INITIAL COMMENTS
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This report is a result of an on-site licensing inspection and complaint investigation conducted from August 17-20, 2020, by staff from the Department of Drug and Alcohol Programs, Bureau of Quality Assurance for Prevention & Treatment. 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 investigation; therefore a plan of correction is required.
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Plan of Correction
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705.28 (d) (1) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(1) Conduct unannounced fire drills at least once a month.
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Observations
The facility failed to conduct unannounced fire drills at least once per month.A review of the fire drill records was conducted on August 18, 2020. There was no documented fire drill for the months of November 2019, March and July 2020.This information was reviewed with the facility staff at the time of the inspection.
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Plan of Correction
Effective September 1, 2020, the Clinical Supervisor and Program Director will track and ensure each episode of a monthly fire drill. Following the completion of the fire drill, the event will be documented and recorded in an emergency evacuation log; it will be signed, dated, and initialed by the Clinical Supervisor. Quarterly, the Clinical Supervisor and Program Director will preselect a date and time each month to implement the execution of random fire drills. To ensure ongoing compliance with the standard of conducting unannounced fire drills at least once a month, the fire drill results will be presented to the Performance Improvement Committee during monthly meetings. |
705.28 (d) (4) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(4) Maintain a written fire drill record including the date, time, the amount of time it took for evacuation, the exit route used, the number of persons in the facility at the time of the drill, problems encountered and whether the fire alarm or smoke detector was operative.
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Observations
The facility failed to document all required information on fire drill records.A review of the fire drill records from September 2019 through July 2020, was conducted on August 18, 2020. The following information was not documented:for evacuation was documented only for December 2019exit route used was not documented for the September 2019, February, March, May and June 2020.of persons evacuated was not documented for October, November, December 2019, January, February and March 2020.This information was reviewed with the facility staff at the time of the licensing inspection.
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Plan of Correction
By September 15, 2020, the Clinical Supervisor and Program Director will update the current Emergency/Evacuation Drill Analysis Report, which will include all of the required information on the fire drill records, including the date, time, the amount of time it took for the evacuation, the exit route used, the number of persons in the facility at the time of the drill, and any associated problems encountered. The Clinical Supervisor and Program Director will ensure timely completion of fire drills each month. To ensure ongoing compliance with the standard, the fire drill results will be presented to the Performance Improvement Committee during the monthly meetings. |
709.28 (b) LICENSURE Confidentiality
§ 709.28. Confidentiality.
(b) The project shall secure hard copy client records within locked storage containers. Electronic records must be stored on secure, password protected data bases.
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Observations
The facility failed to secure hard copy client records within locked storage containers.A physical plant inspection was conducted on August 18, 2020. It was observed that the facility stores client records in the clinician ' s offices, within file cabinets. The file cabinet in the clinical supervisor ' s office did not have a lock, none of the other file cabinets in the clinical offices were locked and staff reported they do not lock these cabinets as the office doors are kept locked. This information was reviewed with the facility staff at the time of the inspection.
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Plan of Correction
On August 25, 2020, the Program Director facilitated a meeting with the counselors and reminded them to lock their file cabinets at the end of each day, in order to comply with the standard of securing hard copy client records within locked storage containers. By September 30, 2020, the Clinical Supervisor and Program Director will ensure the purchase of the Clinical Supervisor's file cabinet to comply with the standard of securing hard copy client records within locked storage containers; this current file cabinet will be replaced by one with a lock to comply with the standard. Until a new file cabinet is purchased, all of the client records from the Clinical Supervisor's office will be redistributed to a file cabinet with a lock.
Ongoing compliance with the standard will be maintained by random checking of the counselors' file cabinets and office doors by the Clinical Supervisor and Program Director.
