INITIAL COMMENTS
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This report is a result of an on-site licensure renewal and buprenorphine monitoring inspection conducted on December 20, 2023 through December 21, 2023 by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, Caron Treatment Centers 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, it was determined that one employee hired as a counselor did not meet the qualification requirements for the position.
Employee # 3 was promoted to the position of counselor on August 21, 2023 and was current in that position at the time of the inspection. At the time of promotion, the employee had a qualifying bachelor's degree but not the required one year of clinical experience for a bachelor's level counselor.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Employee #3 was awarded a Master's Degree on 12/16/23 and now meets the qualifications for the counselor position. Human Resources staff were reeducated on the qualifications for the position of counselor per the regulations, including education and experience requirements, by the Compliance and Enterprise Risk Manager on 1/3/24. Human Resources staff will ensure that prospective employees have the required experience as outlined in the regulation and will seek the Compliance Department's additional review when needed. Human Resources will not hire nor promote candidates until a copy of the degree or transcript is received and reviewed. Personnel file audits will be completed on all new hires and promotions on a quarterly basis for the next 6 months by the Compliance Department. |
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, the facility failed to ensure that one employee received the minimum of 4 hours of TB/STD training within the regulatory timeframe.
Employee # 5 was hired as a counselor on August 1, 2022 and was due to have the TB/STD training no later than August 1, 2023. However, the TB/STD training was not documented as complete until September 22, 2023.
This is a repeat citation from the January 20, 2023 annual licensing inspection.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
New employees will be scheduled for the 4-hour TB/STD training as part of their initial individual training plan. The Training & Education Department has increased the amount of scheduled TB/STD trainings throughout the year, so that there are more offerings available that can fit employees' schedules, to better ensure that the TB/STD training is completed by the required regulatory timeframes.
Additionally, starting by February 15, 2024, an automated Training Compliance Report will be generated and sent to team supervisors. This report will inform the supervisors if they have employees who have not yet completed their mandatory trainings, including TB/STD.
The Supervisor of Training and Education will also monitor the completion of the TB/STD training for new employees on a monthly basis to ensure staff receive the required training within the required regulatory timeframes. |
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 25 clock hours of annual training required for counselors in one of three applicable records reviewed.
Employee # 11 has been employed as a counselor since March 14, 2016. The facility's training year that was reviewed was from July 1, 2022 through June 30, 2023. Employee # 11's personnel record only documented 16.75 hours of training for the period reviewed.
This is a repeat citation from the January 20, 2023 annual licensing inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Clinical leaders were re-educated on the importance of ensuring their staff complete the required number of training hours each training year on by the Corporate Director of Education, Development and Clinical Practice on 1/18/24. Clinical leaders will also re-educate their teams during supervision. The training department has enhanced its monitoring system for the completion of annual training hours in the following ways: the Learning Management System will send an automated report to each employee on a weekly basis, which will inform them of any trainings that are coming due and any that are overdue each month. The Learning Management System also sends a monthly automated report to each employee's supervisor that shows the percentage of training courses completed, as well as the current number of training hours for each employee. The Corporate Director of Education, Development and Clinical Practice will run a quarterly report which contains the status of the completion of trainings for each employee and will communicate the results of this report to department leaders. |
705.10 (c) (4) LICENSURE Fire safety.
705.10. Fire safety.
(c) Fire extinguisher. The residential facility shall:
(4) Instruct all staff in the use of the fire extinguishers upon staff employment. This instruction shall be documented by the facility.
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Observations
Based on a review of eleven personnel records, the facility failed to ensure that each staff was instructed in the use of the fire extinguishers upon employment in one of one applicable record reviewed.
Employee # 1 was hired as the Project Director on September 29, 2023 and was due to be trained in the use of fire extinguishers upon hire; however, fire safety training was not documented as completed in the personnel record until October 12, 2023.
This is a repeat citation from the January 20, 2023 annual licensing inspection.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Currently, all new employees receive training on fire safety emergency procedures, as well as fire extinguisher training with their supervisor on the first day of employment. The new employee signs an attestation indicating they received the training, which is filed in their employee file.
In order to improve upon this process a plan is in place where the Human Resources Business Partners will electronically send new employees training on fire safety emergency procedures, as well as training and instruction on how to use
fire extinguishers prior to their first day of employment. Employees must sign an attestation indicating that they received this training and must return this attestation to the training department by their first day of employment. This attestation will be kept in their training file. The Supervisor of Training and Education will audit new employee files on a monthly basis to ensure compliance with this regulation. The new process is expected to be implemented by 3/1/24.
