INITIAL COMMENTS
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This report is a result of an on-site provisional license follow-up and methadone monitoring inspection conducted on January 8-9, 2025 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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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 obtain a consent to release information form prior to releasing information in three out of twelve records reviewed.
Client #7 was admitted on September 26, 2018. the client passed away on November 26, 2024; however, he remains in active status in the facility's records. There was no release of information form for a funding source in the client's record. Facility confirmed billing had occurred.
Client #8 was admitted on November 17, 2023 and discharged on November 18, 2024. There was no release of information form for a funding source in the client's record. Facility confirmed billing had occurred.
Client #11 was admitted on September 14, 2018 and was still active at the time of the inspection. There was no release of information form for a funding source and lab in the client's record. Facility confirmed billing and laboratory services had occurred.
This is a repeat citation from the July 23, 2024 licensing inspection.
These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
During Treatment Team Meeting on 02/11/2025, the Facility Director will remind staff that prior to the release of confidential information, staff will obtain consent to release confidential information to all persons/organizations requesting information on individuals in our programs. Releases will be completed and signed by the active clients by 02/12/2025. The QA Manager will be responsible for auditing releases on an ongoing basis to ensure that releases for funding sources and laboratory testing facilities will be completed at time of admission and renewed annually. Ongoing compliance with the standard will be the responsibility of the Assistant Clinical Supervisor through random record review and during individual supervision. |
709.28 (c) (3) 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. The consent must be in writing and include, but not be limited to:
(3) Purpose of disclosure.
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Observations
Based on the review of client records, the facility failed to document a completed consent to release information form to include purpose of disclosure in two out of twelve records reviewed.
Client #2 was admitted on November 5, 2024 and was still active at the time of the inspection. A form dated November 5, 2024 was to a lab.
Client #7 was admitted on September 26, 2018. The client passed away on November 26, 2024; however, he remains in active status in the facility's records. A form dated October 4, 2024 to a family member indicated "other" to be disclosed without specifying what additional information could be released.
Client #10 was admitted on November 7, 2011 and was still active at the time of the inspection. A form dated August 12, 2024 was to a lab.
This is a repeat citation from the July 25, 2023 and July 23, 2024 licensing inspection.
These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
During Treatment Team Meeting on 2/11/2025, the Facility Director will remind staff that the purpose of disclosure must be specified on any consent to release confidential information signed by a client. The QA Manager will be responsible for auditing releases on an ongoing basis to ensure the purpose of the release is clearly documented. Ongoing compliance with the standard will be the responsibility of the Assistant Clinical Supervisor through random record review and during individual supervision. |
709.28 (d) LICENSURE Confidentiality
§ 709.28. Confidentiality.
(d) A copy of a client consent shall be offered to the client and a copy maintained in the client record.
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Observations
Based on the review of client records, the facility failed to document if the client was offered a copy of the consent to release information form in one out of twelve records reviewed.
Client #2 was admitted on November 5, 2024 and was still active at the time of the inspection. The form was dated November 5, 2024 to a lab.
This is a repeat citation from the July 25, 2023 and July 23, 2024 licensing inspections.
The finding was reviewed with facility staff during the licensing inspection.
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Plan of Correction
During Treatment Team Meeting on 2/11/2025, the Facility Director will remind staff that all clients who sign consents must be offered a copy of the consent and the offer of a copy of the consent must be documented in the record. The QA Manager will be responsible for auditing releases on an ongoing basis to ensure the documentation that the client has been offered a copy of any signed consent is included in the record. Ongoing compliance with the standard will be the responsibility of the Assistant Clinical Supervisor through random record review and during individual supervision. |
709.31 (a) LICENSURE Data collection system
§ 709.31. Data collection system.
(a) A data collection and recordkeeping system shall be developed that allows for the efficient retrieval of data needed to measure the project ' s performance in relationship to its stated goals and objectives.
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Observations
Based on documentation reviews, the facility failed to have a recordkeeping system that allows for efficient retrieval of data needed to measure the facility's stated goals and objectives. The facility took 11 hours to produce copies of the policy and procedures manual after the documents were requested at the inspection.
This is a repeat citation from the July 23, 2024 licensing inspection.
The finding was reviewed with facility staff during the licensing inspection.
