INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection and methadone monitoring conducted on July 18, 2022 through July 19, 2022 by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, New Directions Treatment Services 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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704.11(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 all staff persons received a minimum of 6 hours of HIV/AIDS training and at least 4 hours of TB/STD and other health related topics training within the regulatory timeframe in one of one applicable personnel record reviewed. Employee # 6 was hired as a counselor on March 1, 2021 and was due to have the HIV/AIDS and TB/STD trainings no later than March 1, 2022; however, the HIV/AIDS and TB/STD trainings were not completed at the time of the inspection.This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
On 7/26/2022, the Program Director met with Employee #6 and reviewed the staff development program - specifically, that the staff member should have received 6 hours of HIV/AIDS and 4 hours of TB/STD/Hepatitis C training within their first year of employment. On 7/27/2022, the Program Director of the facility registered Employee #6 for two mandatory trainings offered by Department of Drug and Alcohol; employee #6 will be taking a virtual training on 8/25/2022 titled TB/STD/Hepatitis. In addition, employee #6 will be taking a virtual training titled HIV Parts 1 and 2 on 10/6/22 and 10/7/22. To ensure ongoing compliance with state policies and regulations, the Program Director of the facility will register all newly hired counselors for mandatory DDAP trainings within the regulatory timeframe, specifically within one year of their hired date. In addition, the Program Director will require all newly hired counselors to set up a Training Management System profile on the DDAP website within the first week of their employment so that there is no delay in registering for mandatory trainings. |
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 ensure that each counselor completed at least 25 clock hours of training annually during the facility's July 1, 2021 through June 30, 2022 training year in one of four applicable personnel records reviewed.Employee # 5 was hired as a counselor on June 17, 2008. The personnel record documented 0 hours of training received during the training year reviewed. This is a repeat citation from the July 29, 2021 annual licensing rewnal inspection. This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
On 8/2/2022, the Program Director met with Employee #5 and addressed the absence of their 25 clock hours of training from July 1, 2021 through June 30, 2022; during the meeting, the Program Director informed Employee #5 that the absence of the 25 training hours will be documented in their Performance Evaluation. If Employee #5 does not fulfill the required 25 hours of training during the next licensing inspection, a Performance Improvement Plan will be implemented. On 8/5/2022, the Program Director registered Employee #5 for 6 upcoming trainings covering various topics (relapse prevention, group counseling skills, ethics, current trends of drugs of abuse, pharmacology, record keeping), and the trainings will total 25 clock hours. Employee #5 will complete all of the 6 trainings by 10/31/2022. Ongoing compliance in meeting the staff development training requirements will be assessed and monitored by the Program Director during individual counseling sessions with each counselor. |
709.28 (c) LICENSURE Confidentiality
§ 709.28. Confidentiality.
(c) The project shall obtain an informed and voluntary consent from the client for the disclosure of information contained in the client record.
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Observations
Based on a review of client records, the facility failed to complete an informed and voluntary consent to release information form prior to the disclosure of information in one of seven client records reviewed.Client # 7 was admitted on March 8, 2021 and was discharged on May 31, 2022. The release of information form to the urinalysis laboratory was signed by the client and witness on March 8, 2021 and the release expired on March 8, 2022. A new release of information form was not signed until April 26, 2022; however, there was evidence of disclosures to the urinalysis laboratory on March 28, 2022 and April 13, 2022, which was after the original release of information form expired but prior to the new release being signed. This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
On 8/4/2022, the Program Director met with the employee overseeing Client #7 and addressed the late release of information that was completed - specifically, that the release of information for the laboratory was completed on 4/26/22 rather than the correct date of 3/8/2022. On 8/4/2022, the Program Director provided the employee with a template including due dates for their clients' upcoming releases of information to ensure that they are completed in a timely manner. During group supervision on 8/9/2022, the Program Director will educate the counselors about the state regulations pertaining to informed consent, confidentiality, and releases of information. At the end of each month, the Program Director will utilize the electronic health record system to identify which clients have upcoming releases of information that are due based on their admission date to the facility. To ensure ongoing compliance in meeting informed consent and confidentiality regulations, the Program Director will complete random chart record reviews; furthermore, Performance Improvement Plans will be implemented for employees who are not in compliance with record keeping pertaining to confidentiality and informed consent. |
709.34 (c) (1) 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:
(1) Physical or sexual assault by staff or a client.
