INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on November 15, 2017 by staff from the Department of Drug and Alcohol Programs, Bureau of Quality Assurance for Prevention and Treatment, Program Licensure Division. 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(b)(1) LICENSURE Individual training plan.
704.11. Staff development program.
(b) Individual training plan.
(1) A written individual training plan for each employee, appropriate to that employee's skill level, shall be developed annually with input from both the employee and the supervisor.
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Observations
Based on a review of 7 personnel records, the facility failed to document an annual individual training plan for the facility's current training year in 2 records reviewed. Employee # 2 was hired as a facility director on 11/15/16 and was still in the position at the time of the inspection.Employee # 3 was hired as a clinical supervisor on 5/9/16 and was still in the position at 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: Employee #2, facility director, will complete an annual individual training plan for the facility's current training year by 12/8/17. Employee #3, clinical supervisor, will complete an annual individual training plan by 12/8/17. Both employees will review the training plans with the Executive Director of the agency.
Persons Responsible: Program Director, Clinical Supervisor, Executive Director |
705.8 (2) LICENSURE Heating and cooling.
705.8. Heating and cooling.
The residential facility:
(2) May not permit in the facility heaters that are not permanently mounted or installed.
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Observations
Based on the physical plant inspection on November 16, 2017 at approximately 10:00 a.m., the facility failed to ensure that all heaters in the facility were permanently mounted or installed. The medical office located across the hall from the administrative offices had a space heater located on the floor behind the door and under the examination table.The findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
Action/Plan: On 11/30/17, the Program Director removed the space heater located in the medical office. A heater will be permanently mounted on to the wall.
Persons Responsible: Program Director; Director of Administration |
709.28 (c) (2) 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:
(2) Specific information disclosed.
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Observations
Based on a review of 12 client records, the facility failed to keep disclosures of client identifying information within the limits established by 4 Pa. Code 255.5 (b) for releases of information in 2 records reviewed.Client #1 was admitted on 3/21/14 and was an active client at the time of inspection. A consent to release form was signed and dated on 3/23/16 and expired on 3/23/17 to an insurance provider and an updated release of information form was not signed until 7/27/17. Evidence of billing between 3/23/17 and 7/27/17 was present in record without a valid consent.Client #2 was admitted on 2/1/17 and was an active client at the time of inspection. An individual counseling session on 8/29/17 was conducted with the client and the client's parent. However, the consent form for the parent was only related to being an emergency contact and not a consent to release information pertaining to therapy. Additionally, a consent to the client's funding source was not completed and there was evidence of billing to the funding source between 2/1/17 and the time of inspection.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Program Director will meet with the counselor providing treatment for Client #1 to ensure that the client signs a release of information for the insurance provider in a timely manner. The client will sign the release of information on 12/9/2017. The Program Director and counselor will review the release of information to ensure that it has been signed and dated by the client. Regarding Client #2, the Program Director will instruct the counselor to have the client sign a release of information permitting the client's family member(s) to actively participate in counseling/family therapy sessions. The counselor will also make sure that Client #2 signs and dates a release of information for her insurance provider. The Program Director will review both of the releases of information to ensure that they have been signed and dated. During weekly supervision meetings with both of the counselors, charts will be reviewed and audited to ensure that releases of information and other pertinent documents are signed and dated in a timely manner.
Persons Responsible: Program Director; Counselor overseeing Client #1; Counselor overseeing Client #2. |
709.32 (b) LICENSURE Medication control
§ 709.32. Medication control.
(b) Verbal orders for medication can be given only by a physician or other medical professional authorized by State and Federal law to prescribe medication and verbal orders may be received only by another physician or medical professional authorized by State and Federal law to receive verbal orders. When a verbal or telephone order is given, it has to be authenticated in writing by a physician or other medical professional authorized by State and Federal law to prescribe medication. In detoxification levels of care, written authentication shall occur no later than 24 hours from the time the order was given. Otherwise, written authentication shall occur within 3 business days from the time the order was given.
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Observations
Based on a review of 12 client records, record # 2 had a verbal order given by the doctor and received by the nursing staff on 6/28/17. However, the order was not signed by the doctor within the 72 hour regulatory timeframe.Client #2 was admitted on 2/1/17 and was active at the time of inspection.The findings were discussed with facility staff during the licensing process.
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Plan of Correction
The Program Director will speak to the narcotic treatment physician to ensure that orders are signed within the 72 hour regulatory timeframe. The Program Director will monitor this following each admission.
