INITIAL COMMENTS
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This report is a result of an on-site provisional licensure renewal and methadone monitoring inspection conducted on March 29 - 31, 2023 by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, Greene 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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709.34 (c) (2) LICENSURE Reporting of unusual incidents
§ 709.34. Reporting of unusual incidents.
(c) To the extent permitted by State and Federal confidentiality laws, the project shall file a written unusual incident report with the Department within 3 business days following an unusual incident involving:
(2) Death or serious injury due to trauma, suicide, medication error or unusual circumstances.
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Observations
Based on a review of the facility client list, administrative information and the unusual incident reports, the facility failed to file a written unusual incident report with the Department within 3 business days following an unusual incident involving a client death.
Seven client deaths were reported to have occurred between June 1, 2022 and February 23, 2023. Five incident reports documenting the client deaths were documented on June 1, 2022, July 1, 2022, October 3, 2022, December 6, 2022 and January 26, 2023 and were not submitted to the Department.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Narcotic Treatment Program failed to file a written Unusual Incident Report with the Department within 48 hours regarding the death of a patient. The Program Director will report, within 48 hours, all unusual incidents, per PA State regulatory requirements. The Program Director/Clinical Supervisors will also provide training to the staff about unusual incident reporting and the time frame for submission to all regulatory bodies, including DDAP. In the absence of the Program Director, the Clinical Supervisors will notify the Program Director of the unusual incident and act as the Director's designee to complete and submit the unusual incident report to DDAP. All unusual incident reports will be kept in a file by the Program Director. |
715.6(a)(1)(i)-(iii) LICENSURE Physician staffing
(a) A narcotic treatment program shall designate a medical director to assume responsibility for administering all medical services performed by the narcotic treatment program
(1) A medical director shall be a physician and shall have obtained one of the following:
(i) Three years documented experience in the provision of services to persons who are addicted to alcohol or other drugs, including at least 1 year of experience in the treatment of narcotic addiction with a narcotic drug.
(ii) Certification in addiction medicine by the American Society of Addiction Medicine.
(iii) A certificate of added qualifications in addiction psychiatry by the American Board of Psychiatry and Neurology, Inc.
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Observations
Based on a review of the personnel records and administrative information, the facility failed to designate a medical director who has obtained one of the following: (i) Three years documented experience in the provision of services to persons who are addicted to alcohol or other drugs, including at least 1 year of experience in the treatment of narcotic addiction with a narcotic drug. (ii) Certification in addiction medicine by the American Society of Addiction Medicine. (iii) A certificate of added qualifications in addiction psychiatry by the American Board of Psychiatry and Neurology, Inc.
Staff #11 was hired as the medical director on August 8, 2022 and is still in the position at the time of the inspection. Staff #11 does not meet the qualifications listed in (i)(ii)or (iii).
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
A training plan was submitted for the Interim Medical Director for approval by the department on 3/30/23. Documentation verifying this will be maintained in the Interim Medical Director's file. The Project Director is responsible for ensuring that the training plan for the Medical Director is fulfilled within the mandated time limitations. The Project Director will meet with the Medical Director quarterly to discuss progress on fulfilling the plan addressing the measures to be taken for the interim medical director to achieve minimal competencies and proficiencies. The Project Director is responsible for maintaining copies of training certificates and other verifying documentation in the Medical Director's file. The Interim Medical Director will have obtained 3 years of documented experience July 2023. |
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 a review of patient records, the facility failed to ensure an annual evaluation of the patient's status was completed by the patient's counselor and was reviewed, dated, and signed by the medical director in two of three applicable patient records.
Patient # 5 was admitted on August 22, 2017 and was discharged on February 4, 2023. An annual evaluation was due to be completed by August 22, 2022 and was completed late on September 21, 2022.
Patient # 6 was admitted on August 18, 2021 and was discharged on January 13, 2023. An annual evaluation was due to be completed by August 18, 2022 and was completed late on September 4, 2022.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Clinical Supervisors have implemented an individual patient tracking system to be put into place to prompt an alert of the patient's chart when their annual clinical paperwork is due. This alert will be added upon patient intake to ensure patients annual paperwork will not be missed. The Facility Director and Clinical Supervisor's will make this part of our ongoing auditing process when reviewing patient files during weekly supervision. |