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b. Roger Smith given admin access to counselor, accounting, and billing functions (by a terminated
employee who is also Roger's spouse).
i. Sole key holder and installer of security system
10. Missing buprenorphine order forms and shipping receipts
11. 222 Forms were retrieved from terminated Program Director’s vehicle, upon request
12. Patients loitering throughout hallways and in parking lot
13. Former PD reports she allowed homeless people to come into facility during morning hours to get coffee and
stay warm
14. Spare keys were taped to the back of the doors, until 11/9-when they were all removed and now can’t be found.
15. Access logs for the CS storage area, not recorded by Tyco
16. Registrant and POA not revoked upon employee termination
17. Locks and security codes not changed upon employee termination.
Admissions and Dosing
1. Procedures to ensure the correct dose is given to right person via a 2-step identification are not taken.
2. Nursing staff do not have record of competency based training for assessing and documenting impairment or
withdrawal
3. Dose adjustments made without COWS assessments, after induction and first day dosing
Treatment Planning
1. Missing and/or questionable treatment planning. Treatment plan signatures missing, treatment plans not
completed, some case notes and treatment plans documented during a period of patient absence.
2. Several charts reviewed without needed or MD referrals to outside agencies. Not reflected in treatment plan
and referrals incomplete.
3. Counseling session notes were missing, incomplete, or illegible for several audited patient charts.
Administrative Policies related to hiring, training, supervision, or termination of employment
1. Employee Termination Procedures and Community Relations
a. 18 police calls related to larceny and trespassing. Former owner/Program Director could return to the
building after termination of business agreement and termination of her role as PD.
b. This was before efforts were taken to secure the facility, inform employees of changes, and ensure
patient confidentiality during staffing changes. As a result, patients and local law enforcement were
triangulated into ownership conflict for several days.
2. Nepotism ROH Policy-Nepotism policy not followed or enforced
a. Spouse of former PD was ROH security guard and direct report to former PD
3. Inappropriate ethics and professional and inter-professional boundaries, with focused CS oversight.
a. Patients report counseling sessions are 5-10 minutes while smoking outside. No nursing supervision has
been done or documented
b. Former Program Director contacted patients after her termination and presented herself as an active
owner and employee at ROH to discuss OTP operations
4. RN Supervision notes not found, nursing staff reports RN has not been on-site or completed formal supervision
since opening.
5. Staff training, related to regulatory and ROH policies has not been completed, staff report that they do not have
access to the Policy and Procedure Manual
6. Former PD and former Counselor were both working as substance abuse counselors, after CCS terminated
supervision agreement.
7. Patient Confidentiality
a. Proper software controls to ensure employees are only able to access needed and required patient
records and administrative access to Methasoft.
b. OTP DVR monitoring hard drive was stolen with recordings of patients receiving services in OTP and the
whereabouts and security of this hard drive are unknown.