INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on December 10, 2024 by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, Northeast Treatment Centers, Inc. 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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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.
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Observations
Based on a review of client records, the facility failed to follow their written procedures for the management of treatment/rehabilitation services in four of six applicable client records reviewed.
The facility policy and procedure manual stated individual treatment and rehabilitation plans are to be completed within 30 days of the client's admission.
Client # 2 was admitted on August 29, 2024 and was active at the time of inspection. The individual treatment and rehabilitation plan was due to be completed no later than September 29, 2024; however, the plan was completed on November 21, 2024.
Client # 4 was admitted on May 16, 2024 and was discharged on August 21, 2024. The individual treatment and rehabilitation plan was due to be completed no later than June 16, 2024; however, the plan was completed on July 22, 2024.
Client # 6 was admitted on January 25, 2024 and was discharged on May 28, 2024. The individual treatment and rehabilitation plan was due to be completed by February 25, 2024; however, the plan was completed on March 13, 2024.
Client # 7 was admitted on March 29, 2024 and was discharged on June 12, 2024. The individual treatment and rehabilitation plan was due to be completed by April 29, 2024; however, there was no plan completed prior to discharge.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The written procedures for the management of treatment/rehabilitation policy indicates that the comprehensive treatment plan will be completed within 60 days of the clients admission, however, the program did not follow this policy. All clinical staff will be re-trained by the Director in the staff meeting on 1/8/25 on the importance of reviewing the weekly caseload report that they receive. The caseload report gives them due dates for when all documents are due. During this training, staff will also be re-trained by the director on when all treatment plan plans are due. This will be monitored by the director. |
709.25 LICENSURE Fiscal Management
§ 709.25. Fiscal management.
The project shall obtain the services of an independent certified public accountant for an annual financial audit of activities associated with the project ' s drug/alcohol abuse services, in accordance with generally accepted accounting principles which include reference to the drug and alcohol treatment activities.
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Observations
Based on an administrative review, the project failed to obtain the services of an independent certified public accountant for the completion of an annual financial audit of activities associated with the project's drug/alcohol abuse services, in accordance with generally accepted accounting principles and including a reference to the drug and alcohol treatment activities, for the project's fiscal year ending June 2023.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
NET did obtain the services of an independent certified public accounting firm for the Fiscal period ending June 2023 however the audit has not yet been completed. The audit is taking so long because NET (although they were searching/recruiting) was without a CFO for a period for over a year. NET has had a new CFO for the past year and has been able to manage and put safeguards in place so that this does not happen again. NET's CFO, and NETs fiscal department has been working closely with the public accounting firm to complete this audit. The audit will be completed by March 31st, 2025. NET will send the results of the audit to DDAP by 3/31/25.
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709.28 (c) (1) 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:
(1) Name of the person, agency or organization to whom disclosure is made.
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Observations
Based on a review of client records, the facility failed to document the name of the person, agency, or organization to whom the disclosure was to be made to on a consent to release information form in one of seven client records reviewed.
Client # 3 was admitted on June 25, 2024 and was active at the time of inspection. A release of information form was signed and dated by the client on June 25, 2024, but the consent form did not include the name of the person, agency, or organization to whom the disclosure was to be made.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
The care manager who completes consent forms with clients to release information was re-retrained by the director on 12/12/24 on the the importance of including the name of the person, agency or organnization to whom the disclosure was being made to. Clinical staff will be re-trained on 1/8/25 by the director during the staff meeting. This will be monitored by the director to ensure that the consent to release information is being filled out correctly. |
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 the disclosure on consent to release information forms in seven of seven client records reviewed.
Client # 1 was admitted on August 22, 2024 and was active at the time of inspection. There were release of information forms to a funding source and an emergency contact signed and dated by the client on August 28, 2024; however, the purpose of the disclosure was not included on either release form.
Client # 2 was admitted on August 29, 2024 and was active at the time of inspection. There were release of information forms to a funding source and an emergency contact signed and dated by the client on August 30, 2024; however, the purpose of the disclosure was not included on either release form.
Client # 3 was admitted on June 25, 2024 and was active at the time of inspection. There was a release of information form to an unnamed contact signed and dated by the client on June 25, 2024; however, the purpose of the disclosure was not included on the release form.
Client # 4 was admitted on May 16, 2024 and was discharged on August 21, 2024. There were release of information forms to a funding source and an emergency contact signed and dated by the client on May 16, 2024; however, the purpose of the disclosure was not included on either release form.
Client # 5 was admitted on January 11, 2024 and was discharged on March 1, 2024. There were release of information forms to a funding source and an emergency contact signed and dated by the client on January 11, 2024; however, the purpose of the disclosure was not included on either release form.
