INITIAL COMMENTS
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This report is a result of an on-site complaint investigation conducted on March 12, 2025 by staff from the Bureau of Program Licensure. Based on the findings of the on-site complaint investigation, New Directions Treatment Services was found not to be in compliance with the applicable chapters of 28 PA Code which pertain to the facility.
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Plan of Correction
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715.17(b) LICENSURE Medication control
(b) A narcotic treatment program shall develop policies and procedures regarding verbal medication orders, including the issuing and receiving of orders, identifying circumstances when orders are appropriate and documenting orders, in accordance with applicable Federal and State statutes and regulations.
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Observations
Based on a review of patient records, the Medication Control/verbal orders policy, and staff interviews, the facility failed to follow its policy and procedures regarding verbal medication orders.Per the facility's Medication Control/verbal orders policy, verbal medication orders will be used when the physician is not onsite. The clinic staff will consult with the physician by telephone to review the case and verbal medication order will be given if necessary. The physician ' s order will be documented and signed within seven days of the order. Patient # 1 was admitted on September 20, 2023, and was still active at the time of this investigation. A doctor's order dated 12/10/24 stated a split dosing regimen was being implemented with one dose in the AM and one in the PM. Per the dosing history, along with confirmation from staff, the full dose has been given to the patient as per an updated verbal order from the Medical Director. The signed documentation of this verbal order was unable to be produced.
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Plan of Correction
By 3/20/2025, the Nursing Director will remind nursing staff that all verbal orders must be signed by the physician within seven days of the date of the verbal order. Nursing staff will be required to notify the Nursing Director within 24 hours of any verbal order issued by the physician. Ongoing compliance with the policy will be the responsibility of the Nursing Director who will verify that all verbal orders will be documented in the record by the physician within seven days in accordance with the policy. |
715.17(c)(4)(i-viii) 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:
(4) Method for control and accountability of drugs. A narcotic treatment program shall develop and implement written policies and procedures regarding who is authorized to remove drugs from the storage area and the method for accounting for all stored drugs. An agent or other drug prescribed or administered shall be documented on an individual medication record or sheet in a manner sufficient to maintain an accurate accounting of medication at all times and shall include:
(i) The name of the medication.
(ii) The date prescribed.
(iii) The dosage.
(iv) The frequency.
(v) The route of administration.
(vi) The date and time administered.
(vii) The name of the person administering the medication.
(viii) The take-home schedule, if applicable.
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Observations
Based on a review of patient records during a complaint investigation conducted on March 12, 2025, along with staff interviews, the facility failed to document on an individual medication record in a manner sufficient to maintain an accurate accounting of medication at all times in 1 of 5 records reviewed.Patient # 1 was admitted on September 20, 2023, and was still active at the time of the investigation. Per the Dose History, it was documented that a medication was administered twice per day, once at the clinic and once as a take-home since 12/27/24, with exceptions for Sunday's and holidays the clinic is not open, for which take-homes are given. Per an interview with the Nursing Supervisor, this Dose History should reflect that the patient was dosed twice per day at the clinic, with exceptions for Sunday's and holidays the clinic is not open, for which take-homes are given.
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Plan of Correction
By 3/20/2025, the Nursing Director will review the medication control regulatory requirements with dispensing staff. Nursing staff will be reminded that dispensed medication must follow the frequency as well as the dose ordered by prescriber. Changes for split dosing must be ordered by the physician, and the order must be documented in the record. As of 3/13/2025, the dispensing frequency and dose for patient # 1 has been in accordance with the physician's order. The nursing Director will be responsible for ongoing compliance with the regulation through a random review of medication records to ensure that all dispensed medications meet the dose and frequency of administration as ordered by the physician. |
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 a review of patient records, the facility failed to review and update treatment and rehabilitation plans at least every 60 days in 3 of 5 records reviewed.Patient # 1 was admitted on September 20, 2023, and was still active at the time of the investigation. A treatment plan update was completed on 10/17/24 and the next update was due no later than 12/17/24 and the next due 2/17/25; however, there was no updates documented in the record after 10/17/24.Patient # 2 was admitted on November 29, 2023, and was still active at the time of the investigation. A treatment plan update was completed on 9/30/24 and the next update was due no later than 11/30/24 and the next due 1/30/25; however, there was no updates documented in the record after 9/30/24.Patient # 4 was admitted on March 22, 2024, and was still active at the time of the investigation. A treatment plan update was completed on 8/30/24 and the next update was due no later than 10/30/24, then 12/30/24 and the next due 3/2/25; however, there was no updates documented in the record after 10/30/24.
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Plan of Correction
By 3/20/2025, the Program Director will remind the clinicians to ensure that clients follow the treatment plan recommendations regarding frequency of counseling mutually agreed upon by the client and the clinicians. The clinicians will provide education to the clients on the lower risk of overdose if MOUD is combined with psychosocial treatment. Clinicians will be reminded to document No Shows in the clinical record, and the interventions used to help the clients meet the counseling attendance goals. The QA Manager will be responsible for auditing the records and coordinating with the Clinical Supervisor for ongoing compliance with the regulation. |
709.92(d) LICENSURE Treatment and rehabilitation services
709.92. Treatment and rehabilitation services.
(d) Counseling shall be provided to a client on a regular and scheduled basis.
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Observations
Based on a review of patient records during a complaint investigation on March 12, 2025, the facility failed to provide counseling to patients on a regular and scheduled basis in 4 out of 5 records reviewed. Patient # 1 was admitted on September 20, 2023, and was still active at the time of the investigation. A progress note for an individual counseling session was dated 10/23/24. There is no documentation of group or individual counseling after 10/23/24 in the patient record.Patient # 2 was admitted on November 29, 2023, and was still active at the time of the investigation. A progress note for an individual counseling session was dated 9/30/24. There is no documentation of group or individual counseling after 9/30/24 in the patient record.Patient # 3 was admitted on September 23, 2024, and was still active at the time of the investigation. A progress note for an individual counseling session was dated 11/13/24. There is no documentation of group or individual counseling after 11/13/24 in the patient record.Patient # 4 was admitted on March 22, 2024, and was still active at the time of the investigation. A non-billable note for an individual counseling session was dated 10/7/24. There is no documentation of group or individual counseling after 10/7/24 in the patient record.
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Plan of Correction
By 3/20/2025 The Facility Director will remind clinicians that treatment plans must be reviewed and updated at least every 60 days. The QA Manager will notify clinicians of the upcoming Treatment Plan Review/Update due dates at the beginning of every month. The QA manager will be responsible for ensuring compliance with the regulation through scheduled auditing of the records to verify that Treatment Plan Reviews and Updates have been completed in accordance with the regulation. The Clinical Supervisor will be responsible for ongoing compliance through random record review and during individual supervision. |