INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection and methadone monitoring conducted on July 27, 2021 through July 29, 2021 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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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 personnel records, the facility failed to document an annual written individual training plan for each employee, appropriate to that employee's skill level, with input from both the employee and the supervisor in two of eight personnel records reviewed. Employee # 1 was hired as the Project Director on July 1, 2013. There was no current individual training plan documented in the personnel record at the time of the inspection.Employee # 2 was hired as the Facility Director on January 15, 2016. The individual training plan was signed by the employee on July 26, 2021; however, there was no indication that it was developed with input from the supervisor. These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
By 9/1/2021, an individual training plan will be completed and documented in Employee #1's personnel record; in addition, by 9/1/2021, an individual training plan will be reviewed and developed for Employee #2, with input from employee #2's supervisor. To ensure ongoing compliance, the annual individual training records for all employees will be devised one month prior to the due date, and they will be done collaboratively with both the employee and supervisor for appropriate input. |
704.11(d)(2) LICENSURE Annual Training Requirements
704.11. Staff development program.
(d) Training requirements for project directors and facility directors.
(2) A project director and facility director shall complete at least 12 clock hours of training annually in areas such as:
(i) Fiscal policy.
(ii) Administration.
(iii) Program planning.
(iv) Quality assurance.
(v) Grantsmanship.
(vi) Program licensure.
(vii) Personnel management.
(viii) Confidentiality.
(ix) Ethics.
(x) Substance abuse trends.
(xi) Developmental psychology.
(xii) Interaction of addiction and mental illness.
(xiii) Cultural awareness.
(xiv) Sexual harassment.
(xv) Relapse prevention.
(xvi) Disease of addiction.
(xvii) Principles of Alcoholics Anonymous and Narcotics Anonymous.
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Observations
Based on a review of eight personnel records, the facility failed to ensure that the Project Director completed at least 12 clock hours of training during the facility's July 1, 2020 through June 30, 2021 training year.Employee # 1 was hired as the Project Director on July 1, 2013. The personnel record documented 0 hours of training during the reviewed training year. This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
By 9/3/2021, all of the Project Director's trainings for the previous training year, July 1, 2020 through June 30, 2021, documenting 12 continuing education clock hours, will be placed in employee #1's personnel file. To ensure ongoing compliance with state regulations, the 12 clock hours of training will be completed and filed in the personnel file one week prior to the annual due date. |
704.11(f)(2) LICENSURE Trng Hours Req-Coun
704.11. Staff development program.
(f) Training requirements for counselors.
(2) Each counselor shall complete at least 25 clock hours of training annually in areas such as:
(i) Client recordkeeping.
(ii) Confidentiality.
(iii) Pharmacology.
(iv) Treatment planning.
(v) Counseling techniques.
(vi) Drug and alcohol assessment.
(vii) Codependency.
(viii) Adult Children of Alcoholics (ACOA) issues.
(ix) Disease of addiction.
(x) Aftercare planning.
(xi) Principles of Alcoholics Anonymous and Narcotics Anonymous.
(xii) Ethics.
(xiii) Substance abuse trends.
(xiv) Interaction of addiction and mental illness.
(xv) Cultural awareness.
(xvi) Sexual harassment.
(xvii) Developmental psychology.
(xviii) Relapse prevention.
(3) If a counselor has been designated as lead counselor supervising other counselors, the training shall include courses appropriate to the functions of this position and a Department approved core curriculum or comparable training in supervision.
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Observations
Based on a review of personnel records, the facility failed to ensure that each counselor completed at least 25 clock hours of training annually during the facility's July 1, 2020 through June 30, 2021 training year in two of three applicable personnel record reviewed.Employee # 6 was hired as a counselor on March 31, 2014. The personnel record documented 10 hours of training received during the training year reviewed. Employee # 7 was hired as a counselor on April 21, 2004. The personnel record documented 21 hours of training received during the training year reviewed. These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
On August 5, 2021, the Program Director met with Employee #6 and Employee #7 and registered both of the employees for upcoming trainings: 9/17/2021 (a training on spirituality and recovery) 6 credit hours; 10/8/2021 (a training on ethics) 6 credit hours; and 11/12/2021 (a training on effective communication and facilitating groups) 6 credit hours. The Program Director also registered both Employee #6 and Employee #7 for a training on 8/25/2021 (Trauma and Growth) which will offer 1 hour of credit. Following the completion of these four trainings, both employee #6 and employee #7 will have accrued 19 training hours; upon completion of the 4th training, on 11/12/2021, the Program Director will meet with employees #6 and #7 to register for a 5th training offering 6 training hours, which will give them a total of 25 hours. During monthly individual supervision with each counselor, the Program Director will review any trainings that the counselor has attended in the preceding month; each training will be documented and recorded on a spreadsheet for each counselor. The training spreadsheet will be reviewed each month during individual supervision with each counselor to ensure that all of the counselors are working towards 25 training hours. |
709.26 (b) (3) LICENSURE Personnel management.
§ 709.26. Personnel management.