Client # 6 was admitted on January 25, 2024 and was discharged on May 28, 2024. There were release of information forms to a funding source and an emergency contact signed and dated by the client on January 24, 2024; however, the purpose of the disclosure was not included on either release form.
Client # 7 was admitted on March 29, 2024 and was discharged on June 12, 2024. There were release of information forms to a funding source and an emergency contact signed and dated by the client on March 29, 2024; however, the purpose of the disclosure was not included on either release form.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The care manager was re-trained by the director on 12/12/24 to add the purpose of the disclosure of records being released. The clinical staff will be retrained on 1/8/25 by the director in the staff meeting on the important of adding the purpose to the consent form of why specific infromation is being released. This will be monitoed by the director. |
709.28 (c) (4) 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:
(4) Dated signature of client or guardian as provided for under 42 CFR 2.14(a) and (b) and 2.15 (relating to minor patients; and incompetent and deceased patients).
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Observations
Based on a review of client records, the facility failed to document the dated signature of the client on a release of information form in one of seven client records reviewed.
Client #7 was admitted on March 29, 2024 and was discharged on June 12, 2024. The release of information form to a funding source was signed and dated by a witness on March 29, 2024, but there was no dated signature of the client included on the release form.
This finding was reviewed with facility staff during the licensing inspection.
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Plan of Correction
There was a gliche on the consent form that clients sign to release information to the funding source. The gliche was that the date for the information to be released disappeared from the form. A ticket was submitted to the IT department on 12/26/24 to have this form corrected. The form will be updated by 1/8/25 to re-include that box to the form so that the client signature and date canbe recorded. The care manager was re-trained on 12/12/24 by the OP director that if she notices that this box is missing to inform the director. The director also re-trained the care manager on 12/12/24 the importance of including that date on the form. This will be monitored by the OP director. |
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 a copy of a client consent to release information form was offered to the client in two of seven client records reviewed.
Client # 1 was admitted on August 22, 2024 and was still active at the time of the inspection. The release of information form to an emergency contact was signed by the client on August 28, 2024; however, there was no documentation indicating a copy of the release form was offered to the client.
Client # 2 was admitted on August 29, 2024 and was still active at the time of the inspection. The release of information form to an emergency contact was signed by the client on August 30, 2024; however, there was no documentation indicating a copy of the release form was offered to the client.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The care manager was re-trained on 12/12/24 by the OP director on the importance of offering a copy of the client consent form to the client. She was also trained on why this is so important to have a copy of the consent in the elctronic health record. This will be monitored weekly by the OP director. Client #1 has not been to treatment since 12/19/24. Multiple outreach attmepts have been completed. If he returns, we will offer him a copy of the client consent to release information form. Client #3 has not been to treatment since 12/13/24 and is discharged today, 1/6/25 as he is now inpatient in a higher level of care. |
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 ensure treatment and rehabilitation plans were reviewed and updated at least every 60 days in two of three applicable client records reviewed.
Client # 1 was admitted on August 22, 2024 and was active at the time of inspection. The individual treatment plan was completed on September 19, 2024 and the first update was due no later than November 19, 2024; however, the update was not completed as of the date of the inspection.
Client # 6 was admitted on January 25, 2024 and was discharged on May 28, 2024. The individual treatment plan was completed on March 13, 2024 and the first update was due no later than May 13, 2024; however, the update was not completed prior to discharge.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The written procedures for the management of treatment/rehabilitation policy indicates that the treatment plan will be completed every 60 days, however, the program did not follow this policy. All clinical staff will be re-trained by the Director in the staff meeting on 1/8/25 on the importance of reviewing the weekly caseload report that they receive. The caseload report gives them due dates for when all documents are due. During this training, staff will also be re-trained by the director on when all treatment plan plans are due. The retraining for staff along with discussions with staff during individual supervision will address the deficiency.
This will be monitored by the director on a weekly basis.
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709.93(a)(8) 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:
(8) Case consultation notes.
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Observations
Based on a review of client records, the facility failed to a maintain a complete client record on an individual, which is to include the documentation of case consultation notes, in two of five applicable client records reviewed.
Client #1 was admitted on August 22, 2024 and was active at the time of inspection. There were no case consultation notes documented in the record at the time of the inspection.
Client #2 was admitted on August 29, 2024 and was active at the time of inspection. There were no case consultation notes documented in the record at the time of inspection.
These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
NET uses a caseload report to monitor all due dates of all DDAP regulatulations including the case consultation note. The caseload report is sent to clinical staff weekly. Staff will be re-trained to use the caseload report on 1/8/25. Staff will also be trained on the importance of completing timely documentation of the case consultation notes. Both client 1 and client 2 were completed in the clients record on 1/3/25. This will be monitored ona regular basis by the director. |