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705.10 (d) (1) LICENSURE Fire safety.
705.10. Fire safety.
(d) Fire drills. The residential facility shall:
(1) Conduct unannounced fire drills at least once a month.
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Observations
Based on a review of fire drill logs from February 2023 through October 2023, the facility failed to conduct fire drills each month. Fire drills were not conducted in Building 700 in October, Building 1000 in February, Building 3100 between February and July, and Building 3200 between February and May.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The buildings referenced in the citation were vacant during the months referenced. The fire drill schedule has been revised to include vacant buildings, to ensure that at least one drill per month is completed on any building that is vacant. The Director of Facilities will monitor the completion of the fire drill son a monthly basis to ensure fire drills are completed as required. |
705.10 (d) (3) LICENSURE Fire safety.
705.10. Fire safety.
(d) Fire drills. The residential facility shall:
(3) Ensure that all personnel on all shifts are trained to perform assigned tasks during emergencies.
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Observations
Based on a review of eleven personnel records, the facility failed to ensure that one of one applicable staff member was trained to perform assigned tasks during emergencies prior to being on shift.
Employee # 1 was hired as the Project Director on September 29, 2023 and is current in that position. Employee # 1 began working shifts on September 29, 2023, but was not trained to perform assigned tasks during emergencies until October 12, 2023.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Currently, all new employees receive training on fire safety emergency procedures, as well as fire extinguisher training with their supervisor on the first day of employment. The new employee signs an attestation indicating they received the training, which is filed in their employee file.
In order to improve upon this process a plan is in place where the Human Resources Business Partners will electronically send new employees training on fire safety emergency procedures, as well as training and instruction on how to use
fire extinguishers prior to their first day of employment. Employees must sign an attestation indicating that they received this training and must return this attestation to the training department by their first day of employment. This attestation will be kept in their training file. The Supervisor of Training and Education will audit new employee files on a monthly basis to ensure compliance with this regulation. The new process is expected to be implemented by 3/1/24.
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709.33 (a) LICENSURE Notification of termination.
§ 709.33. Notification of termination.
(a) Project staff shall notify the client, in writing, of a decision to involuntarily terminate the client ' s treatment at the project. The notice shall include the reason for termination.
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Observations
Based on a review of client records, the facility failed to document that the client was notified, in writing, of the facility's decision to involuntarily terminate the client's treatment at the project in two of two applicable records reviewed.
Client # 1 was admitted to the Detoxification level of care on December 2, 2023 and was involuntarily discharged on December 8, 2023. There was no documentation that the client was notified, in writing, of the facility's decision to involuntarily terminate.
Client # 20 was admitted to the Partial Hospitalization level of care on November 27, 2023 and was involuntarily discharged on December 4, 2023. There was no documentation that the client was notified, in writing, of the facility's decision to involuntarily terminate.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The current process for demonstrating that the patient was notified in writing of a termination from treatment, is that the patient signs the Notification of Termination Form. As an added measure to demonstrate that the patient was notified of the termination in writing, the Notification of Termination template will be modified to include a drop down box, which allow staff to designate whether or not the patient accepted or declined a copy of the form. The Executive Director and Clinical Directors will reeducate staff on the process for Notification of Termination during Clinical Supervision by 2/2/24. The Quality Analyst will conduct quarterly chart reviews to review compliance and will report progress to leadership. |
709.82(a) LICENSURE Treatment and rehabilitation services
709.82. Treatment and rehabilitation services.
(a) An individual treatment and rehabilitation plan shall be developed with a client. This plan shall include, but not be limited to, written documentation of:
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Observations
Based on a review of client records and the policies and procedures of the facility, the facility failed to ensure that an individual treatment and rehabilitation plan was developed with the client within seven days of admission, per the facility policy, in two of five applicable records reviewed.
Client # 18 was admitted on July 27, 2023 and was discharged on August 23, 2023. The individual treatment and rehabilitation plan was due to be completed by August 3, 2023; however, the record did not contain documentation that an individual treatment plan was completed.
