INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection and methadone monitoring conducted on November 3, 2023 and November 6, 2023 by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, Northeast Family Healthcare, LLC 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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704.7(b) LICENSURE Counselor Qualifications
704.7. Qualifications for the position of counselor.
(a) Drug and alcohol treatment projects shall be staffed by counselors proportionate to the staff/client and counselor/client ratios listed in 704.12 (relating to full-time equivalent (FTE) maximum client/staff and client/counselor ratios).
(b) Each counselor shall meet at least one of the following groups of qualifications:
(1) Current licensure in this Commonwealth as a physician.
(2) A Master's Degree or above from an accredited college with a major in chemical dependency, psychology, social work, counseling, nursing (with a clinical specialty in the human services) or other related field which includes a practicum in a health or human service agency, preferably in a drug and alcohol setting. If the practicum did not take place in a drug and alcohol setting, the individual's written training plan shall specifically address a plan to achieve counseling competency in chemical dependency issues.
(3) A Bachelor's Degree from an accredited college with a major in chemical dependency, psychology, social work, counseling, nursing (with a clinical specialty in the human services) or other related field and 1 year of clinical experience (a minimum of 1,820 hours) in a health or human service agency, preferably in a drug and alcohol setting. If a person's experience did not take place in a drug and alcohol setting, the individual's written training plan shall specifically address a plan to achieve counseling competency in chemical dependency issues.
(4) An Associate Degree from an accredited college with a major in chemical dependency, psychology, social work, counseling, nursing (with a clinical specialty in the human services) or other related field and 2 years of clinical experience (a minimum of 3,640 hours) in a health or human service agency, preferably in a drug and alcohol setting. If a person's experience was not in a drug and alcohol setting, the individual's written training plan shall specifically address a plan to achieve counseling competency in chemical dependency issues.
(5) Current licensure in this Commonwealth as a registered nurse and a degree from an accredited school of nursing and 1 year of counseling experience (a minimum of 1,820 hours) in a health or human service agency, preferably in a drug and alcohol setting. If a person's experience was not in a drug and alcohol setting, the individual's written training plan shall specifically address a plan to achieve counseling competency in chemical dependency issues.
(6) Full certification as an addictions counselor by a statewide certification body which is a member of a National certification body or certification by another state government's substance abuse counseling certification board.
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Observations
Based on a review of personnel records, it was determined that one employee hired as a counselor did not meet the qualification requirements for the position.Employee # 3 was hired as a counselor on May 30, 2023 and was current in that position at the time of the inspection. At the time of hire, the employee had a qualifying bachelor's degree but not the required one year of clinical experience for a bachelor's level counselor.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
All staff responsible for recruiting, interviewing, and hiring staff will be trained in 704 regulations by 12/8/2023. Any new staff who will be responsible for recruiting and/or hiring will be trained in 704 regulations by the ED and/or the Talent Team. The staff in question has since resigned from the organization however, if that staff were still employed, they would be demoted to Counselor Assistant until such time that they met the criteria for Counselor. |
704.9(c) LICENSURE Supervised Period
704.9. Supervision of counselor assistant.
(c) Supervised period.
(1) A counselor assistant with a Master's Degree as set forth in 704.8 (a)(1) (relating to qualifications for the position of counselor assistant) may counsel clients only under the close supervision of a trained counselor or clinical supervisor for at least the first 3 months of employment.
(2) A counselor assistant with a Bachelor's Degree as set forth in 704.8 (a)(2) may counsel clients only under the close supervision of a trained counselor or clinical supervisor for at least the first 6 months of employment.
(3) A registered nurse as set forth in 704.8 (a)(3) may counsel clients only under the close supervision of a trained counselor or clinical supervisor for at least the first 6 months of employment.
(4) A counselor assistant with an Associate Degree as set forth in 704.8 (a)(4) may counsel clients only under the close supervision of a trained counselor or clinical supervisor for at least the first 9 months of employment.
(5) A counselor assistant with a high school diploma or GED equivalent as set forth in 704.8 (a)(5) may counsel clients only under the direct observation of a trained counselor or clinical supervisor for the first 3 months of employment. For the next 9 months, the counselor assistant may counsel clients only under the close supervision of a lead counselor or a clinical supervisor.