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Observations
Based on a review of the facility's August 2021 through July 2022 unusual incident logs, the facility failed to file a written unusual incident report with the Department within 3 business days following incidents at the facility of physical assaults involving clients on November 29, 2021 and December 6, 2021. These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Program Director is responsible for ensuring compliance with the reporting of unusual incidents. On 8/1/2022, the Executive Director educated the Program Director on 709.34 (c)(1) - specifically, the expectation that an unusual incident involving physical or sexual assault by staff or a client is filed and submitted to the Department of Drug and Alcohol within three business days. The Executive Director reviewed the incidents of physical assaults involving clients on 11/29/2021 and 12/6/2021 with the Program Director and discussed the proper procedure to follow with regard to submitting reports to DDAP in a timely manner (3 business days). Moving forward, the Program Director will submit an internal incident report pertaining to physical assault incidents withing 24 hours; the incident report will be submitted to the Department of Drug and Alcohol within three business days. |
709.34 (c) (4) 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:
(4) Event at the facility requiring the presence of police, fire or ambulance personnel.
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Observations
Based on a review of the facility's August 2021 through July 2022 unusual incident logs, the facility failed to file a written unusual incident report with the Department within 3 business days following incidents that required the presence of police and/or ambulance personnel at the facility on November 29, 2021 and February 27, 2022. This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
On 7/28/2022, the Executive Director educated the Program Director on 709.34 - specifically, that a written unusual incident report be submitted to the Department of Drug and Alcohol within three business days following incidents requiring the presence of police or ambulance personnel. Moving forward, any time an incident at the facility requires the presence and intervention of police and/or ambulance personnel, the Program Director of the facility will submit an internal incident report to the Executive Director within 24 hours; in addition, a written unusual incident report will be submitted electronically within three business days to the Department of Drug and Alcohol. |
715.12(1-5) LICENSURE Informed patient consent
A narcotic treatment program shall obtain an informed, voluntary, written consent before an agent may be administered to the patient for either maintenance or detoxification treatment. The following shall appear on the patient consent form:
(1) That methadone and LAAM are narcotic drugs which can be harmful if taken without medical supervision.
(2) That methadone and LAAM are addictive medications and may, like other drugs used in medical practices, produce adverse results.
(3) That alternative methods of treatment exist.
(4) That the possible risks and complications of treatment have been explained to the patient.
(5) That methadone is transmitted to the unborn child and will cause physical dependence.
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Observations
Based on a review of patient records, the facility failed to obtain an informed, voluntary, written consent, including all required components, before an agent was administered to the patient for maintenance treatment in three of three applicable patient records reviewed. In each applicable patient record reviewed (patient #1, patient #2, and patient #3), the patient-signed informed, voluntary, written consent did not include that methadone is transmitted to the unborn child and will cause physical dependence.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Program Director is responsible for ensuring compliance with a patient's informed consent. On 7/28/2022, the Executive Director met with the Program Director and reviewed the correct Consent to Participate in Opioid Pharmacotherapy Treatment document which includes the following paragraph: For Female Patients of Childbearing Age - there is no evidence that methadone pharmacotherapy is harmful during pregnancy. If I am or become pregnant, I understand that I should tell my medical provider right away so that I can receive appropriate care and referrals. I have been informed that infants born to mothers, who have been taking opioids (including methadone) regularly prior to delivery, will be physically dependent and have a high incidence of Neonatal Abstinence Syndrome (NAS). NAS can be treated satisfactorily without any severe neonatal effects. I understand that there are ways to maximize the healthy course of my pregnancy while I am receiving opioid pharmacotherapy. The Program Director, on 8/1/2022, met with the employees overseeing patients #1, #2, and #3 and reviewed the correct informed consent document to complete with new patients at the time of an intake. On 8/2/2022, during group supervision with all of the counselors, the Program Director distributed the correct informed consent document to be utilized during every intake. To ensure ongoing compliance with 715.12 (1-5), the Program Director will audit all charts immediately following a new intake to confirm that the correct consent form is being utilized. Furthermore, to ensure ongoing compliance, the Program Director will conduct random chart audits once per week to confirm that the correct consent form is being used. |
715.14(a) LICENSURE Urine testing
(a) A narcotic treatment program shall complete an initial drug-screening urinalysis for each prospective patient and a random urinalysis at least monthly thereafter.
