INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on November 29-30, 2016 by staff from the Division of Drug and Alcohol 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 the Staffing Requirements Facility Summary Report on November 29-30, 2016, the facility failed to ensure that all other nonclinical employees had completed a minimum of 6 hours HIV/AIDS and at least 4 hours of TB/STD training within the first 2 years of employment. Employee #10 was hired for Security on 12/24/2012 and was due to complete both trainings by 12/24/2014. Employee #10 did not complete the training by the time of the inspection.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Action/Plan: The Clinical Director will maintain a tracking system to ensure that all new clinical staff members complete the mandatory HIV/AIDS and TB/STD trainings within the first year of their hire date. This tracking system will also ensure that non-clinical employees will complete the required TB/STD and HIV/AIDS training within the first two years of their hire date. Employee #10 has been registered for a "Basic HIV" course, on 1/26/17, from 9am-4pm, in Essington, PA.
Person(s) Responsible: Clinical Director, Program Director
Date of Full Compliance: 1/26/2017 |
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 patient records on November 29-30, 2016, the facility failed to obtain an informed and voluntary consent which documented the purpose of the disclosure and the name of the person, agency or organization to whom the disclosure was made in two of nine patient records reviewed.Patient #5 was admitted to treatment on 5/27/2016 and is still an active patient. The facility staff did not ensure that an informed and voluntary consent was completed for the patient's funding source.Patient #6 was admitted to treatment on 1/13/2016 and is still an active patient. The facility staff did not ensure that an informed and voluntary consent was completed for the patient's funding source.These findings were reviewed with facility staff during the licensing process..
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Plan of Correction
Action/Plan: On 1/4/2017, the Clinical Director spoke to the counselor overseeing patient #5 to ensure that the consent/release of information was completed for the patient's funding source. The Clinical Director will continue to monitor proper documentation during random chart reviews.Also, on 1/4/17, the Clinical Director spoke to the counselor overseeing patient #6 to ensure that a voluntary consent/release of information was completed for the patient's funding source. The Clinical Director will continue to remind clinicians, during supervision and staff meetings, to comply with proper documentation in charts.
Person(s) Responsible: Clinical Director; Assistant Clinical Supervisor
Date: 1/4/2017 |
709.34 (c) (2) 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:
(2) Death or serious injury due to trauma, suicide, medication error or unusual circumstances.
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Observations
Based on the review of Administrative Documents on November 29-30, 2016, the facility failed to file a written report with the Department within 3 business days following an unusual incident involving a death.An Incident Report dated 9/4/2015 was reviewed stating that a patient's sister came to the facility to report that the patient was found unconscious at home and transported to the hospital where he died. The Department never received a written report.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Action/Plan: On December 1, 2016, the Clinical Director scanned and emailed two documents to the Department of Drug and Alcohol in Harrisburg: 1. Incident Report and 2. Methadone Death/Incident Case Review Form. The incident report identified a client's sister who informed the clinic that her brother was found unconscious. The client was taken to a local hospital where he later expired. The other document, completed by the former Program Director, was completed on 9/4/2015; this was the Methadone Death/Incident Case Review Form. This, too, as mentioned previously, was scanned and emailed to the Department on 12/1/2016. The document identified the cause of the client's death as "intercranial bleeding." The report also indicated that the client's health was "average and stable." The report also identified the client's counseling sessions for the three months prior to his death in September 2015. The Clinical Director will ensure that unusual incident reports are emailed or faxed to the Department within 3 business days following an unusual incident involving a death. During staff meetings, the Clinical Director will remind counselors about the importance of communicating deaths to the supervisor in a timely manner.
Person(s) Responsible: Clinical Director, Program Director
Date of full compliance: 12/1/2016 |
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 a review of patient records on November 29-30, 2016, the facility failed to screen each individual to determine eligibility for admission prior to the administration of an agent in two of seven patient records.Patient # 5 was admitted to treatment on 5/27/2016 and is still an active patient. The patient's identity, including name, address, and date of birth was not documented in the patient record.Patient #9 was admitted to treatment on 8/31/1992 and is still an active patient. The patient's identity, including name, address, and date of birth was not documented in the patient record.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Action/Plan: On 12/6/2016, the Clinical Director reviewed charts pertaining to patient #5 and #9 to ensure that the required photo IDs were in the chart. During a group supervision meeting with counselors on 12/6/16, the Clinical Director reminded everyone that they must obtain the proper identification from clients at the time of an intake. The Clinical Director will continue to audit charts, randomly, to ensure that a client's identity (name/address/date of birth) is recorded in the chart.
Person Responsible: Clinical Director
Date of Full Compliance: 12/6/2016 |
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 patient records on November 29-30, 2016, the facility failed to ensure that counseling services were provided according to the individual treatment and rehabilitation plan in five of nine patient records.Patient #4 was admitted to treatment on 1/13/2016 and is still active patient. Patient #4 was to attend 1 hour per month of individual treatment. He last attended on 9/6/2016. There was no documentation of Patient #4 attending the months of October and November 2016.Patient #5 was admitted to treatment on 5/27/2016 and is still an active patient. Patient #5 was to attend 1 hour per week of individual treatment. Patient #5 did not attend the week of 9/26/2016, 10/31/2016, 11/14/16, or 11/21/2016.Patient #6 was admitted to treatment on 1/13/2016 and is still an active patient. Patient #6 was to attend 1 hour per week of individual treatment. Patient #6 did not attend the week of 9/28/2016, 10/17/2016, 10/24/2016 or 11/7/2016.Patient #7 was admitted to treatment on 10/14/2015 and was discharged on 6/7/2016. He was to attend 1 hour per month of individual treatment. Patient #7 did not attend the month of February 2016.Patient #9 was admitted to treatment on 8/31/1992 and is still an active patient. Patient #9 was to attend 1 hour per month of individual treatment. There was no documentation for the months of September and October 2016.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Action/Plan: During a weekly group supervision meeting with all of the counselors on 1/3/2017, the Clinical Director instructed clinicians to make sure that all "no shows" and "cancelations" are being documented in progress notes. The Clinical Director spoke to the counselor overseeing patient #4 and instructed the counselor to make sure the client is being seen once per month for individual counseling. The Clinical Director spoke to the counselor overseeing patient #5 and instructed the clinician to make sure the client is being seen for counseling on a weekly basis; the counselor was told, on 1/3/17, that there must be documentation any time the client misses a counseling session. On 1/3/17, Clinical Director informed the counselor overseeing patient #6 that the client needs to be seen every week for individual counseling. Clinical Director informed the counselor that there was no documentation indicating why the client missed counseling sessions the week of 9/28/16, 10/17/16, 10/24/16, and 11/7/16. The counselor was informed that all sessions, including no shows and cancelations, must be documented. The Clinical Director, on 1/3/17, spoke to the counselor overseeing patient #7 and informed the clinician that no documentation was made indicating why counseling did not occur during February 2016. On 1/3/17, Clinical Director spoke to the counselor overseeing patient #9 and informed the clinician that no documentation was noted for September and October 2016; the client is required to attend counseling once per month. The Clinical Director will continue to audit charts, randomly, to ensure that notes are being documented and filed in a timely manner. Clinical Director, during weekly supervision meetings, will remind the counselors that clients must be compliant with counseling sessions.
Person Responsible: Clinical Director
Date of Full Compliance: 1/3/2017 |