INITIAL COMMENTS
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This report is a result of an on-site licensure renewal and methadone and buprenorphine monitoring inspection conducted on July 17-18, 2024 by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, WPIC Narcotic Addiction Treatment Program 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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704.6(a) LICENSURE Clinical Supervisor Qualifications
704.6. Qualifications for the position of clinical supervisor.
(a) A drug and alcohol treatment project shall have a full-time clinical supervisor for every eight full-time counselors or counselor assistants, or both.
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Observations
Based on a review of the facility ' s Staffing Requirement Facility Summary Report (SRFSR), the project failed to have a full-time clinical supervisor for every eight full-time counselors and/or counselor assistants.
The full-time equivalent (FTE) calculation for the number of clinical supervisors needed is as follows:
The total # of hours project-wide devoted to D&A clients divided by the project ' s standard workweek.
The project calculation was: 1198 hours / 40 hours = 29.95 FTE.
The project must have a full-time clinical supervisor on staff for every 8 FTE clinical staff. Based on the FTE calculation, the project is required to have three full-time clinical supervisors. Based on the SRFSR, the project currently employs two full-time clinical supervisors.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Program supervisor was able to promote clinical lead into a supervisor role, effective 7/19/2024. Program director will continue to monitor staffing ratios on a monthly basis, effective 7/19/2024. |
705.28 (c) (3) LICENSURE Fire safety.
705.28. Fire safety.
(c) Fire extinguishers. The nonresidential facility shall:
(3) Ensure fire extinguishers are inspected and approved annually by the local fire department or fire extinguisher company. The date of the inspection shall be indicated on the extinguisher or inspection tag. If a fire extinguisher is found to be inoperable, it shall be replaced or repaired within 48 hours of the time it was found to be inoperable.
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Observations
Based on a physical plant inspection, the facility failed to ensure fire extinguishers were inspected and approved annually by the local fire department or fire extinguisher company. The facility ' s fire extinguishers were last inspected in June of 2023.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
On 7/25/24, Program director contacted maintenance supervisor to ensure that the fire extinguishers are inspected and approved annually. The inspection was inadvertently missed due to changes in landlord. The fire extinguishers will be inspected by 8/31/2024. |
705.28 (d) (4) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(4) Maintain a written fire drill record including the date, time, the amount of time it took for evacuation, the exit route used, the number of persons in the facility at the time of the drill, problems encountered and whether the fire alarm or smoke detector was operative.
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Observations
Based on a review of the facility ' s fire drill logs for the months of July 2023 through June 2024, the facility failed to maintain a written fire drill record that included the number of persons in the facility at the time of the drill for the April 2024, May 2024, June 2024, and July 2024 fire drills.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
On 7/19/2024, Program Director educated safety officer regarding the requirement to document the number of person's int he facility at the time of the drill. Program director provided safety officer with the correct form on 7/19/2024. |
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 the review of the facility's fire drill log for the months of July 2023 through July 2024, the facility failed to conduct fire drills on different days of the week, at different times of the day and night and on different staffing shifts. Ten out of thirteen fire drills were conducted between 11:57am and 12:30pm.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
On 7/19/24, Program Director educated Safety Officer on the requirements to conduct fire drills on different days of the week, different times of the day, and different staff shifts. Program director will monitor the monthly fire drill logs, effective 8/1/2024 |
715.9(a)(1) 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:
(1) Verify that the individual has reached 18 years of age.
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Observations
Based on applicable patient records reviewed, the facility failed to verify that an individual had reached 18 years of age prior to the administration of an agent in one of seven records.
Patient #3 was admitted on March 28, 2024 and still active at the time of the inspection. There was no verification that the patient had reached 18 years of age at the time of the inspection.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
During staff meeting, Program Director educated staff on the requirement that all individuals receiving treatment must have some sort of ID verifying age, 18 or over, effective 7/31/2024.
Patient #3 is currently working with UPMC's Center of Excellence (COE) to obtain an ID. NATP will collaborate with the COE in obtaining a copy of patient #3 ID, 9/30/2024. UPMC's Electronic Medical Record states that patient DOB is 1/13/1990.
Program director will educate staff that during intake all new patients are required to have an ID to verify age. If individual does not have a valid form of ID to verify age, NATP will not conduct intake, effective 8/7/2024 |
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 applicable patient records reviewed, the facility failed to verify an individual ' s identity, including name, address, date of birth, emergency contact, and other identifying data prior to the administration of an agent in one of seven records.
Patient #3 was admitted on March 28, 2024 and still active at the time of the inspection. There was no verification of the patient ' s date of birth in the patient record at the time of the inspection.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
Patient #3 is currently working with UPMC's Center of Excellence (COE) to obtain an ID. NATP director will collaborate with the COE in obtaining a copy of patient #3 ID, 9/30/2024. UPMC's Electronic Medical Record states that patient DOB is 1/13/1990.
