INITIAL COMMENTS
|
This report is a result of an on-site complaint investigation conducted on October 8-10, 2019, by staff from the Bureau of Quality Assurance for Prevention & Treatment. Based on the findings of the on-site complaint investigation, New Directions Treatment Services. was found to be not in compliance with the applicable chapters of 28 PA Code which pertain to the facility.
|
Plan of Correction
|
705.22 (4) LICENSURE Building exterior and grounds.
705.22. Building exterior and grounds.
The nonresidential facility shall:
(4) Store all trash, garbage and rubbish in noncombustible, covered containers that prevent the penetration of insects and rodents, and remove it at least once every week.
|
Observations
The facility failed to ensure that all refuse containers were covered.The trash receptacle in the parking area near the entrance to the facility was not covered as the flap over the opening was not in place or was missing.
|
Plan of Correction
By November 23, 2019, the Director of Operations will contact the owner of the building to request that the trashcan receptacle be replaced. The Director of Operations will monitor this on a weekly basis to ensure that the environment is free of garbage and rubbish. The Director of Operations will ensure, weekly, that the trashcan is properly covered. |
705.27 (3) LICENSURE General safety and emergency procedures.
705.27. General safety and emergency procedures.
The nonresidential facility shall:
(3) Limit smoking to designated smoking areas.
|
Observations
The facility failed to limit smoking to designated smoking areas.DDAP staff were onsite from 10/8-10/19; during that time clients were observed on numerous occasions smoking directly outside of the main entrance despite this being designated a " no smoking " area.
|
Plan of Correction
Based on the policy delineated on page 6 of the Client Handbook, "smoking is not permitted inside the clinic, and only in designated areas outside the clinic." By November 1, 2019, the Director of Operations will meet with the security officers to review the non-smoking policy and remind them to enforce it. The security officers will report any clients who have violated this policy to the Director of Operations for further action. Counselors will address any policy violations during counseling sessions. The Director of Operations will perform random checks to ensure both client and staff compliance. |
709.24 (a) (3) LICENSURE Treatment/rehabilitation management.
§ 709.24. Treatment/rehabilitation management.
(a) The governing body shall adopt a written plan for the coordination of client treatment and rehabilitation services which includes, but is not limited to:
(3) Written procedures for the management of treatment/rehabilitation services for clients.
|
Observations
The facility failed to enforce their policy regarding loitering after dosing time.On Wednesday 10/9/19. DDAP staff observed the parking area outside the facility from 5:45 am until Facility policy states that clients are to leave the premises immediately after dosing, however, clients were observed loitering in the parking area for up to 30 minutes following their dosing time and no staff were observed making rounds in order to be able to enforce this policy.
|
Plan of Correction
By November 1, 2019, the Director of Operations will meet with the security officers to review the non-loitering policy and to enforce compliance. The security officers will report any clients who have violated this policy to the Director of Operations for further action. Counselors will address any policy violations during counseling sessions. The Director of Operations will monitor this on a daily basis to ensure compliance. |
709.30 (1) LICENSURE Client rights
§ 709.30. Client rights.
The project shall develop written policies and procedures on client rights and document written acknowledgement by clients that they have been notified of those rights.
(1) A client receiving care or treatment under section 7 of the act (71 P. S. § 1690.107) shall retain civil rights and liberties except as provided by statute. No client may be deprived of a civil right solely by reason of treatment.
|
Observations
Based on a review of client records on October 8-10, 2019, the facility failed to document written acknowledgement by clients that they have been notified of those rights.There was no documentation in client #4's record that verified that she received a client handbook which contains the "Client Bill of Rights."Client #4 was admitted on 3/14/17.
|
Plan of Correction
To ensure ongoing compliance, the Clinical Supervisor will continue to meet with counselors, on a monthly basis, to review the documentation responsibilities. On October 29, 2019, the Clinical Supervisor and Program Director will meet with all of the counselors and review the protocol to ensure that the Client Bill of Rights is being reviewed upon admission and annually. On October 29, 2019, all counselors attended an educational session, facilitated by the Program Director and Clinical Supervisor, reviewing correct clinical documentation. At the time of an intake, the client "Bill of Rights" (28 Pa. code 709.30)is reviewed with the client by the counselor and signed and dated by the client. Once a year, an Annual Review is completed by the counselor with the client; the client "Bill of Rights" is reviewed during the completion of an Annual Review. To ensure ongoing compliance, the Clinical Supervisor and Program Director will audit charts, on a monthly basis, to ensure that the client "Bill of Rights" is being reviewed upon admission and annually, in order to meet regulatory requirements. |
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.
|
Observations
During an on-site complaint investigation, conducted on October 8-10, 2019, the facility failed to provide requested data in a timely manner.On 10/8/19 at approximately 10 am the following data was requested by DDAP staff: Physician ' s work hours and dispensing staff work hours from July 29, 2019 through the present date, an average patient census for each week in that period, and a Staffing Requirements Facility Summary Report. This information was not provided until Thursday 10/10/19 and was incomplete in that no physician ' s or dispensing staff hours were provided for the period 9/30-10/6/19 and the Staffing Requirements Facility Summary Report contained the name and casload information for a clinical staff member who had been terminated on 10/4/2019.