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Plan of Correction
On 01/14/2025, the Facility Director met with supervisory staff to review procedures for record retention. Supervisors will ensure that support staff maintain copies of records in a secure location for timely retrieval during an audit until the transition to a new EMR has been completed. A current, updated copy of the Policy and Procedure Manual will be maintained at all locations where OTP services are provided. The site Assistant Clinical Supervisor will be responsible for updating any changes to policies on an ongoing basis. Ongoing compliance with record storage and retrieval will be the responsibility of the QA Manager through random review of the appropriate maintenance and storage of clinical records at the facility. |
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 client records and discussions with facility staff, the facility failed to inform the Department of two unusual incidents within the required three days. The facility became aware of two recent deaths of clients on December 11, 2024 and November 18, 2024. The incidents were not reported to the Department.
This is a repeat citation from the July 23, 2024 licensing inspection.
These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
On 02/11/2025, the Facility Director will meet with the treatment team to remind staff that all deaths, including deaths from ill health that are not due to serious injury, trauma, suicide, medication error or unusual circumstances, must be reported to the Department as an Unusual Incident. Clinical staff will notify the Nursing Director and/or the Facility Director of all patient deaths, including deaths due to illness, immediately upon receipt of notification of an active patient's death. By 02/07/2025, the Facility Director will report the recent deaths to the Department in the online portal. Ongoing compliance with the reporting requirement of an Unusual Incident will be the responsibility of the Facility Director or the Nursing Director.
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715.9(a)(2) LICENSURE Intake
(a) Prior to administration of an agent, a narcotic treatment program shall screen each individual to determine eligibility for admission. The narcotic treatment program shall:
(2) Verify the individual 's identity, including name, address, date of birth, emergency contact and other identifying data.
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Observations
Based on the review of patient records, the facility failed to document an emergency contact in one out of twelve records reviewed.
Patient #11 was admitted on September 14, 2018 and was still active at the time of the inspection.
This is a repeat citation from the July 23, 2024 licensing inspection.
The finding was reviewed with facility staff during the licensing inspection.
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Plan of Correction
On 02/11/2025, the MO55: During Treatment Team Meeting on 2/11/2025, the Facility Director will remind staff of the requirement to document an emergency for all clients enrolled in the program. The QA Manager will be responsible for auditing releases on an ongoing basis to ensure that documentation of the client's emergency contact information and consent to release information is included in the record. Ongoing compliance with the standard will be the responsibility of the Assistant Clinical Supervisor through random record review and during individual supervision.
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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 facility failed to document the notification to the previous narcotic treatment program of the admission and initial dose of the patient in two out of two applicable records.
Patient #1 was admitted on October 1, 2024 and was still active at the time of the inspection.
Patient #4 was admitted on November 11, 2024 and was still active at the time of the inspection.
This is a repeat citation from the July 23, 2024 licensing inspection.
These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
By 02/11/2025 The Nursing Director will remind medical staff that confirmation of the admission and the initial dose administered to all transferred clients must be sent to the sending clinic. A copy of the transfer confirmation will be included in the medical record. Ongoing compliance with the regulation will be the responsibility of the Nursing Supervisor through ongoing audits of all transferred clients. |
715.23(b)(5) LICENSURE Patient records
(b) Each patient file shall include the following information:
(5) The results of all annual physical examinations given by the narcotic treatment program which includes an annual reevaluation by the narcotic treatment physician.
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Observations
Based on the review of patient records, the facility failed to document an annual physical examination by the narcotic treatment physician according to the facility's policy and procedures manual in four out of five applicable records. The manual states the examination occur during the anniversary month of admission.
Patient #9 was admitted on October 28, 2015 and was still active at the time of the inspection. The annual physical exam was due no later than October 31, 2024; however, none was completed.
Patient #10 was admitted on November 7, 2011 and was still active at the time of the inspection. The annual physical exam was due no later than November 30, 2024; however, none was completed.
Patient #11 was admitted on September 14, 2018 and was still active at the time of the inspection. The annual physical exam was due no later than September 30, 2024; however, none was completed.
Patient #12 was admitted on September 2, 2004 and was still active at the time of the inspection. The annual physical exam was due no later than September 30, 2024; however, it was completed on October 18, 2024.
This is a repeat citation from the July 25, 2023 and July 23, 2024 licensing inspections.
The findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
M225: on 01/24/2025, the Facility Director revised the Policy & procedure Manual to require that an Annual Physical Examination will be completed within 30 days of the anniversary of the client's admission date. As of 02/07/25 the QA Manager will share due dates of upcoming annual physical examinations with the Nursing Director and/or his/her designee who will enter appointment reminders in the dispensing record. Dispensing staff will remind clients of upcoming annual physicals scheduled. Medical staff will document all "No Shows" for annual physical examinations to ensure that annual physical examinations are completed within the agency policy requirement. Monitoring ongoing compliance with the regulation will be the responsibility of the QA Manager through review of the medical records of all active clients. |
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 document an annual clinical evaluation, that has been reviewed, dated and signed by the medical director within the timeframe outline in the facility's policy and procedures manual in four out of four applicable records. The manual states an annual review by the clinician occur during the anniversary month of admission to treatment.
