INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection and methadone monitoring conducted on July 24, 2023 through July 25, 2023 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(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, 2022 through June 30, 2023 training year in one of two applicable personnel records reviewed.Employee #4 was hired as a counselor on April 21, 2004. The personnel record documented 21.5 hours of training received during the training year reviewed. This is a repeat citation from the July 29, 2021 and July 19, 2022 annual licensing renewal inspections.This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
By 9/5/23, the Facility Director will meet with HR staff to review the regulatory annual training requirements for staff. The Clinical Supervisor will be responsible for scheduling all required training and for forwarding certificates of completion as well as the number of hours completed to the HR department within ten days of the completion of the training. The HR training specialist will be responsible for tracking completed hours and certificates of training submitted. Ongoing compliance will be the responsibility of the HR staff who will notify the Clinical Supervisor of the staff member's compliance with the training requirement on a monthly basis to ensure the regulatory training requirement has been met. |
705.28 (d) (6) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(6) Conduct fire drills on different days of the week, at different times of the day and on different staffing shifts.
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Observations
Based on a review of the facility's July 2022 through June 2023 fire drill logs, the facility failed to conduct fire drills at different times of the day and on different staffing shifts. The facility's hours of operation are Monday through Friday 5:30AM - 2:00PM and Saturday through Sunday 7:00AM - 10:00AM. None of the drills completed were conducted during the facility's afternoon hours of operation. This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
Beginning on 9/8/2023, the Director of Administration will be responsible for conducting the monthly fire drills during all staffing shifts throughout the clinic hours of operation. The Facility Director will be responsible for ongoing compliance with the regulation through regular review of the Fire Drill records to verify that the drills are being conducted during the morning and afternoon shifts to meet the requirements of the regulation. |
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 two of three applicable personnel records reviewed. Employee #1 was hired as the Project Director on July 1, 2013. There was no annual performance evaluation documented in the record as of the date of the inspection.Employee #4 was hired as a counselor on April 21, 2004. The annual written performance evaluation was completed by the supervisor on July 7, 2023; however, the evaluation was not reviewed and signed by the employee as of the date of the inspection. These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Beginning on 9/01/2023, annual written performance evaluations will be completed, presented to employees by supervisors and will include employee signatures within 30 days of the end of each fiscal year. Employee #4 will receive a copy of the 22-23 FY evaluation and receipt of the annual evaluation will be documented by the employee by 8/31/2023. Annual evaluation for employee #1 was completed and signed by the employee on 8/3/23. |
709.28 (c) (3) 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:
(3) Purpose of disclosure.
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Observations
Based on a review of client records, the facility failed to document the purpose of a disclosure on a consent form in one of seven client records reviewed. Client #4 was admitted on November 2, 2020 and was discharged on October 13, 2022. A release of information form to a physician, signed and dated by the client on November 30, 2021, did not include the purpose of the disclosure.This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
By 8/22/23, during weekly team meeting, all clinicians were reminded of the requirement to document the specific information to be disclosed when completing a release of information for disclosure of client PHI. The Clinical Supervisor will be responsible for monitoring ongoing compliance with the regulation through random record review and during clinical supervision with clinicians. |
709.28 (d) LICENSURE Confidentiality
§ 709.28. Confidentiality.
(d) A copy of a client consent shall be offered to the client and a copy maintained in the client record.
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Observations
Based on a review of client records, the facility failed to ensure that a copy of a client consent to release information form was offered to the client in one of seven client records reviewed.Client #1 was admitted on March 8, 2022 and was discharged on April 28, 2023. A release of information form to an emergency contact was signed and dated by the client on February 22, 2023. There was no documentation, in the record, that a copy of the release of information form was offered to the client.This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
During weekly treatment team meeting on 8/22/23, the Facility Director will review the requirement that releases of confidential information should include documentation that a copy of the release has been offered to the client. The Clinical Supervisor will be responsible for ensuring ongoing compliance with the regulation through random record review and during individual supervision meetings with clinicians. |
715.11 LICENSURE Confidentiality of patient records
A narcotic treatment program shall physically secure and maintain the confidentiality of all patient records in accordance with 42 CFR 2.22 (relating to notice to patients of Federal confidentiality requirements) and § 709.28 (relating to confidentiality).
