity within seven (7) days of the request of the patient. The counselors will document what materials were sent to the receiving narcotic treatment program in the EMR, and a copy of the documents will be kept in the patient records. This will be addressed at the November 20, 2023, counselor staff meeting. The clinical supervisor is responsible for compliance, and it will be reviewed during the monthly record review. |
715.23(b)(5) LICENSURE Patient records
(b) Each patient file shall include the following information:
(5) The results of all annual physical examinations given by the narcotic treatment program which includes an annual reevaluation by the narcotic treatment physician.
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Observations
Based on one of five applicable patient records reviewed, the facility failed to provide documentation of an annual physical examination given by the narcotic treatment program which includes an annual reevaluation by the narcotic treatment physician.
Patient # 7 was admitted on July 15, 2021, and was discharged July 26, 2023. An annual physical exam was due no later than July 15, 2023. There was no annual physical exam documented in the patient record.
These findings were reviewed with facility staff during the licensing process.
This is a repeat citation from the November 3, 2022 and December 3, 2021 annual licensing inspections.
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Plan of Correction
The physician or physician assistant is responsible for completing the patient's annual physical. The physician or physician assistant will complete the annual physical exam including the full documentation of a re-evaluation on the patient on a timely basis. The physician will sign ? off on the medical record within the required timeframe. This will be addressed with the physician and physician assistant in the medical staff meeting on November 15, 2023. The clinic director is responsible for compliance with the standard. Implementation will begin immediately and reviewed on an on-going basis. |
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 two of five applicable patient records reviewed, the facility failed to document an annual evaluation of each patient 's status completed by the patient 's counselor and reviewed, dated, and signed by the medical director in patient records # 6 and 7.
Patient # 6 was admitted on September 25, 2017, and was still active at the time of the inspection. An annual evaluation was completed on September 21, 2023. The annual evaluation was not reviewed, dated, and signed by the medical director.
Patient # 7 was admitted on July 15, 2021, and was discharged July 26, 2023. An annual evaluation was due no later than July 15, 2023. There was no annual evaluation documented in the patient record.
These findings were reviewed with facility staff during the licensing process.
This is a repeat citation from the November 3, 2022, December 3, 2021, December 11, 2020, and February 6, 2020 annual licensing inspections.
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Plan of Correction
DHBC counselors will perform an annual evaluation of each patient the review will be documented in the patient's medical record. The DHBC counselor will review the clients due for their annual evaluation at the beginning of each month. The counselor will complete the annual evaluation prior to the client's anniversary date. DHBC counselors will report weekly to the clinical supervisor the status of the annual evaluations due. The medical director will review date and sign the evaluation. The issue will be addressed at the staff meeting on November 20, 2023. This will be monitored by the clinical supervisor during the monthly record review. |
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 one of three 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 # 12 was admitted on September 23, 2016, and discharged on May 8, 2023. There was no transition plan documented in the client record.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Counselors will complete a transition plan approximately thirty (30) days prior to transition/discharge and provide the transition plan to the client at discharge. This will be addressed at the counselor meeting on November 20, 2023. The clinical supervisor is responsible for compliance, and it will be reviewed during the monthly record review.
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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 patient records, the facility failed to comply with plans of correction that were approved by the Department.
Plans of correction for psychotherapy hours and annual physical examinations were submitted and approved by the Department for the November 3, 2022, and December 3, 2021, annual licensing inspections. Psychotherapy hours and annual physical examinations was again found to be a deficiency in the October 19-20, 2023, annual licensing inspection.
Plans of correction for annual clinical evaluations were submitted and approved by the Department for the November 3, 2022, December 3, 2021, February 6, 2020, and December 11, 2020, annual licensing inspections. Annual clinical evaluations were again found to be a deficiency in the October 19-20, 2023, annual licensing inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
A Plan of correction for deficiencies approved by the department will be monitored by the clinic director to ensure they are being followed and implemented.
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