Patient #7 was admitted on September 26, 2018. The client passed away on November 26, 2024; however, he remains in active status in the facility's records. An annual clinical evaluation was completed on September 13, 2024 but it was not signed by a medical practitioner.
Patient #9 was admitted on October 28, 2015 and was still active at the time of the inspection. An annual clinical evaluation was due on October 31, 2024; however, it was completed on November 5, 2024. The evaluation was not signed by a medical practitioner.
Patient #10 was admitted on November 7, 2011 and was still active at the time of the inspection. An annual evaluation was completed on August 12, 2024 but it was not signed by a medical practitioner.
Patient #11 was admitted on September 14, 2018 and was still active at the time of the inspection. An annual clinical evaluation was due on September 30, 2024; however, none was completed.
This is a repeat citation from the July 23, 2024 licensing inspection.
These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
On 01/24/2025, the Facility Director revised the Policy & Procedure manual to require that an Annual Evaluation of each patient's status in treatment will be completed by the counselor and will be reviewed, dated and signed by the Narcotic Treatment Physician within thirty days of the anniversary date of the patient's admission to treatment. Clinicians will be notified of the requirement during treatment team meeting on 02/11/2025. Ongoing compliance will be the responsibility of the QA Manager through tracking of the completion of the documentation during ongoing audits of the clinical records. |
709.92(a) 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:
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Observations
Based on the review of client records, the facility failed to document a comprehensive treatment plan within guidelines established by the facility's policy and procedures manual in five out of five applicable records. The manual states the comprehensive treatment plan must be completed within 30 days following admission.
Client #1 was admitted on October 1, 2024 and was still active at the time of the inspection. A comprehensive treatment form was signed by the client on October 28, 2024; however, the form was blank.
Client #2 was admitted on November 5, 2024 and was still active at the time of the inspection. A comprehensive treatment plan was due on December 5, 2024; however, none was completed.
Client #3 was admitted on October 30, 2024 and was still active at the time of the inspection. A comprehensive treatment form was signed by the client on October 31, 2024; however, the form was blank.
Client #4 was admitted on November 11, 2024 and was still active at the time of the inspection. A comprehensive treatment form was due on December 11, 2024; however, none was completed.
Client #6 was admitted on September 23, 2024 and discharged on November 5, 2024. A comprehensive treatment plan was due on October 23, 2024; however, none was completed.
This is a repeat citation from the July 23, 2024 licensing inspection.
These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
By 02/11/2025, the Facility Director will remind staff that a Comprehensive Treatment Plan must be completed within 30 days of the date of admission. The QA Manager will create a tracking record of new admissions and will forward reminders to clinicians when the Treatment Plans are due. The QA manager will be responsible for ensuring ongoing compliance with the regulation through audit of the records to verify that Comprehensive Treatment Plans are completed by the due date and will forward compliance reports to the Clinical Supervisor for ongoing follow- up. |
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 document treatment plan updates within the regulatory timeframe in nine out of nine applicable records reviewed.
Client #1 was admitted on October 1, 2024 and was still active at the time of the inspection. A comprehensive treatment plan was signed by the client on October 28, 2024 and the next update was due no later than December 28, 2024; however, none was completed.
Client #3 was admitted on October 30, 2024 and was still active at the time of the inspection. A comprehensive treatment plan was signed by the client on October 31, 2024 and the next update was due no later than December 31, 2024; however, none was completed.
Client #5 was admitted on January 20, 2021 and was still active at the time of the inspection. A treatment plan update was completed on September 13, 2024 and the next update was due no later than November 13, 2024; however, none was completed.
Client #7 was admitted on September 26, 2018. The client passed away on November 26, 2024; however, he remains in active status in the facility's records. A treatment plan update was completed on July 11, 2024 and the next one was due no later than September 11, 2024; however, it was completed on September 19, 2024. In addition, the next update was due no later than November 19, 2024; however, none was completed.
Client #8 was admitted on November 17, 2023 and discharged on November 18, 2024. A treatment plan update was completed on August 30, 2024 and the next update was due no later than October 30, 2024; however, none was completed.
Client #9 was admitted on October 28, 2015 and was still active at the time of the inspection. A treatment plan update was completed on November 5, 2024 and the next update was due no later than January 5, 2025; however, none was completed.