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Observations
Based on a review of patient records, the narcotic treatment program failed to complete a random urinalysis at least monthly in one of seven patient records reviewed.Patient # 6 was admitted on December 17, 2013 and was discharged on January 18, 2022. There was no documented drug screen urinalysis, in the record, for the month of September 2021.This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
The Nursing Supervisor is responsible for ensuring compliance with 715.14(a) - specifically, making sure that a random urinalysis will be completed at least monthly for all active patients. On 8/1/2022, the Program Director met with the Nursing Supervisor and reviewed the case of patient #6 and composed an action plan in which a "patient without a urine drug screen report" will be run using information from the electronic health record system. This particular report will be run at the end of each week to track which patients have not given a urine drug screen. If the tracking report identifies any patients who have not given a urine drug screen, a "hold" will be placed on their dose to ensure that a urine drug screen is provided prior to getting the methadone dispensed. This process will be ongoing, and it will be monitored by the Nursing Supervisor to ensure compliance with 715.14 (a). |
715.19(1) LICENSURE Psychotherapy services
A narcotic treatment program shall provide individualized psychotherapy services and shall meet the following requirements:
(1) A narcotic treatment program shall provide each patient an average of 2.5 hours of psychotherapy per month during the patient 's first 2 years, 1 hour of which shall be individual psychotherapy. Additional psychotherapy shall be provided as dictated by ongoing assessment of the patient.
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Observations
Based on a review of patient records, the facility failed to provide an average of 2.5 hours of psychotherapy per month during the patient's first 2 years in treatment in four of five applicable patient records reviewed. Patient # 1 was admitted on January 24, 2022 and was still active at the time of the inspection. The record of service and progress notes documented that during the following months less than 2.5 hours of psychotherapy per month was provided to the patient: June 2022: 45 minutes of psychotherapy; May 2022: 2 hours 25 minutes of psychotherapy; April 2022: 2 hours 25 minutes of psychotherapy; and March 2022: 1 hour 30 minutes of psychotherapy.Patient # 2 was admitted on November 16, 2021 and was still active at the time of the inspection. The record of service and progress notes documented that during the following months less than 2.5 hours of psychotherapy per month was provided to the patient: June 2022: 50 minutes of psychotherapy; May 2022: 0 hours of psychotherapy; April 2022: 1 hour 15 minutes of psychotherapy; and March 2022: 1 hour 15 minutes of psychotherapy.Patient # 3 was admitted on August 21, 2021 and was still active at the time of the inspection. The record of service and progress notes documented that during the following months less than 2.5 hours of psychotherapy per month was provided to the patient: June 2022: 0 hours of psychotherapy; May 2022: 0 hours of psychotherapy; and April 2022: 0 hours of psychotherapy.Patient # 7 was admitted on March 8, 2021 and was discharged on May 31, 2022. The record of service and progress notes documented that during the following months less than 2.5 hours of psychotherapy per month was provided to the patient: April 2022: 45 minutes of psychotherapy; March 2022: 30 minutes of psychotherapy; February 2022: 0 minutes of psychotherapy; and January 2022: 45 minutes of psychotherapy.This is a repeat citation from the July 29, 2021 annual licensing renewal inspection. This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
The Program Director is responsible for ensuring compliance with psychotherapy/counseling services. On 8/2/2022, during group supervision, the Program Director reviewed the requirements for counseling services with all of the counselors - specifically, that all clients must participate in a minimum of 2.5 hours of counseling/psychotherapy during the first two years of treatment. The Program Director also met with the employees overseeing patients #1, #2, #3, and #7 and addressed the program rules and state guidelines that must be adhered to with regard to the counseling component. Effective 8/2/2022, all of the counselors will be required to share their Outlook calendars with the Program Director so that counseling sessions and attendance are monitored on a weekly basis. In addition, to ensure that clients are meeting the 2.5 hour counseling requirement, all counselors will be required to facilitate group counseling sessions each week, in addition to individual counseling sessions, so that the mandatory counseling hours are attained. Counselors who are not meeting the 2.5 hour counseling requirement with their clients will be placed on a Performance Improvement Plan. |
715.19(3) LICENSURE Psychotherapy services
A narcotic treatment program shall provide individualized psychotherapy services and shall meet the following requirements:
(3) After 4 years of treatment, a narcotic treatment program shall provide each patient with at least 1 hour of group or individual psychotherapy every 2 months. Additional psychotherapy shall be provided as dictated by ongoing assessment of the patient.