Program director will educate staff by 8/7/2024 that during intake all new patients are required to verify an individual's identify, including name, DOB, and emergency contact. If patient is unable to provide verification, NATP will not conduct intake, effective 8/7/2024 |
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 applicable patient records reviewed, the facility failed to provide each patient with an average of 2.5 hours of psychotherapy per month during the patient ' s first 2 years of treatment, 1 hour of which shall be individual psychotherapy, in one of one records.
Patient #3 was admitted on March 28, 2024 and still active at the time of the inspection. The patient ' s record indicates that there were zero hours of therapy in June 2024.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
Program Director educated clinical staff during a staff meeting on 7/25/24 on the requirement to provide patients with an average of 2.5 hours of therapy per month during the first 2 years of treatment, 1 hour of which shall be individual therapy. Program director will conduct monthly chart audits to ensure documentation of treatment being offered and if the patient declined or participated in therapy, effective 8/1/2024. |
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 applicable patient records reviewed, the facility failed to provide each patient with at least 1 hour per month of group or individual psychotherapy during the patient ' s third and fourth years of treatment in two of two records.
Patient #4 was readmitted on December 4, 2023 and still active at the time of the inspection. The patient ' s record indicates that there were zero hours of therapy in February 2024, five minutes of therapy in March 2024, zero hours of therapy in April 2024, ten minutes of therapy in May 2024, and zero hours of therapy in June 2024.
Patient #6 was admitted on August 10, 2021 and discharged on May 9, 2024. The patient ' s record indicates that there were zero hours of therapy in November 2023, zero hours of therapy in December 2023, zero hours of therapy in February 2024, and forty minutes of therapy in March 2024.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
Program Director educated clinical staff during a staff meeting on 7/25/24 on the requirement to provide patients with at least 1 hour per month of group or individual therapy during the patient's 3rd and 4th years of treatment. Program director will conduct monthly chart audits to ensure documentation of treatment being offered and if the patient declined or participated in therapy, effective 8/1/2024.
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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 applicable patient records reviewed, the facility failed to provide each patient with at least 1 hour per month of group or individual psychotherapy every two months after the patient ' s fourth year of treatment in one of one records.
Patient #7 was transferred to the facility on January 10, 2023 and discharged on May 31, 2024. The patient ' s record indicates that there were zero hours of therapy from December 2023 through March 2024.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
Program Director educated clinical staff during a staff meeting on 7/25/24 on the requirement to provide patients with at least 1 hour per month of group or individual psychotherapy every 2 months after the patient's 4th year of treatment.
Program director will conduct monthly chart audits to ensure documentation of treatment being offered and if the patient declined or participated in therapy, effective 8/1/2024.
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715.28(c)(1-5) LICENSURE Unusual incidents
(c) A narcotic treatment program shall file a written Unusual Incident Report with the Department within 48 hours following an unusual incident including the following:
(1) Complaints of patient abuse (physical, verbal, sexual and emotional).
(2) Death or serious injury due to trauma, suicide, medication error or unusual circumstances.
(3) Significant disruption of services due to a disaster such as a fire, storm, flood or other occurrence.
(4) Incidents with potential for negative community reaction or which the facility director believes may lead to community concern.
(5) Drug related hospitalization of a patient.
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Observations
Based on a review of unusual incident reports provided by the facility, the facility failed to file a written Unusual Incident Report with the Department within 48 hours following an unusual incident.
The facility completed a report about death or serious injury due to trauma, suicide, medication error, or unusual circumstances on November 14, 2023. The Department did not receive a copy of that report.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
Program Director provided education to staff on 7/25/24 regarding the requirement to submit unusual incident reports to DDAP within 24 hours following an incident. Program director and supervisor received access to the DDAP incident report portal on 7/29/24. Program director will review unusual incident reports to ensure they have been submitted in DDAP portal, effective 8/5/2024. |
711.93(a)(6) LICENSURE Aftercare Plans
711.93. Client records.
(a) Record requirements. There shall be a complete client record on an individual which includes information relative to the client's involvement with the project. In addition to the requirements in 115.32 (relating to contents), the client record shall include the following:
(6) Aftercare plans, if applicable.
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Observations
Based on applicable client records reviewed, the facility failed to complete an aftercare plan in accordance with the facility policy and procedure manual in one of two client records.
The facility policy and procedure manual indicated an aftercare plan will be completed with the client for all planned discharges.
Client #7 was admitted on January 10, 2023 and successfully completed the program on May 31, 2024. An aftercare plan was not completed at the time of the inspection.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
On 7/25/24, Program Director educated staff regarding the requirement to complete an aftercare plan for patients with a successful completion. Program director and supervisor are reviewing all discharges to ensure an aftercare plan is completed, as necessary, effective 7/25/24. |