Client # 19 was admitted on August 30, 2023 and was discharged on September 27, 2023. The individual treatment and rehabilitation plan was due to be completed by September 6, 2023; however, the plan was not completed until September 25, 2023.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Executive Director and Clinical Directors will re-educate staff on the process for the development of individual treatment and rehabilitation plans in a timely manner by 2/2/24. The Clinical Director will conduct chart reviews on a monthly basis to ensure that individual treatment and rehabilitation plans are completed on time. The Quality Analyst will conduct quarterly chart reviews to review compliance with the process and will report progress to leadership |
709.82(d)(1) LICENSURE Treatment and rehabilitation services
709.82. Treatment and rehabilitation services.
(d) Counseling shall be provided to a client on a regular and scheduled basis. The following services shall be included and documented:
(1) Individual counseling, at least twice weekly.
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Observations
Based on a review of client records, the facility failed to provide individual counseling sessions two times weekly for clients in the partial hospitalization activity in three of five applicable records reviewed.
Client # 16 was admitted on November 30, 2023 and was active at the time of the inspection. The record only documented one individual counseling session for the weeks of December 4, 2023 and December 11, 2023.
Client # 18 was admitted on July 27, 2023 and was discharged on August 23, 2023. The record only documented one individual counseling session for the weeks of July 31, 2023 and August 7, 2023 and no individual sessions for the week of August 14, 2023.
Client # 19 was admitted on August 30, 2023 and was discharged on September 27, 2023. The record only documented one individual counseling session for the week of September 11, 2023.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Executive Director and Clinical Director will re-educate staff on the requirement for individual counseling, at least twice weekly, during clinical supervision by 2/2/24. The Clinical Director will conduct chart reviews on a monthly basis to ensure that individual counseling is documented at least twice weekly. The Quality Analyst will conduct quarterly chart reviews to review compliance with this process and will report progress to leadership.
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709.83(a)(11) LICENSURE Client records
709.83. 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 a review of client records and the facility's policies and procedures, the facility failed to ensure a complete client record included information relative to the client's involvement with the project, to include follow-up information within 17 days of discharge, per facility policy, in two of four applicable records reviewed.
Client # 19 was admitted on August 30, 2023 and was discharged on September 27, 2023. The client record did not contain documentation of follow-up information.
Client # 20 was admitted on November 27, 2023 and was discharged on December 4, 2023. The client record did not contain documentation of follow-up information.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The internal workflow for the follow-up process has been enhanced to ensure that every patient receives follow up after discharge, and that the follow-up is documented in the electronic health record. The Executive Director and Clinical Directors will educate staff on the process by 2/2/24. The Quality Analyst will conduct quarterly chart reviews and will report progress to leaders to ensure compliance. |
709.63(a)(8) LICENSURE Follow-up Information
709.63. 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:
(8) Follow-up information.
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Observations
Based on a review of client records and the facility's policies and procedures, the facility failed to ensure a complete client record included information relative to the client's involvement with the project, to include follow-up information within 17 days of discharge, per facility policy, in one of two applicable records reviewed.
Client # 7 was admitted on June 19, 2023 and was discharged on June 24, 2023. The client record did not contain documentation of follow-up information.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The internal workflow for the follow-up process has been enhanced to ensure that every patient receives follow up after discharge, and that the follow-up is documented in the electronic health record. The Executive Director and Clinical Directors will educate staff on the process by 2/2/24. The Quality Analyst will conduct quarterly chart reviews and will report progress to leaders to ensure compliance. |
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 a review of patient records, the facility failed to ensure the narcotic treatment physician determined the initial dose and schedule. It was documented in patient records that the facility's Certified Registered Nurse Practitioner (CRNP) rather than the narcotic treatment physician, determined the initial dose for four of four applicable patients.
Patient # 2 was admitted to the Detoxification level of care on April 1, 2023 and transferred to a lower level of care on April 2, 2023. The initial medication order was communicated by the CRNP on April 1, 2023, and signed by the prescriber on April 5, 2023.
Patient # 3 was admitted to the Detoxification level of care on July 19, 2023 and transferred to a lower level of care on July 23, 2023. The initial medication order was communicated and signed by the CRNP on July 22, 2023.
Patient # 4 was admitted to the Detoxification level of care on August 23, 2023 and was discharged on August 28, 2023. The initial medication order was communicated and signed by the CRNP on August 24, 2023.
Patient # 9 was admitted to the Rehabilitation level of care on May 19, 2023 and was discharged on June 16, 2023. The initial medication order was communicated and signed by the CRNP on May 19, 2023.
Additionally, during an observation of medication administration on December 21, 2023, the nurse was observed to be looking at a computer monitor on the opposite side of the room as the patient, instead of observing patient when ingesting the agent.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Narcotic Treatment Physicians will be the only providers who will determine and sign the patient's initial and subsequent dose and schedule. The Medical Director and Assistant Medical Director educated the Medical Team on this process during a Medical Team Meeting on 1/18/24. The Senior Director of Health Records Management will run weekly reports of Narcotic Treatment Program orders to ensure compliance with this process.