Person(s) Responsible: Program Director, Narcotic Treatment Physician, and Nurse Manager |
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 the review of the facility's unusual incident reports on 11/17/17, it was discovered that the facility failed to notify the Department within 3 business days of the following unusual incidents below.The incident date and reason are:9/5/17 - Police presence requested10/21/17 - Physical Violence with a weapon These findings were reviewed with project and facility staff during the licensing process.
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Plan of Correction
Regarding the facility's reporting of unusual incidents to the Department, the Program Director will ensure that all unusual incidents, as identified in 709.34, will be reported within 3 days of the unusual incidents. During a staff meeting on 12/12/17, the Program Director will remind all clinicians that they must inform the Program Director any time an unusual incident occurs so that they can be documented and reported to the Department. The Program Director will keep a binder identifying all unusual incidents that must be reported to the Department within 3 business days.
Person(s Responsible: Program Director, Director of Administration, Facility Staff |
715.9(a)(4) 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:
(4) Have a narcotic treatment physician make a face-to-face determination of whether an individual is currently physiologically dependent upon a narcotic drug and has been physiologically dependent for at least 1 year prior to admission for maintenance treatment. The narcotic treatment physician shall document in the patient 's record the basis for the determination of current dependency and evidence of a 1 year history of addiction.
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Observations
Based on a review of 12 client records, the facility failed to document the physician's face to face contact and one-year documentation required by the physician in 1 record.Client # 11 was admitted on 7/18/16 and was discharged on 1/13/17. The findings were discussed with facility staff during the licensing process.
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Plan of Correction
With regard to Client #11, the Program Director spoke to the Narcotic Treatment Physician to address why face-to-face contact was not documented. The Program Director also met with the Narcotic Treatment Physician to find out why there was no documented evidence of 12 months of physiological dependence on a narcotic drug. The Program Director will meet with the Narcotic Treatment Physician following each intake admission to ensure that proper documentation is noted to comply with code 715.9(a)(4).
Person(s) Responsible: Program Director; Narcotic Treatment Physician |
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 12 client records, the facility failed to obtain and document an initial urinalysis for client #11, whom was admitted on 7/18/16 and was discharged 1/13/17.The findings were discussed with facility staff during the licensing process.
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Plan of Correction
Regarding client #11, the Program Director spoke to the Narcotic Treatment Physician to discuss why the client's initial urinalysis was not obtained and documented. To comply with 715.14(a), the Program Director will meet with the Narcotic Treatment Physician to ensure that prospective patients' drug screens are obtained and documented.
Person(s) Responsible: Narcotic Treatment Physician; Nurse Manager; Program Diretor |
715.23(b)(4) LICENSURE Patient records
(b) Each patient file shall include the following information:
(4) The results of an initial intake physical examination.
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Observations
Based on a review of 12 client records, the facility failed to conduct an initial physical examination in 1 record reviewed.Client #11was admitted on 7/18/16 and was discharged on 1/13/17.The findings were discussed with facility staff during the licensing process.
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Plan of Correction
With regard to Client #11, the Program Director spoke to the Narcotic Treatment Physician to find out why an initial physical examination was not conducted. Following each intake admission, the Program Director will consult with the Narcotic Treatment Physician to ensure that physical examinations are conducted and documented to comply with code 715.23(b)(4).
Person(s) Responsible: Program Director; Narcotic Treatment Physician; Nurse Manager |
715.23(b)(6) LICENSURE Patient records
(b) Each patient file shall include the following information:
(6) Results of laboratory tests or other special examinations given by the narcotic treatment program.
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Observations
Based on a review of 12 client records, the facility failed to document the results of the facility's serological test in 1 record reviewed.Client #11 was admitted on 7/18/16 and was discharged on 1/13/17.The findings were discussed with facility staff during the licensing process.
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Plan of Correction
Regarding Client #11, the Program Director met with the Narcotic Treatment Physician to find out why the results of the client's serological tests were not documented and recorded. At the time of each intake admission, the Program Director will ensure that the Narcotic Treatment Physician documents the results of clients' serological tests, in order to comply with code 715.23(b)(6).
Person(s) Responsible: Program Director; Narcotic Treatment Physician; and Nurse Manager |
715.23(f) LICENSURE Patient records
(f) If a narcotic treatment program keeps patient information in more than one file or location, it is the responsibility of the narcotic treatment program to provide the entire patient record to authorized persons conducting narcotic treatment program approval activities at the narcotic treatment program, upon request.