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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
The facility failed to update consents annually in one of five applicable records. Client #3 was admitted on 9/22/2008 and was an active client at the time of the licensing inspection. The facility consent to releases information form states that the consent will expire one year from the date of the clients ' signature; the following deficiencies were identified:Two consents to release information, one to the funding source and one to a diagnostic lab, expired on 8/15/2020 and were not updated at the time of the licensing inspection.Additionally, the consent to release information to the emergency contact expired on 9/20/2019 and was not updated at the time of the licensing inspection.This information was reviewed with the facility staff at the time of the licensing inspection.
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Plan of Correction
On September 15, 2020, the Clinical Supervisor and Program Director will facilitate an educational training to re-educate the counselors on the regulatory requirement to update clients' Consent to Release Confidential Information annually. To help clinicians comply with the regulation, they will be notified of upcoming due dates at the beginning of every month by the Program Director. Ongoing compliance with the standard will be monitored by the Program Director and the Clinical Supervisor through weekly review of a sample of the clinical records of every counselor. |
715.6(d) LICENSURE Physician Staffing
(d) A narcotic treatment program shall provide narcotic treatment physician services at least 1 hour per week onsite for every ten patients
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Observations
The facility failed to provide one hour per week of physician ' s services per every ten clients. The following deficiencies were identified:During the week of March 29 through April 4, 2020: Census- 527, Required hours- 52.7, documented hours- 52.5 During the week of June 28 through July 4, 2020: Census- 551, Required hours- 55.1, documented hours- 53.5 This information was reviewed with the facility staff at the time of the licensing inspection.
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Plan of Correction
Effective September 7, 2020, at the beginning of each week, the Nurse Manager will review the scheduled medical providers' hours. If a planned vacation, holiday, or paid time off will result in not meeting the standard, the Nurse Manager will schedule other NDTS and/or per diem medical providers for sufficient hours to ensure compliance with the standard. Ongoing compliance will be monitored by the Facility Director by a review of the weekly medical hours provided and census data provided by the Nurse Manager to ensure that one hour of physician services will be provided for every ten active clients in the program. |
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
The facility failed to update the treatment plan every 60 days in five of seven records reviewed.A review of the client records was conducted on August 18-20, 2020. The following deficiencies were identified.Client #2 was admitted on 2/19/18 and discharged on 7/14/2020.A treatment plan update was documented on 1/15/2020; another treatment plan update was due by 3/15/2020, not doc until 4/9/2020Client #3 was admitted on 9/22/2008 and was an active client at the time of the licensing inspection. A treatment plan update was documented on 1/7/2020; another treatment plan update was due by 3/7/2020, but was not documented until 3/13/2020; another treatment plan update was due by 5/13/2020 but was not documented until 5/27/2020 and another treatment plan update due by 7/27/2020 but was not documented at the time of the inspection. Client #4 was admitted on 7/31/2017 and was an active client at the time of the licensing inspection. A treatment plan update was documented on 6/10/2020; a treatment plan update was due by 8/10/2020 but was not documented at the time of the inspection. Client #5 admit 3/15/2010 and discharged on 3/16/2020-A treatment plan update was documented on 12/9/2019; a treatment plan update was due by 2/9/2020, but not documented until 2/24/2020.Client #6 was admitted on 2/12/2020 and discharged 5/5/2020-The Comprehensive Treatment plan was documented on 2/24/2020; a treatment plan update was due by 4/24/2020 but was not documented at the time of the inspection.This information was reviewed with the facility staff at the time of the licensing inspection.
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Plan of Correction
On September 15, 2020,during an educational training, the Program Director and Clinical Supervisor will re-educate the counselors on regulatory documentation requirements and the importance of completing treatment plans every 60 days. Ongoing compliance will be monitored by the Program Director and the Clinical Supervisor during monthly individual supervision and by a weekly review of a sample of each clinician's records. To bring active records into compliance, the counselor overseeing client #3, whose treatment plan was due by 7/27/20, wrote a treatment plan on 8/25/2020. The counselor overseeing client #4, whose treatment plan was due by 8/10/20, wrote a treatment plan review on 8/26/20; the Program Director reviewed these particular charts, on 8/28/20, to ensure that the records are brought into compliance to meet regulatory standards. |