(b) The personnel records must include, but are not limited to:
(3) Annual written individual staff performance evaluations, copies of which shall be reviewed and signed by the employee.
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Observations
Based on the review of personnel records, the facility failed to document annual written individual staff performance evaluations, copies of which shall be reviewed and signed by the employee in five of five applicable personnel records. Employee # 1 was hired as the Project Director on July 1, 2013. There was no annual performance evaluation documented in the personnel record at the time of the inspection.Employee # 2 was hired as the Facility Director on January 15, 2016. There was no annual performance evaluation documented in the personnel record at the time of the inspection.Employee # 6 was hired as a counselor on March 31, 2014. The annual written performance evaluation was completed by the supervisor on June 30, 2021; however, it was not reviewed and signed by the employee at the time of the inspection. Employee # 7 was hired as a counselor on April 21, 2004. The annual written performance evaluation was completed by the supervisor on July 4, 2021; however, it was not reviewed and signed by the employee at the time of the inspection. Employee # 8 was hired as a counselor on January 8, 2007. The annual written performance evaluation was completed by the supervisor on July 4, 2021; however, it was not reviewed and signed by the employee at the time of the inspection. This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
On August 25, 2021, employee #6, employee #7, and employee #8 met with the Program Director to review and sign their annual performance evaluations. By 9/3/2021, an annual performance evaluation will have been completed, reviewed, and signed by employee #1 and employee #2. To ensure ongoing compliance, the Program Director will meet with all of the employees/counselors to review and discuss annual performance evaluations at least two weeks before the due date. The Facility Director's supervisor, to ensure ongoing compliance with state regulations, will complete the annual performance evaluation and review it with the Facility Director by the designated due date. The supervisor overseeing the Project Director will complete and review the annual performance evaluation with the Project Director by the designated due date to ensure ongoing compliance with regulations. |
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
Based on a physical plant inspection, the facility failed to secure hard copy client records within locked storage containers. On July 29, 2021 at approximately 8:30 AM, there were unsecured paper client records in a counselor's office. This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
On August 11, 2021, the Program Director met with the employee who failed to secure client records in a locked file cabinet. The Program Director reviewed corporate compliance policies with the employee to ensure proper storage of client records and information. To ensure ongoing compliance with state regulations and HIPPA laws, the Program Director will facilitate random inspections of counselors' offices to make sure that client records are locked securely. |
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 client records, the facility failed to keep consent forms for the disclosures of client identifying information within the limits established by 4 Pa. Code 255.5 (a) for releases of information in one of seven client records reviewed. Client # 7 was admitted on May 18, 2020 and was still active at the time of the inspection. There was a release of information form to a government agency, signed and dated by the client and witness on March 15, 2021, that allowed for the release of lab results, which exceeded the limits established by 4 Pa. Code 255.5. This finding was reviewed with facility staff during the licensing inspection.
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Plan of Correction
On August 10, 2021, the Program Director facilitated a clinical staff meeting/group supervision and reviewed what items and information can be released to government agencies; specifically, all of the clinical staff members were informed that clients' lab results cannot be released to outside agencies, such as government agencies. On 8/23/2021, client #7 will sign a release of information for a government agency identifying the presence in treatment and nature of project, not lab results. To ensure ongoing compliance, the Program Director will review releases of information, during individual supervision and random chart/record reviews, to make sure that the correct information on releases is being identified, and that the information does not exceed the limits established by PA Code 255.5 |
715.19(1) LICENSURE Psychotherapy services
A narcotic treatment program shall provide individualized psychotherapy services and shall meet the following requirements:
(1) A narcotic treatment program shall provide each patient an average of 2.5 hours of psychotherapy per month during the patient 's first 2 years, 1 hour of which shall be individual psychotherapy. Additional psychotherapy shall be provided as dictated by ongoing assessment of the patient.
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Observations
Based on a review of patient records, the facility failed to provide each patient an average of 2.5 hours of psychotherapy per month during the patient's first 2 years in treatment in three of four applicable patient records reviewed. Patient # 1 was admitted on November 4, 2020 and was still active at the time of the inspection. The record of service and progress notes showed that less than 2.5 hours of psychotherapy per month were provided during the following months: February 2021 - 0 hours documented; March 2021 - 0 hours documented; April 2021 - 0 hours documented; May 2021 - 1 hour documented; and June 2021 - 30 minutes documented.Patient # 3 was admitted on October 19, 2020 and was still active at the time of the inspection. The record of service and progress notes showed that less than 2.5 hours of psychotherapy per month were provided during the following months: April 2021 - 1 hour and 20 minutes documented; May 2021 - 2 hours and 15 minutes documented; and June 2021 - 1 hour and 45 minutes documented.Patient # 7 was admitted on May 18, 2020 and was still active at the time of the inspection. The record of service and progress notes showed that less than 2.5 hours of psychotherapy per month were provided during the following months: March 2021 - 1 hour documented; and June 2021 - 0 hours documented.This finding was reviewed with facility staff during the licensing inspection.