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Observations
Based on a review of patient records, the facility failed to physically secure and maintain the confidentiality of all patient records in accordance with 42 CFR 2.22 (relating to notice to patients of Federal confidentiality requirements) and 709.28 (relating to confidentiality), in two of seven patient records reviewed.Patient #1 was admitted on March 8, 2022 and was discharged on April 28, 2023. There was another patient's dosing history included in this patient's record. Patient #2 was admitted on January 8, 2020 and was discharged on September 6, 2022. There was another patient's dosing history included in this patient's record. These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
By 8/22/23 the Nursing Director will review confidentiality regulations with Nursing staff to remind staff to maintain compliance with the regulations by filing client information in the correct record. The dosing records for other clients were removed from the records of discharged patient #1 and Patient #2 on 8/17/23. Ongoing compliance with the regulation will be the responsibility of the Clinic Supervisor through regular record auditing prior to the closeout of all discharge records. |
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 an average of 2.5 hours of psychotherapy per month during the patient's first 2 years in treatment in two of five applicable patient records reviewed. Patient #1 was admitted on March 8, 2023 and was discharged on April 28, 2023. The record of service and progress notes documented that during the following months less than 2.5 hours of psychotherapy per month was provided to the patient: January 2023: 1 hour of psychotherapy; February 2023: no hours of psychotherapy.Patient #6 was admitted on December 9, 2020 and was discharged on February 7, 2023. The record of service and progress notes documented that during the following months less than 2.5 hours of psychotherapy per month was provided to the patient: August 2022: 1 hour of psychotherapy; September 2022: no hours of psychotherapy; October 2022: no hours of psychotherapy; November 2022: 1 hour and 45 minutes of psychotherapy. This is a repeat citation from the July 29, 2021 and July 19, 2022 annual licensing renewal inspections.This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
On 8/30/23 the Facility Director will facilitate a training for clinicians on recommended interventions to ensure that clients receive the required number of hours of therapy stipulated by the regulations. The Clinical Supervisor will assist the clinicians with implementation of the interventions and will be responsible for ongoing compliance with the regulation by reviewing monthly audits of the hours of therapy provided to clients. |
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 one of one applicable patient records reviewed. Patient #3 was admitted on May 2, 2018 and was discharged on June 26, 2023. The record of service and progress notes showed that no group or individual psychotherapy was provided to the client during the consecutive months of September 2022 through June 2023.This is a repeat citation from the July 19, 2022 and July 29, 2021 annual licensing renewal inspections.This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
By 8/30/23 the Facility Director will facilitate a training for clinicians on recommended interventions to ensure that clients receive the required number of hours of therapy stipulated by the regulations. The Clinical Supervisor will assist the clinicians with implementation of the interventions and will be responsible for ongoing compliance with the regulation by reviewing monthly audits of the hours of therapy provided to clients. |
715.23(b)(5) LICENSURE Patient records
(b) Each patient file shall include the following information:
(5) The results of all annual physical examinations given by the narcotic treatment program which includes an annual reevaluation by the narcotic treatment physician.