|
Plan of Correction
Effective November 12, 2019, the Nurse Manager will track and record the medical provider hours and census, on a weekly basis, to ensure that the clinic is meeting regulatory standards based on the census. To ensure ongoing compliance, the Nurse Manager will, on a weekly basis, report the census and medical provider hours, to the Program Director, in order to meet regulatory requirements. The Nurse Manager, to ensure ongoing compliance, will develop a tracking system , by November 12, 2019, so that access to provider information is readily available. The Nurse Manager will provide the information to the Program Director, on a weekly basis, to ensure that the clinic is in compliance with regulatory standards and requirements.
In addition to the tracking system mentioned, New Directions Treatment Services will retrieve data in a timely manner, effective November 12, 2019, by delegating each specific requested data to department supervisors. Each supervisor, including the Director of Operations, Nurse Manager, Clinical Supervisor, and Program Director, will instruct supporting personnel to retrieve requested data and present the information to supervisors immediately upon request. |
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.
|
Observations
The facility failed to document written notification of a decision to involuntarily terminate a client.Client #4 was admitted on 3/14/17 and was an active client at the time of the investigation. A case not was documented on 9/10/19 that stated the client would be administratively discharged and placed on a 45 day taper, however there was no documentation that the client was notified of this by the facility.
|
Plan of Correction
On November 1, 2019, the Clinical Supervisor and Program Director will meet with the counselors to review the protocol for administrative tapers. All termination notices and letters will be reviewed by the Clinical Supervisor and Program Director. As of November 1, 2019, the Clinical Supervisor and Program Director will review administrative taper letters with counselors before issuing them to clients. Effective November 1, 2019, to ensure ongoing compliance, the Clinical Supervisor and Program Director will make sure that all administrative taper letters are reviewed, signed, and dated by clients who have been placed on administrative tapers.
Finally, effective November 1, 2019, all termination letters will be presented to clients prior to the start of an administrative taper. The Program Director will present the termination letters to clients, during face to face meetings, to ensure ongoing compliance in order to meet state regulations. |
715.6(d) LICENSURE Physician Staffing
(d) A narcotic treatment program shall provide narcotic treatment physician services at least 1 hour per week onsite for every ten patients
|
Observations
Based on a review of the Physician ' s and Physician's extender hours, conducted on September 25-26, 2019, the facility failed to provide narcotic treatment physician services at least 1 hour per week onsite for every ten patients.A schedule was submitted that indicated the hours worked for the physician and the physician extender staff, as well as the patient census, for the period from July 29 through October 6, 2019. The facility was not in compliance for the following weeks:July 29-August 4, 2019: census 571, coverage 42.5 hrsAugust 5-11, 2019: census 576, coverage 46.5 hrsAugust 12-18, 2019: census 574, coverage 46.5 hrsAugust 19-25, 2019: census 568, coverage 46.5 hrsAugust 26-September 1, 2019: census 563, coverage 31.5 hrsSeptember 2-8, 2019: census 555, coverage 23 hrsSeptember 9-15, 2019: census 551, coverage 39 hrsSeptember 16-22, 2019: census 547, coverage 25.5 hrsSeptember 23-29, 2019: census 544, coverage 33.5 hrsSeptember 30-October 6, 2019: census 539, No data provided.
|
Plan of Correction
On November 18, 2019, a full time Certified Registered Nurse Practitioner will be an employee at New Directions Treatment Services. In the event that a medical staff member is out on vacation, or is sick, the part time Narcotic Treatment Physician will increase her hours to ensure that the clinic is meeting regulatory requirements. In the event that the Narcotic Treatment Physician is out on vacation, or is sick, the hours will be covered by a per diem Certified Registered Nurse Practitioner. To ensure ongoing compliance, the Nurse Manager will report the medical providers' weekly hours to the Program Director in order to meet regulatory compliance.
|
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.
|
Observations
The facility failed to document that clients in the first two years of treatment received 2.5 hours of psychotherapy a month in one client record. Client #5, an active MAT client, was admitted on 5/1/18 and was an active client at the time of the inspection. This client received only the following counseling sessions in the last 4 months: Individual counseling on 5/30/19, 8/6 & 8/30/19.
|
Plan of Correction
Effective October 25, 2019, during weekly group supervision and monthly individual supervision with counselors, the counseling compliance of the clients on each individual caseload will be reviewed and monitored. To ensure ongoing compliance, the Clinical Supervisor and Program Director will meet with counselors on a weekly basis, during group supervision, and monthly basis, during individual supervision, and review caseloads to ensure that each client is complying with counseling requirements.