The Nursing Clinic set up has been re-arranged, where an additional computer desk on wheels could be utilized by nursing if needed, so that the computer monitor is not on the opposite side of the room and out of view of the patient. The Director of Nursing and the Assistant Director of Nursing re-educated the nursing team on the process for directly observing the patient while the patient is ingesting the agent. The Director of Nursing and Assistant Director of Nursing will observe dosing 1x a week to ensure that the patient is being observed by nursing. The Compliance and Enterprise Risk Manager will also observe dosing 1x monthly to ensure compliance with this process.
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709.52(b) LICENSURE TX Plan update
709.52. Treatment and rehabilitation services.
(b) Treatment and rehabilitation plans shall be reviewed and updated at least every 30 days. For those projects whose client treatment regime is less than 30 days, the treatment and rehabilitation plan, review and update shall occur at least every 15 days.
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Observations
Based on a review of seven client records, the facility failed to ensure treatment and rehabilitation plans were reviewed and updated at least every 15 days in four of six applicable records reviewed.
Client # 9 was admitted on May 19, 2023 and was discharged on June 16, 2023. The individual treatment and rehabilitation plan was completed on May 24, 2023 and the treatment plan update was due to be completed by June 8, 2023; however, the treatment plan update was not completed until June 16, 2023.
Client # 11 was admitted on October 27, 2023 and was discharged on December 8, 2023. A treatment plan update was completed on November 11, 2023 and the next treatment plan update was due to be completed by November 26, 2023; however, no treatment plan updates were completed prior to discharge.
Client # 12 was admitted on July 23, 2023 and was discharged on August 19, 2023. The individual treatment and rehabilitation plan was completed on July 28, 2023 and the treatment plan update was due to be completed by August 12, 2023; however, the treatment plan update was not completed until August 19, 2023.
Client # 13 was admitted on November 2, 2023 and was discharged on November 30, 2023. The individual treatment and rehabilitation plan was completed on November 7, 2023 and the treatment plan update was due to be completed by November 22, 2023; however, the treatment plan update was not completed until November 29, 2023.
This is a repeat citation from the January 20, 2023 annual licensing inspection.
These finding were discussed with facility staff during the licensing process.
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Plan of Correction
The Executive Director and Clinical Directors will re-educate staff on the treatment planning process, including that treatment and rehabilitation plans must be reviewed and updated in the timeframes specified. The re-education will occur in group supervision by 2/2/24. The Clinical Director will conduct chart reviews on a monthly basis to ensure that individual treatment and rehabilitation plan updates are completed on time. The Quality Analyst will conduct quarterly chart reviews to ensure compliance with this process and will report progress to leadership. |
709.52(c) LICENSURE Provision of Counseling Services
709.52. 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 a review of client records, the facility failed to ensure that counseling services were provided according to the individual treatment and rehabilitation plans in four of six applicable records reviewed.
Client # 8 was admitted on July 27, 2023 and was discharged on August 24, 2023. The treatment plans completed on August 3, 2023 and August 15, 2023, indicated that the client was to receive one individual session per week; however, the record contained no documentation of an individual session the week of August 14, 2023.
Client # 10 was admitted on April 2, 2023 and was discharged on April 30. The individual treatment and rehabilitation plan completed on April 14, 2023, indicated that the client was to receive one individual session per week; however, the record contained no documentation of an individual session the week of April 17, 2023.
Client # 11 was admitted on October 27, 2023 and discharged on December 8, 2023. The treatment plan completed on November 11, 2023, indicated that the client was to receive one individual session per week; however, the record contained no documentation of an individual session the week of November 13, 2023.
Client # 12 was admitted on July 23, 2023 and was discharged on August 19, 2023. The individual treatment and rehabilitation plan completed on July 28, 2023, indicated that the client was to receive one individual session per week; however, the record contained no documentation of an individual session the weeks July 31, 2023 and August 7, 2023.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Executive Director and Clinical Directors will re-educate staff on the treatment planning process, including that counseling services must be provided according to the individual treatment and rehabilitation plan by 2/2/24. The Clinical Directors will complete monthly chart reviews to ensure the record accurately reflect services being delivered, as outlined the treatment plan. The Quality Analyst will conduct quarterly chart reviews to ensure compliance with this process and will report progress to leadership. |