Client #10 was admitted on November 7, 2011 and was still active at the time of the inspection. A treatment plan update was completed on October 11, 2024 and the next update was due no later than December 11, 2024; however, none was completed.
Client #11 was admitted on September 14, 2018 and was still active at the time of the inspection. A treatment plan update was completed on May 24, 2024 and the next update was due no later than July 24, 2024; however, the next update was completed on November 13, 2024.
Client #12 was admitted on September 2, 2004 and was still active at the time of the inspection. A treatment plan update was completed on September 20, 2024 and the next update was due no later than November 20, 2024; however, none was completed.
These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
The Facility Director will remind clinicians of the requirement that treatment plans must be reviewed and updated at least every 60 days during the Treatment Team meeting on 02/11/2025. The QA Manager will create a tracking record of Treatment Plan Review/Update due dates and will forward reminders to clinicians when the reviews and updates are due on a monthly basis. The QA manager will be responsible for ensuring ongoing compliance with the regulation through audit of the records to verify that Treatment Plan Reviews and Updates have been completed every 60 days and will forward compliance reports to the Clinical Supervisor for ongoing follow up. |
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 that the clients received counseling services according to their individual treatment plans in eight out of nine applicable records.
Client #1 was admitted on October 1, 2024 and was still active at the time of the inspection. A preliminary treatment plan, dated October 1, 2024 indicated one hour per week of individual counseling. There were no sessions between October 2 - October 27, 2024. Additionally, a progress note from a October 28, 2024 individual session stated counseling sessions should occur 2.5 hours per month and weekly group session for six weeks. There were no sessions documented starting October 29, 2024.
Client #2 was admitted on November 5, 2024 and was still active at the time of the inspection. A preliminary treatment plan dated November 5, 2024 indicated one hour per week of individual sessions. There were no sessions documented in the client's record.
Client #3 was admitted on October 30, 2024 and was still active at the time of the inspection. A progress note dated October 31, 2024 indicated sessions 2.5 hours per month. There were no additional sessions documented in the client's record.
Client #4 was admitted on November 11, 2024 and was still active at the time of the inspection. A progress note dated November 19, 2024 indicated sessions 2.5 hours per month. there were no additional sessions documented in the client's record.
Client #5 was admitted on January 20, 2021 and was still active at the time of the inspection. A treatment plan update dated September 13, 2024 indicated monthly sessions. There were no additional sessions documented in the client's record.
Client #8 was admitted on November 17, 2023 and discharged on November 18, 2024. A treatment plan updated dated August 30, 2024 indicated sessions 2.5 hours per month. In September and October 2024, there were only 30 minutes each month of documented sessions.
Client #9 was admitted on October 28, 2015 and was still active at the time of the inspection. A treatment plan update dated November 5, 2024 indicated monthly sessions. There were no sessions documented in September, October and December 2024.
Client #10 was admitted on November 7, 2011 and was still active at the time of the inspection. A treatment plan update dated October 11, 2024 indicated bi-monthly individual sessions. There were no documented sessions after October 11, 2024.
This is a repeat citation from the July 23, 2024 licensing inspection.
These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
By 02/11/2025, the Facility Director will review the regulatory requirement with the clinical staff to ensure that services are provided in accordance with the service goals outlined in the treatment plan and in the treatment plan updates and amendments. The Assistant Clinical Supervisor will remind clinicians of the importance of documenting when a patient is a "no show" for a treatment service as well as ensuring that documentation of any change in the type and/or frequency of the service is documented in the record. Ongoing compliance with the regulation will be the responsibility of the QA Manager who will review treatment plans and the record of service to ensure that services are being provided and documented in accordance with the Individual Treatment Plans, Updates and Amendments |
709.93(a)(3) LICENSURE Client records
709.93. Client records.
(a) There shall be a complete client record on an individual which includes information relative to the client's involvement with the project. This shall include, but not be limited to, the following:
(3) Record of services provided.
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Observations
Based on a review of client records, the facility failed to document a complete record of service in twelve out of the twelve records reviewed.
Client #1 was admitted on October 1, 2024 and was still active at the time of the inspection. There was no record of service in the client's record.
Client #2 was admitted on November 5, 2024 and was still active at the time of the inspection. There was no record of service in the client's record.
Client #3 was admitted on October 30, 2024 and was still active at the time of the inspection. The record of service was incomplete, as the October 31, 2024 counselor session was omitted from the document.
Client #4 was admitted on November 11, 2024 and was still active at the time of the inspection. The record of service only had the first counseling session on November 11, 2024 documented.
