INITIAL COMMENTS
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This report is a result of an on-site licensure renewal and methadone monitoring inspection conducted on September 24-25, 2024 by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, New Castle 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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709.92(b) LICENSURE Treatment and rehabilitation services
709.92. Treatment and rehabilitation services.
(b) Treatment and rehabilitation plans shall be reviewed and updated at least every 60 days.
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Observations
Based on client records reviewed, the facility failed to review and update the treatment and rehabilitation plan at least sixty days in three of seven applicable records.
Client #1 was admitted on October 17, 2023 and was still active at the time of the inspection. A treatment and rehabilitation plan was developed on June 13, 2024. A treatment and rehabilitation plan update was due no later than August 13, 2024, but was not completed until August 16, 2024.
Client #6 was admitted on May 13, 2022 and was discharged on June 19, 2024. A treatment and rehabilitation plan was developed on November 13, 2023. A treatment and rehabilitation plan update was due no later than January 3, 2024, but was not completed until January 16, 2024.
Client #8 was admitted on July 15, 2021 and was still active at the time of the inspection. A treatment and rehabilitation plan was developed on July 9, 2024. A treatment and rehabilitation plan update was due no later than September 9, 2024, but was not completed until September 12, 2024.
A treatment and rehabilitation plan was developed on March 6, 2024. A treatment and rehabilitation plan update was due no later than May 6, 2024, but was not completed until May 14, 2024.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
1. Clinic Director clinical supervisor reviewed the expectation and regulation for treatment plan updates on 10.2.2024
2. Clinical supervisor reviewed expectation of treatment plan updates during clinical group supervision on 10.10.2024.
Action Steps and Plan:
1.Clinical Supervisor will continue to review regulations related to treatment plan updates during each individual supervision.
2. Clinical Supervisor will review treatment plan compliance in the EHR weekly and schedule meetings to increase individual and group supervision as needed to ensure treatment plans are being completed within the time frames based on regulation
3. Clinical Supervisor will review with Clinic Director the barriers to the clinical team meeting these guidelines and establish performance improvement plans as needed.
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709.92(c) LICENSURE Treatment and rehabilitation services
709.92. 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 the clients received counseling services according to their individual treatment plan in three of eight applicable records reviewed.
Client #1 was admitted on October 17, 2023 and was still active at the time of the inspection. A treatment plan dated April 18, 2024 indicated two and a half hours of psychotherapy per month. In June 2024, the client only received ninety minutes of psychotherapy. In July 2024, the client only received two hours of psychotherapy.
Client #4 was admitted on March 10, 2022 and was active at the time of the inspection. A treatment plan dated March 11, 2024 indicated one hour of psychotherapy a month. In April 2024, the client only received thirty minutes of psychotherapy.
Client #6 was admitted on May 13, 2022 and was discharged June 19, 2024 A treatment plan dated January 16, 2024 indicated one hour of psychotherapy a month. In February 2024, the client received zero hours of psychotherapy. In March 2024, the client received zero hours of psychotherapy.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
1. Clinic Director Clinical supervisor reviewed the expectation of counseling requirements of patients which are to have 2.5, 2.0, 1.0, or .5 hour of counseling per month on 10.2.2024.
2. Clinical supervisor reviewed with clinical staff the expectation of counseling requirements of patients with required hours of counseling during group supervision on 10.10.2024.
Action Steps/ Plan:
1. Clinical Supervisor review counseling requirements in clinical group supervisions.
2. Monthly individual supervision will address counseling requirements and include discussion related to requirements met and barriers to meeting requirements.
3. Individual patient charts will be reviewed during individual supervision.
4. Counseling requirements will be reviewed and monitored with random chart audits completed by the Clinical supervisor and reviewed with the multidisciplinary team as needed
5. Clinical Supervisor will review with Clinic Director barriers to the clinical team meeting these guidelines and establish performance improvement plans as needed.
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