During weekly group supervision, the Program Director will review counselors' caseloads and discuss the need to provide counseling sessions to clients based on their clinical needs, not simply based on the duration of one's treatment. Specifically, the Program Director will remind counselors, during weekly group supervision, that clients who have been in treatment for over two years should be seen more than once a month if there is a clinical need: i.e., significant psychosocial stressors impacting their treatment, grief and loss issues, relapse, loss of employment, loss of housing, etc. Furthermore, during weekly group supervision, the Program Director will remind counselors that clients, in the first two years of treatment, should be receiving more than the minimum of 2.5 hours of counseling per month if there is a clinical issue impacting treatment: i.e., ongoing stressors that have not been resolved, thus impacting one's treatment.
To ensure ongoing compliance, the Program Director will continue to audit charts, on a weekly basis, to make sure that clients are fulfilling counseling requirements based on their length in treatment, as well as their clinical needs.
|
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.
|
Observations
Based on a review of client records on October 8-10, 2019, the facility failed to update treatment plans every 60 days.Client #2 was admitted on a 2/25/09 and was an active client at the time of the inspection. A treatment plan update was documented on 04/19/19; another update was due by 6/19/19 but was not documented until 08/05/19. Client #5 was admitted on 5/1/18 and was an active client at the time of the inspection. A treatment plan update was documented on 5/23/19; another update was due by 7/23/19 but was not documented until 9/05/19. Client #6 was admitted on 7/11/18 and was an active client at the time of the inspection. A treatment plan update was documented on 8/1/19; another update was due by 10/1/19 but was not documented at the time of the investigation.
|
Plan of Correction
During group supervision on October 22, 2019, the Program Director re-educated the counselors on proper documentation and timeliness of treatment plans. During monthly individual supervision, each counselor will be required to review charts with the Program Director to ensure that treatment plans are being completed every 60 days. |
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.
|
Observations
The facility failed to document that clients received treatment according to the treatment plan in one client record. Client #5 was admitted on 5/1/18 and was an active client at the time of the inspection. A treatment plan update was documented on 5/23/19 which specified individual counseling was to be provided " 2 hours per month " however 60-minute individual counseling sessions were conducted on 5/30/19, 8/6 & 8/30/19 only.
|
Plan of Correction
On October 29, 2019, the Program Director facilitated an educational forum with all of the counselors, and reviewed the counseling requirements that clients are required to fulfill. Counselors signed and dated a document indicating that they attended the educational forum that was held on 10/29/2019. To ensure ongoing compliance, the Clinical Supervisor and Program Director will meet with the counselors weekly, during group supervision, and monthly, during individual supervision, and will review the counseling requirements for clients on each caseload. Once a month, to ensure ongoing compliance, the Clinical Supervisor and Program Director will audit and review charts to make sure that clients are fulfilling the counseling requirements.
During weekly group supervision, the Program Director will review counselors' caseloads and discuss the need to provide counseling sessions to clients based on their clinical needs, not simply based on the duration of one's treatment. Specifically, the Program Director will remind counselors, during weekly group supervision, that clients who have been in treatment for over two years should be seen more than once a month if there is a clinical need: i.e., significant psychosocial stressors impacting their treatment, grief and loss issues, relapse, loss of employment, loss of housing, interpersonal relationship issues, etc. Furthermore, during weekly group supervision, the Program Director will remind counselors that clients, in the first two years of treatment, should be receiving more than the minimum of 2.5 hours of counseling per month if there is a clinical issue impacting treatment: i.e., ongoing stressors that have not been resolved, thus impacting one's treatment, life altering events impacting one's recovery. Finally, during weekly group supervision, the Program Director and Clinical Supervisor will inform counselors that clients, who have been in treatment for over four years, should receive more than one hour of counseling every other month if they have experienced a significant psychosocial stressor impacting their lives, thus raising the risk of a relapse.
To ensure ongoing compliance, the Program Director will continue to audit charts, on a weekly basis, to make sure that clients are fulfilling counseling requirements based on their length in treatment, as well as their clinical needs. |
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.
|
Observations
The facility failed to document a record of services in two client records reviewed. Client #7 was admitted on 4/6/16 and was an active client at the time of the investigation. There was no record of service in the client record from March 2018 to the present, however individual progress notes were documented on 1/9/19, 2/14, 3/6, 4/19, 5/29, 6/26, 8/2, 9/6 & 10/3/19.Client #8 was admitted on 10/2/17 and was an active client at the time of the investigation. There was no record of service in the client record from February 5 through May 23, 2019, however individual progress notes were documented on 2/12/19, 2/19, 2/27, 3/13, 3/19, 3/25, 4/11 & 4/25/19.
|
Plan of Correction
The Clinical Supervisor and Program Director met with all of the counselors during group supervision, on October 29, 2019, and reviewed the correct procedure for keeping track of the record of service logs. To ensure ongoing compliance, the Clinical Supervisor and Program Director, during weekly group supervision and monthly individual supervision, will meet with counselors and review clinical chart documentation and record of service logs. Furthermore, the Clinical Supervisor and Program Director will audit charts, monthly , to ensure that record of service logs are signed and dated by the clients, and placed in charts. |