Client #5 was admitted on January 20, 2021 and was still active at the time of the inspection. There was no record of service in the client's record.
Client #6 was admitted on September 23, 2024 and discharged on November 5, 2024. The record of service only had the first counseling session on September 23, 2024 documented.
Client #7 was admitted on September 26, 2018. The client passed away on November 26, 2024; however, he remains in active status in the facility's records. There was no record of service in the client's record.
Client #8 was admitted on November 17, 2023 and discharged on November 18, 2024. There was no record of service in the client's record.
Client #9 was admitted on October 28, 2015 and was still active at the time of the inspection. There was no record of service in the client's record.
Client #10 was admitted on November 7, 2021 and was still active at the time of the inspection. There was no record of service in the client's record.
Client #11 was admitted on September 14, 2018 and was still active at the time of the inspection. There was no record of service in the client's record.
Client #12 was admitted on September 2, 2004 and was still active at the time of the inspection. There was no record of service in the client's record.
This is a repeat citation from the July 23, 2004 licensing inspection.
These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
By 02/11/2025, the Nursing Director will remind staff to complete the Record of Service in the clinical record after any service has been provided. The Clinical Supervisor will be responsible for monitoring ongoing compliance with the requirement through random record review and during individual supervision. |
709.93(a)(8) LICENSURE Client records
709.93. Client records.
(a) There shall be a complete client record on an individual which includes information relative to the client's involvement with the project. This shall include, but not be limited to, the following:
(8) Case consultation notes.
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Observations
Based on a review of client records, the facility failed to document case consultations within guidelines established by the facility's policy and procedures manual in six out of six applicable records. The manual states a case consultation must be completed every 90 days for the first twelve months following admission and annually thereafter.
Client #1 was admitted on October 1, 2024 and was still active at the time of the inspection. A case consultation was due on December 31, 2024; however, none was completed.
Client #5 was admitted on January 20, 2021 and was still active at the time of the inspection. A case consultation was completed on October 15, 2024, with documentation showing only one staff person was present.
Client #7 was admitted on September 26, 2018. The client passed away on November 26, 2024; however, he remains in active status in the facility's records. A case consultation was completed on September 13, 2024, with documentation showing only one staff person was present.
Client #10 was admitted on November 7, 2011 and was still active at the time of the inspection. A case consultation was completed on September 9, 2024, with documentation showing only one staff person was present.
Client #11 was admitted on September 14, 2018 and was still active at the time of the inspection. A case consultation was due on September 14, 2024; however, none was completed.
Client #12 was admitted on September 2, 2004 and was still active at the time of the inspection. A case consultation was completed on September 20, 2024, with documentation showing only one staff person was present.
This is a repeat citation from the July 23, 2024 licensing inspection.
These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
By 02/11/2025, the Facility Director will review the regulation and the requirement to document a Case Consultation every ninety days during the first year of treatment and annually thereafter as well as the requirement to document all individuals present during the Case Consultation.
The QA Manager will be responsible for monitoring ongoing compliance with the regulation through tracking and sending monthly reminders of upcoming due dates to clinicians on an ongoing basis. The Assistant Clinical Supervisor will be responsible for ensuring ongoing compliance with the regulations through random audita of the Case Consultation records and during individual and group supervision.
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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 patient records, the facility failed to comply with plans of correction that were approved by the Department.
A plan of correction for consent to release information forms containing purpose of disclosure were submitted and approved by the Department for the July 25, 2023 and July 23, 2024 annual licensing inspection. Consent to release information forms were again found to be a deficiency in the January 9, 2025 licensing inspection.
A plan of correction for consent to release information forms in which a copy is offered to the client were submitted and approved by the Department for the July 25, 2023 and July 23, 2024 annual licensing inspection. Consent to release information forms were again found to be a deficiency in the January 9, 2025 licensing inspection.
A plan of correction for annual physical examinations were submitted and approved by the Department for the July 25, 2023 and July 23, 2024 annual licensing inspection. Annual physical examinations were again found to be a deficiency in the January 9, 2025 licensing inspection.
These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
By 2/11/2025, the Facility Director will meet with the Treatment Team to review the Plans of Correction submitted to the Department in response to the licensing audit on 01/09/2024. The Plans of Correction will also be addressed during individual supervision meetings by the Clinical Supervisor. On 01/30/2025, the Facility Director shared the Plans of Correction with the new QA manager to ensure that staff compliance with the plans will be monitored on an ongoing basis. The Performance Improvement Committee will be responsible for reviewing compliance with the plans during monthly PI Meetings to ensure ongoing compliance with the regulations. |