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Observations
Based on a review of seven personnel records, the facility failed to maintain documentation that counselor assistants received direct observation as part of their close supervision, in one applicable record.Employee # 7 was hired by the facility on June 29, 2022 and transitioned to the position of counselor assistant on February 5, 2023. The supervision notes provided at the time of the inspection did not indicate that direct observation of the provision of counseling services was a part of the close supervision. These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
All supervising staff were trained by the ED in the documentation necessary for direct observation for Counselor Assistants on 11/8/2023. All new supervisory staff will be trained in how to document direct observation in the supervision tool. |
704.11(c)(1) LICENSURE Mandatory Communicable Disease Training
704.11. Staff development program.
(c) General training requirements.
(1) Staff persons and volunteers shall receive a minimum of 6 hours of HIV/AIDS and at least 4 hours of tuberculosis, sexually transmitted diseases and other health related topics training using a Department approved curriculum. Counselors and counselor assistants shall complete the training within the first year of employment. All other staff shall complete the training within the first 2 years of employment.
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Observations
Based on a review of seven personnel records and the facility's Staffing Requirement Facility Summary Report (SRFSR) form, the facility failed to ensure that one employee received the minimum of 4 hours of TB/STD training and 6 hours of HIV/AIDS training within the regulatory timeframe.Employee # 5 was hired as a counselor assistant on July 25, 2022 and was due to have the communicable disease trainings no later than July 25, 2023. However, there was no documentation of the completion of the TB/STD or HIV/AIDS trainings as of the date of the inspection.The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
All staff were retrained on DDAP required trainings and timeframes on 11/8/2023 by the ED. ED will create a spreadsheet to track DDAP required trainings for all staff by 12/8/2023. |
705.28 (a) (1) (iv) LICENSURE Fire safety.
705.28. Fire safety.
(a) Exits.
(1) The nonresidential facility shall:
(iv) Clearly indicate exits by the use of signs.
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Observations
Based on a physical plant inspection on November 6, 2023, the facility failed to clearly indicate exits by the use of signs. A door labeled with an Emergency Exit sign in the staff break room, was not actually an emergency exit and instead led to the server room. The door was obstructed on the one side by a table and by supplies on the other. The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Emergency Exit sign from the building's former back door will be removed from the building on 12/6/2023 as this door is no longer an exit. |
705.28 (d) (1) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(1) Conduct unannounced fire drills at least once a month.
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Observations
Based on a review of fire drill logs from June 2023 through September 2023, the facility failed to conduct unannounced fire drills during August and September 2023.The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
All leadership staff will be trained in facilitating drills by the ED to ensure completion monthly by 12/15/2023.
ED will monitor completion of all drills before the last week of every month through the online system the site uses to record all drills and events. |
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 review of client records and the policy and procedure manual, the facility failed to follow the project's written procedures for the management of treatment/rehabilitation services in three applicable records reviewed. The policy and procedure manual stated that clients may be placed on inactive status after three missed doses and may remain on inactive status for up to 30 days. Client records remained open beyond 30 days of program inactivity in two of four records reviewed.Client # 4 was admitted on August 15, 2023 and was active at the time of the inspection. The most recent client attendance at the facility was August 26, 2023.Client # 9 was admitted on July 6, 2023 and was active at the time of the inspection. The most recent documented contact with the client occurred on August 22, 2023.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
All staff to be retrained in discharge procedures by the ED by 12/8/2023. ED and clinical leadership will run reports weekly to ensure that patients are being discharged by the 30th day of absence or that reasons for delays in discharge are clearly documented in the patients chart (e.g. set release dates from incarceration/HLOC). |
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 client records, the facility failed to ensure that verbal medication orders were authenticated in writing by a physician or other medical professional within three business days in four of ten records reviewed. Client # 4 was admitted on August 15, 2023 and was active at the time of the inspection. A verbal order was given on August 21, 2023, and was not authenticated in writing until October 14, 2023. A verbal order was given on August 24, 2023, and was not authenticated in writing until October 14, 2023. Client # 5 was admitted on January 17, 2019 and was active at the time of the inspection. A verbal order was given on October 27, 2023, and was not authenticated in writing until November 1, 2023. Client # 6 was admitted on July 21, 2023 and was discharged on August 14, 2023. A verbal order was given on July 21, 2023, and was not authenticated in writing until July 27, 2023. Client # 9 was admitted on July 6, 2023 and was active at the time of the inspection. A verbal order was given on July 6, 2023, and was not authenticated in writing until July 27, 2023. A verbal order was given on July 10, 2023, and was not authenticated in writing until July 27, 2023.These findings were reviewed with project staff during the licensing process.
