INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on November 26, 27 and 28, 2007 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, New Directions Treatment Services (Bethlehem) 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 and a plan of correction is due on January 1, 2008.
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Plan of Correction
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704.12(a)(6) LICENSURE OutPatient Caseload
704.12. Full-time equivalent (FTE) maximum client/staff and client/counselor ratios.
(a) General requirements. Projects shall be required to comply with the client/staff and client/counselor ratios in paragraphs (1)-(6) during primary care hours. These ratios refer to the total number of clients being treated including clients with diagnoses other than drug and alcohol addiction served in other facets of the project. Family units may be counted as one client.
(6) Outpatients. FTE counselor caseload for counseling in outpatient programs may not exceed 35 active clients.
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Observations
Based on a review of the facility's staffing compliance plan and the active patient to counselor caseload list presented by the program director on November 26, 2007 it was determined that the facility failed to comply with the exception for the patient to counselor ratio granted by the Division on January 25, 2005. A review of documented correspondence between New Directions Treatment Services and the Division dated November 4, December 9 and 13, 2004 and January 11 and 25, 2005 indicated that qualified counselors must have been employed with the NTP for minimally one year. The staffing compliance plan signed and dated by the facility director on November 28, 2007 revealed that counselors #7 and 12 did not meet the qualifications based on their hire dates of March 5, 2007 and April 26, 2007, respectively. Counselor #7 had a caseload of 37 patients with two patients on reduced counseling status. Counselor #12 had a caseload of 38 patients with nine patients on reduced counseling status.
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Plan of Correction
This facility does not file electronically, a Plan of Correction is on file with the Department of Health. |
709.33(a) LICENSURE Notification of Termination
709.33. Notification of termination.
(a) Project staff shall notify the client, in writing, of a decision to involuntarily terminate the client's treatment at the project. The notice shall include the reason for termination.
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Observations
Based on a review of client records on November 27 and 28, 2007, it was determined that the facility failed to inform the client of the facility's reason for involuntarily terminating the client's treatment at the project. A review of two of two client records, specifically #16 and 23, indicated that the notice of termination given to the client failed to include the facility's reason for involuntarily terminating the client's treatment.
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Plan of Correction
This facility does not file electronically, a Plan of Correction is on file with the Department of Health. |
709.91(b)(5) LICENSURE Intake and admission
709.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(5) Physical examination, if applicable.
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Observations
Based on a review of client records on November 26, 27 and 28, 2007, it was determined that the facility failed to document the general appearances and physician's impressions on the physical examination forms. A review of 16 of 18 client records, specifically #1, 2, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13, 18, 19, 20 and 21, revealed that the facility failed to document the client's general appearance and physician's impressions.
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Plan of Correction
This facility does not file electronically, a Plan of Correction is on file with the Department of Health. |
709.91(b)(6) LICENSURE Intake and admission
709.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(6) Psychosocial evaluation.
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Observations
Based on a review of client records on November 26, 27 and 28, 2007, it was determined that the facility failed to ensure that the psychosocial evaluation contained a clinical analysis of the client's problems/needs, assets/strengths, support systems, coping mechanisms, negative factors, client's attitude toward treatment and overall impressions. A review of seven of thirteen client records, specifically #2, 8, 10, 16, 18, 19 and 21, indicated that the psychosocial evaluation failed to document the client's problems/needs, assets/strengths, support systems, coping mechanisms, negative factors, client's attitude toward treatment and overall impressions based on the clinician's analysis of the collected historical information.
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Plan of Correction
This facility does not file electronically, a Plan of Correction is on file with the Department of Health. |
709.92(a)(1) 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:
(1) Short and long-term goals for treatment as formulated by both staff and client.
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Observations
Based on a review of client records on November 26, 27 and 28, 2007, it was determined that the facility failed to ensure that the short and long-term goals in the individual treatment plan were individualized for each client. A review of nine of thirteen client records, specifically #1, 2, 3, 4, 7, 10, 16, 20 and 21, indicated that the facility failed to individualize the short and long-term goals on the individual treatment and rehabilitation plan. The individual treatment and rehabilitation plan documented in the client records revealed generalized goals that were not measurable or specific to each client's issues and/or needs.
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Plan of Correction
This facility does not file electronically, a Plan of Correction is on file with the Department of Health. |
709.92(a)(3) 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:
(3) Proposed type of support service.
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Observations
Based on a review of client records on November 26, 27 and 28, 2007, it was determined that the facility failed to include support services on the individual treatment and rehabilitation plan. A review of five of thirteen client records, specifically #1, 2, 8, 18 and 20, indicated that support services specific to the client's needs were not identified.
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Plan of Correction
This facility does not file electronically, a Plan of Correction is on file with the Department of Health. |