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Observations
Based on a review of patient records, the facility failed to provide at least 1 hour of group or individual psychotherapy every 2 months after 4 years of treatment in one of two applicable patient records reviewed. Patient # 5 was admitted on September 10, 2018 and was discharged on January 6, 2022. The record of service and progress notes showed that only 45 minutes of group or individual psychotherapy was provided for the months of September 2021 through December 2021.This is a repeat citation from the July 29, 2021 annual licensing inspection. This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
The Program Director is responsible for ensuring compliance with psychotherapy/counseling services. On 8/2/2022, during group supervision, the Program Director reviewed the requirements for counseling services with all of the counselors - specifically, that all clients who have been in treatment for 4 or more years must participate in at least 1 hour of individual or group counseling each month. The Program Director met with the employee overseeing patient #5 and addressed the program rules and state guidelines that must be adhered to with regard to the counseling component. Effective 8/2/2022, all of the counselors will be required to share their Outlook calendars with the Program Director so that counseling sessions and attendance are monitored on a weekly basis. Furthermore, to ensure that long term clients (clients in treatment for 4 or more years) are meeting the 1 hour of counseling every two months, all counselors will be required to facilitate group counseling sessions, in addition to individual counseling sessions, so that the mandatory counseling is attained. Any counselor who is not meeting the 1 hour of counseling every two months for clients in treatment for four or more years will be placed on a Performance Improvement Plan. |
715.20(4) LICENSURE Patient transfers
A narcotic treatment program shall develop written transfer policies and procedures which shall require that the narcotic treatment program transfer a patient to another narcotic treatment program for continued maintenance, detoxification or another treatment activity within 7 days of the request of the patient.
(4) The receiving narcotic treatment program shall document in writing that it notified the transferring narcotic treatment program of the admission of the patient and the date of the initial dose given to the patient by the receiving narcotic treatment program.
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Observations
Based on a review of patient records, the narcotic treatment program failed to document, in writing, that it notified the transferring narcotic treatment program of the date of the admission of the patient and the date of the initial dose given to the patient in one of one applicable patient records reviewed. Patient # 2 was transferred in and admitted on November 16, 2021 and was still active at the time of inspection. There was no documentation in the record that the transferring narcotic treatment program was notified of the date of admission and the date the initial dose was given. This is a repeat citation from the July 29, 2021 annual licensing inspection. This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
The Program Director of the facility is responsible for ensuring compliance with patient transfers 715.20(4) - specifically, that the receiving narcotic treatment program will inform the transferring narcotic treatment program of a patient's admission to the program, as well as the date of their initial dose. On 7/25/2022, the Program Director composed and faxed a letter to Patient #2's transferring clinic to inform them that the client was admitted to the receiving facility on 11/16/2021, and a methadone dose was dispensed on the same day. Effective 8/5/2022, a transfer acknowledgement letter will be created and added to the current list of templates, making it easily accessible for the Program Director to use immediately following a client's transfer and admission to the new facility. All transfer admissions will be reviewed for accuracy by the Program Director to ensure that a letter has been submitted to the transferring facility. |
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 that 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 three of four applicable patient records reviewed. Patient # 5 was admitted on September 10, 2018 and was discharged on January 6, 2022. The annual evaluation of the patient's status was due to be completed by the counselor in September 2021; however, the eval was not completed until November 5, 2021.Patient # 6 was admitted on December 17, 2013 and was discharged on January 18, 2022. The annual evaluation of the patient's status was due to be completed by the counselor in December 2021; however, the eval was not completed prior to discharge.Patient # 7 was admitted on March 8, 2021 and was discharged on May 31, 2022. The annual evaluation of the patient's status was due to be completed by the counselor in March 2022; however, the eval was not completed until April 26, 2022.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
On 8/1/2022, the Program Director met with the employees overseeing Patients #5, #6, and #7 and discussed the protocol for completing an annual evaluation - specifically, that the annual evaluation must address areas including employment, education, legal issues, substance abuse, finances, mental health and physical health, support network, and fulfillment of treatment goals and objectives. On 8/1/2022, the Program Director informed the employees overseeing Patients #5, #6, and #7 that the annual evaluation must be completed on a patient's date of admission to the program. On 8/9/2022, during group supervision, the Program Director will re-educate all of the counselors on the correct format for completing annual reviews. During the group supervision meeting on 8/9/2022, the Program Director will distribute a spreadsheet that the counselors will be required to use as a way to ensure that annual reviews are completed in a timely manner. To ensure ongoing compliance in meeting the annual clinical evaluation requirement, the Program Director will conduct random chart reviews, in addition to reviewing annual reviews in individual supervision. |
709.92(a)(2) LICENSURE Treatment and rehabilitation services
709.92. 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:
(2) Type and frequency of treatment and rehabilitation services.