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Observations
Based on a review of 12 client records, the facility was not able to produce the medical portion of the client's chart upon request in 1 record.Client # 11 was admitted on 7/18/16 and was discharged on 1/13/17. The findings were discussed with facility staff during the licensing process.
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Plan of Correction
Regarding Client #11, the Program Director spoke to all staff members to find out if the medical portion of the chart was located in their offices. The Program Director will ensure that all charts, including the medical portion, are filed in the correct places.
Person(s) Responsible: Administrative Staff; Program Director; Narcotic Treatment Physician; Counselors; Dosing Nurses; Nurse Manager |
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 12 client records, 7 records had treatment plan updates completed after the regulatory timeframe. Additionally, 2 records had treatment plan updates missing at the time of the inspection.Client #1 was admitted on 3/21/17 and was active at the time of inspection. A treatment plan update was completed 8/28/17 and the next update was due no later than 10/28/17. However, the next update was not completed until 11/9/17. Client #2 was admitted on 2/1/17 and was active at the time of inspection. A treatment plan update was completed 2/22/17 and the next update was due no later than 4/22/17. However, the next update was not completed until 5/17/17. Client #3 was admitted on 7/16/14 and was an active patient at time of inspection. A treatment plan was completed 3/30/17 and the next update was due no later than 5/30/17. However, the next update was not completed until 6/12/17. Additionally, a treatment plan was completed 6/12/17 and the next update due no later than 8/12/17. However, the next update was not completed until 8/28/17. Client #5 was admitted on 3/20/17 and was active at the time of inspection. A treatment plan update was completed 5/31/17 and the next update was due no later than 7/31/17. However, the next update was not completed until 8/16/17. Client #7 was admitted on 1/30/13 and was active at the time of inspection. A treatment plan update was completed 12/21/16 and the next update was due no later than 2/21/17. However, the next update was not completed until 4/19/17. Also, a treatment plan update was completed 6/21/17 and the next update was due no later than 8/21/17. However, the next update was not completed until 9/6/17. Additionally, a treatment plan update was completed 9/6/17 and the next update was due no later than 11/6/17. However, the next update was not completed at the time of inspection.Client #9 was admitted on 6/14/16 and was discharged 10/12/17. A treatment plan update was completed 3/14/17 and the next update was due no later than 5/14/17. However, the next update was not completed until 7/21/17. Additionally, a treatment plan update was completed 7/21/17 and the next update was due no later than 9/21/17. However, the next update was not completed at the time of inspection.Client #10 was admitted on 3/3/17 and was discharged 9/26/17. A treatment plan update was completed 6/2/17 and the next update was due no later than 8/2/17. However, the next update was not completed until 9/21/17. These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
With regard to 709.2 and the completion of treatment plans reviewed and updated every 60 days, the Program Director met with all of the counselors on 11/21/2017 and emphasized that all treatment plans must be completed in a timely manner, every 60 days. Program Director informed the counselors that they will be placed on a Performance Improvement Plan if they do not complete treatment plans in a timely manner. The Program Director met with the counselor overseeing Client #1 to find out why the treatment plan was done on 11/9/17, rather than 10/28/17. The Program Director met with the counselor overseeing client #2 to find out why the client's treatment plan was done on 5/17/17, rather than the due date of 4/22/17. Regarding client #3, the Program Director met with the counselor to find out why 2 treatment plans were late (done on 6/12/17 and 8/28/17). The Program Director met with the counselor overseeing client #5 to learn why the treatment plan was late; it was due on 7/31/17, but was not completed until 8/16/17. The Program Director met with the counselor to discuss client #7 and why the treatment plan was done on 4/19/17 instead of 2/21/17. In addition, the Program Director spoke with the same counselor to find out why the same client's treatment plan was done on 9/6/17, instead of 8/21/17. Finally, the Program Director spoke with the counselor to find out why client 7's treatment plan, due on 11/6/17, was not done at the time of inspection on 11/16/17. Regarding client #9, the Program Director spoke to the counselor to find out why the treatment plan for this client was not done until 7/21/17; it was due on 5/14/17. The same counselor was spoken to about why client 9's treatment plan, due on 9/21/17, was not done at the time of the inspection on 11/16/17. Finally, the Program Director spoke to the counselor regarding client #10 to learn why the treatment plan was done on 9/21/17, rather than 8/2/17.
The Program Director will review counselors' charts on a consistent basis to ensure that treatment plans are completed in a timely manner, every 60 days.
Person(s) Responsible: Program Director; Counselors |