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Plan of Correction
On August 3, 2021, the Program Director met with all of the counselors during group supervision and reminded them about the requirement to meet the minimum counseling attendance requirements for any client receiving medication assisted treatment for less than two years. During the meeting on 8/3/2021, counselors were also reminded about the requirement to meet the counseling attendance requirement of one hour each month following two years of treatment, and one hour of counseling every other month after four years of treatment. To ensure ongoing compliance, the Program Director will monitor and review counseling attendance records and clinical documentation to make certain that the counselors are using appropriate and necessary interventions to assist clients meet the state regulatory requirements. |
715.19(3) LICENSURE Psychotherapy services
A narcotic treatment program shall provide individualized psychotherapy services and shall meet the following requirements:
(3) After 4 years of treatment, a narcotic treatment program shall provide each patient with at least 1 hour of group or individual psychotherapy every 2 months. Additional psychotherapy shall be provided as dictated by ongoing assessment of the patient.
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Observations
Based on a review of patient records, the facility failed to provide at least 1 hour of group or individual psychotherapy every 2 months after 4 years of treatment in two of three applicable patient records reviewed. Patient # 4 was admitted on October 7, 2009 and was discharged on May 24, 2021. The record of service and progress notes showed that only 30 minutes of group or individual psychotherapy was provided every 2 months from September 2020 through April 2021. Patient # 6 was admitted on September 30, 2009 and was discharged on May 24, 2021. The record of service and progress notes showed that only 30 minutes of group or individual psychotherapy was provided every 2 months from September 2020 through April 2021. This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
On August 17, 2021, the Program Director facilitated group supervision and reminded the counselors of the minimum counseling attendance required for clients receiving treatment for four or more years of medication assisted treatment. To ensure ongoing compliance, the Program Director will review counseling attendance logs/records based on one's time in treatment. In addition, during individual supervision and random record reviews, the Program Director will assess and review interventions being used to ensure that counseling requirements are being met. Additional group counseling sessions will be added to the current group schedule, which will give individuals different opportunities to participate in counseling to ensure that the counseling requirement is being met. |
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 client records, the facility failed to 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 in one of one applicable patient records reviewed. Patient # 1 was transferred to the facility from another narcotic treatment program on November 4, 2020. The facility notified the transferring facility of the patient's admission on November 5, 2020; however, the notification did not document the date that the initial dose was given to the patient. This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
Effective August 3, 2021, to ensure ongoing compliance pertaining to notification of a client's admission to the receiving program from a clinic where a client is transferring, the Program Director will compose a letter identifying the following information: whether or not the client was admitted to the receiving clinic, the date of admission, the initial methadone dose that was dispensed, and the date of the initial dose that was dispensed. To ensure ongoing compliance with state regulations, the Program Director will fax the letter to the transferring facility within 24 hours of a client's intake at the receiving clinic. |
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 review and update each client's treatment plan at least every 60 days in six of seven applicable client records reviewed.Client # 1 was admitted on November 4, 2020 and was still active at the time of the inspection. A treatment plan update was completed on February 4, 2021 and the next update was due no later than April 4, 2021; however, the update was not completed until May 13, 2021. Client # 2 was admitted on December 9, 2020 and was still active at the time of the inspection. The comprehensive treatment plan was completed on January 11, 2021, and the next update was due no later than March 11, 2021; however, the update was not completed until May 20, 2021.Client # 3 was admitted on October 19, 2020 and was still active at the time of the inspection. The comprehensive treatment plan was completed on October 30, 2020, and the next update was due no later than December 30, 2020; however, the update was not completed until January 21, 2021.Client # 5 was admitted on July 30, 1999 and was discharged on March 22, 2021. A treatment plan update was completed on November 4, 2020 and the next update was due no later than January 4, 2021; however, the update was not completed until January 21, 2021. Client # 6 was admitted on September 30, 2009 and was discharged on May 24, 2021. A treatment plan update was completed on November 6, 2020 and the next update was due no later than January 6, 2021; however, the update was not completed until January 29, 2021. These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
On August 3, 2021, the Program Director facilitated a group supervision meeting with all of the counselors and reviewed the state guidelines and regulations pertaining to the timely completion of treatment plans; all of the employees were reminded about the requirement that every client's treatment plan be completed every 60 days. During individual supervision, on August 5, 2021, the Program Director met with employees #1, #2, and #3, and reviewed treatment plan deficiencies that were found on the reviewed charts (client #1's treatment plan was due on 4/4/21 but was not completed until 5/13/21; client #2's treatment plan was due on 3/11/21 but was not completed until 5/20/21; client #3's treatment plan was due on 12/30/20 but was not completed until 1/21/21; client #5's treatment plan was due on 1/4/21 but was not completed until 1/21/21; and client #6's treatment plan was due on 1/6/21 but was not completed until 1/29/21). The Program Director provided employees #1, #2, and #3 with spreadsheets so that they can accurately track when treatment plans are due for all of the clients on their caseloads. To ensure ongoing compliance, during monthly individual supervision, the Program Director will review the treatment plan spreadsheets with all of the counselors. The Program Director will conduct random chart reviews for all of the counselors on a weekly basis to ensure ongoing compliance. |