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Observations
Based on a review of client records, the facility failed to document the type and frequency of treatment and rehabilitation services on the individual treatment and rehabilitation plan in two of three applicable client records reviewed.Client # 2 was admitted on November 16, 2021 and was still active at the time of the inspection. The individual treatment and rehabilitation plan was completed on December 15, 2021; however, the plan did not document the type of treatment and rehabilitation services the client was to receive. Client # 3 was admitted on August 11, 2021 and was still active at the time of the inspection. The individual treatment and rehabilitation plan was completed on September 10, 2021; however, the plan did not document the type of treatment and rehabilitation services the client was to receive. These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Program Director is responsible for ensuring compliance with documenting the type and frequency of treatment and rehabilitation services on individual treatment plans. On 8/9/2022 during group supervision with all of the counselors, the Program Director reviewed the correct way to document the type and frequency of treatment on individual treatment plans - specifically, if a client has been in treatment for under two years, the treatment plan must specify a minimum of 2.5 hours of counseling each month (1.5 hour group counseling and 1 hour of individual counseling). If a client has been in treatment for 2 or more years, the treatment plan must specify that 1 hour of either individual or group counseling takes place once per month. Additionally, if a client has been in treatment for over 4 years, the treatment plan must specify that 1 hour of group or individual counseling takes place every 2 months. On 8/9/2022, in addition to facilitating group supervision, the Program Director met individually with the employees overseeing clients #2 and #3 and reviewed the missing components on their treatment plans - specifically, not identifying the frequency and type of treatment/rehabilitation. Ongoing compliance in meeting the type and frequency of treatment rehabilitation on treatment plans will be addressed by the Program Director when random chart reviews are completed. The Program Director will give a verbal warning to any counselor who is not completing treatment plans correctly using the proper format; if treatment plans continue to have missing components (type and frequency of treatment, for example), a Performance Improvement Plan will be presented to the individual employee. |
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 client records, the facility failed to review and update treatment and rehabilitation plans at least every sixty days in five of seven applicable client records reviewed. Client # 1 was admitted on January 24, 2022 and was still active at the time of the inspection. The individual treatment plan was completed on February 15, 2022 and an update was due no later than April 15, 2022; however, the update was not completed until April 28, 2022. Additionally, a treatment plan update was completed on April 28, 2022 and the next update was due no later than June 28, 2022; however, the update was not completed until July 7, 2022. Client # 2 was admitted on November 16, 2021 and was still active at the time of the inspection. A treatment plan update was completed on March 25, 2022 and an update was due no later than May 25, 2022; however, the update was not completed until June 22, 2022. Client # 3 was admitted on August 11, 2021 and was still active at the time of the inspection. A treatment plan update was completed on February 23, 2022 and an update was due no later than April 23, 2022; however, the update was not completed at the time of the inspection. Client # 6 was admitted on December 17, 2013 and was discharged on January 18, 2022. A treatment plan update was completed on September 28, 2021 and an update was due no later than November 28, 2021; however, the update was not completed prior to discharge. Client # 7 was admitted on March 8, 2021 and was discharged on May 31, 2022. A treatment plan update was completed on September 30, 2021 and an update was due no later than November 30, 2021; however, the update was not completed until January 3, 2022. This is a repeat citation from the July 29, 2021 and August 20, 2020 annual licensing renewal inspections. These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
On 8/2/2022, during group supervision, the Program Director will re-educate the counselors on proper documentation and timeliness of treatment plans. Effective 8/2/2022, the counselors will be required to utilize a spreadsheet identifying the specific due dates of their clients' treatment plans. Ongoing compliance will be monitored by the Program Director during monthly individual supervision and by a weekly review of a sample of each counselor's records. On 8/4/2022, the employee overseeing client #3 submitted a treatment plan update/review that included measurable goals and objectives; the Program Director met with the employee to discuss this particular treatment plan. |
709.17(a)(3) LICENSURE Subchapter B.Licensing Procedures.Refusal/rev
709.17. Refusal or revocation of license.
(a) The Department may revoke or refuse to issue a license for any of the following reasons:
(3) Failure to comply with a plan of correction approved by the Department, unless the Department approves an extension or modification of the plan of correction.
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Observations
Based on a review of administrative documents, the facility failed to comply with plans of correction that were approved by the Department. A plan of correction for late treatment plan updates was submitted and approved by the Department for the July 29, 2021 and August 20, 2020 annual licensing inspections. Late treatment plan updates were again found to be a deficiency in the July 18, 2022 through July 19, 2022 licensing inspection.This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
The Program Director is responsible for ensuring that plan of corrections are adhered to and followed in order to comply with state regulations and guidelines. By 10/1/2022, a new tracking system will be created and used in the electronic health record system as a way to track due dates for treatment plans. The tool in the electronic health record system will give alerts on the computer to inform counselors of due dates for upcoming treatment plans. To ensure ongoing compliance with plan of corrections and treatment plans, the Program Director will place counselors on Performance Improvement Plans if their treatment plans are not completed and documented in a timely manner. |