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Observations
Based on a review of patient records, the facility failed to document the results of all annual physical examinations given by the narcotic treatment program, which includes an annual reevaluation by the narcotic treatment physician, in one of six applicable records.Patient #3 was admitted on May 2, 2018 and was discharged on June 26, 2023. A physical exam was completed on May 30, 2022, and the next exam was due no later than May 30, 2023; however, the exam was not completed prior to discharge.This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
Beginning on 9/11/2023, an alert and tracking system will be implemented in the EMR that will provide notification to staff of the names of clients who are due to have an annual physical examination during the upcoming month. Nursing staff will be responsible for scheduling and reminding clients of upcoming appointments. The Nursing Director will be responsible for ongoing compliance with the regulation by monitoring the record of completed examinations and ensuring that clients who miss appointments are rescheduled and attend their appointments in a timely manner. |
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 treatment and rehabilitation plans at least every 60 days in seven of seven client records reviewed.Client #1 was admitted on March 8, 2022 and was discharged on April 28, 2023. A treatment plan update was completed on July 29, 2022 and the next update was due no later than September 29, 2022; however, the update was not completed until October 13, 2022. Additionally, a treatment plan update was completed on October 13, 2022 and the next update was due no later than December 13, 2022; however, the update was not completed until January 10, 2023. Also, a treatment plan update was completed on January 10, 2023 and the next update was due no later than March 10, 2023; however, the update was not completed until March 24, 2023. Client #2 was admitted on January 8, 2020 and was discharged on September 6, 2022. A treatment plan update was completed on April 6, 2022, and the next update was due no later than June 6, 2022; however, the update was not completed prior to discharge.Client #3 was admitted on May 2, 2018 and was discharged on June 26, 2023. A treatment plan update was completed on September 27, 2022, and the next update was due no later than November 27, 2022; however, the update was not completed prior to discharge.Client #4 was admitted on November 2, 2020 and was discharged on October 13, 2022. A treatment plan update was completed on June 8, 2022, and the next update was due no later than August 8, 2022; however, the update was not completed prior to discharge.Client #5 was admitted on January 24, 2022 and was discharged on November 30, 2022. A treatment plan update was completed on September 15, 2022 and the next update was due no later than November 15, 2022; however, the update was not completed prior to discharge. Client #6 was admitted on December 9, 2020 and was discharged on February 7, 2023. A treatment plan update was completed on May 16, 2022 and the next update was due no later than July 16, 2022; however, the update was not completed until November 18, 2022. Additionally, a treatment plan update was completed on November 18, 2022 and the next update was due no later than January 18, 2023; however, the update was not completed prior to discharge.Client #7 was admitted on December 18, 2019 and was discharged on August 9, 2022. A treatment plan update was completed on May 26, 2022 and the next update was due no later than July 26, 2022; however, the update was not completed prior to discharge. This is a repeat citation from the August 20, 2020, July 29, 2021, and July 19, 2022 annual licensing renewal inspections.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
By 9/30/2023, the IT Director will implement an alert and tracking system in the EMR to notify clinicians of the due dates for the review and update of treatment and rehabilitation plans. Alerts will be included in the Task List and will remain active until the Review and Update has been completed in accordance with the regulatory requirement.
The Clinical Supervisor will be responsible for ensuring ongoing compliance with the regulation through random record review and during individual supervision.
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709.17(a)(3) LICENSURE Subchapter B.Licensing Procedures.Refusal/rev
709.17. Refusal or revocation of license.
(a) The Department may revoke or refuse to issue a license for any of the following reasons:
(3) Failure to comply with a plan of correction approved by the Department, unless the Department approves an extension or modification of the plan of correction.
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Observations
Based on a review of administrative documents, the facility failed to comply with plans of correction that were approved by the Department. A plan of correction for failing to update treatment plans at least every 60 days was submitted and approved by the Department for the July 19 2022, July 29, 2021, and August 20, 2020 annual licensing inspections. Failing to update treatment plans at least every 60 days was again found to be a deficiency in the July 24, 2023 through July 25, 2023 licensing inspection.A plan of correction for failing to provide 2.5 hours of psychotherapy per month during a patient ' s first two years in treatment was submitted and approved by the Department for the July 19, 2022 and July 29, 2021 annual licensing inspections. Failing to provide 2.5 hours of psychotherapy per month during a patient ' s first two years in treatment was again found to be a deficiency in the July 24, 2023 through July 25, 2023 licensing inspection.A plan of correction for failing to provide 1 hour of psychotherapy every 2 months for a patient in treatment four years or longer was submitted and approved by the Department for the July 19, 2022 and July 29, 2021 annual licensing inspections. Failing to provide 1 hour of psychotherapy every two months for a patient in treatment four years or longer was again found to be a deficiency in the July 24, 2023 through July 25, 2023 licensing inspection.A plan of correction for failing to ensure each counselor completed 25 hours of annual training was submitted and approved by the Department for the July 19, 2022 and July 29, 2021 annual licensing inspections. Failing to ensure each counselor completed 25 hours of annual training was again found to be a deficiency in the July 24, 2023 through July 25, 2023 licensing inspection.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
By 9/12/2023,the Facility Director will meet with the Treatment Team to review the Plans of Correction submitted and approved by the Department on July 19,2022, July 29,2021,and August 20,2020 to review the regulatory requirement to follow all plans of correction approved by the Department. The QA/UR Manager and the Clinical Supervisor will be responsible for ongoing compliance with meeting the requirements through monthly record of service audits and during group and individual Clinical Supervision. |