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Plan of Correction
Medical staff to be retrained on signature timeframes by ED by 12/8/2023. ED to run signature report every other day to ensure that verbal orders are being signed as expected according to policy. |
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.
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Observations
Based on a review of eleven client records, the facility failed to document that the client was notified, in writing, of the facility's decision to involuntarily terminate the client's treatment at the project in one of one applicable record reviewed.Client # 6 was admitted on July 21, 2023 and was involuntarily discharged on August 14, 2023. There was no documentation that the client was notified, in writing, of the facility's decision to involuntarily terminate.This is a repeat citation from the May 22, 2023 through May 23, 2023 annual renewal licensing inspection. The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
All staff will be retrained in documentation required for administrative discharge by ED by 12/8/2023. All administrative discharges will be reviewed by clinical leadership prior to discharge to ensure all documentation necessary is in the chart. |
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
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Observations
Based on the review of three months of physician and certified registered nurse practitioner timesheets, the facility failed to provide at least one hour of physician time a week on site for every ten patients in one week reviewed. During the week of July 2, 2023 through July 8, 2023, the patient census was 301. The facility was required to provide at least 30.1 physician hours. There were 29.14 hours documented.This is a repeat citation from the May 22, 2023 through May 23, 2023 annual renewal licensing inspection. These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Site medical staff will coordinate PTO with regional medical director to ensure adequate coverage for all days clinic is operational. ED will review PTO process with medical staff by 12/8/2023. |
715.6(e) LICENSURE Physician Staffing
(e) A physician assistant or certified registered nurse practitioner may perform functions of a narcotic treatment physician in a narcotic treatment program if authorized by Federal, State and local laws and regulations, and if these functions are delegated to the physician assistant or certified registered nurse practitioner by the medical director, and records are properly countersigned by the medical director or a narcotic treatment physician. One-third of all required narcotic treatment physician time shall be provided by a narcotic treatment physician. Time provided by a physician assistant or certified registered nurse practitioner may not exceed two-thirds of the required narcotic treatment physician time.
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Observations
Based on the review three months of physician time sheets, the facility failed to provide the required number of hours onsite for the physician based on the census for one week reviewed. A physician must provide one-third of the required hours, with a certified registered nurse practitioner or physician's assistant providing the remaining two-thirds of the required hours. During the week of July 2, 2023 through July 8, 2023, the patient census was 301. The physician was required to provide one-third of the 30.1 hours, which equals to 10 hours. The physician provided 5 hours. These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Site medical staff will coordinate PTO with regional medical director to ensure adequate coverage for all days clinic is operational. ED will review PTO process with medical staff by 12/8/2023. |
715.12(1-5) LICENSURE Informed patient consent
A narcotic treatment program shall obtain an informed, voluntary, written consent before an agent may be administered to the patient for either maintenance or detoxification treatment. The following shall appear on the patient consent form:
(1) That methadone and LAAM are narcotic drugs which can be harmful if taken without medical supervision.
(2) That methadone and LAAM are addictive medications and may, like other drugs used in medical practices, produce adverse results.
(3) That alternative methods of treatment exist.
(4) That the possible risks and complications of treatment have been explained to the patient.
(5) That methadone is transmitted to the unborn child and will cause physical dependence.
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Observations
Based on a review of patient records, the facility failed to obtain an informed, voluntary, written consent before an agent was administered in one of six applicable records reviewed.Patient # 4 was admitted on August 15, 2023 and was active at the time of the inspection. The patient was initially administered an agent on August 15, 2023; however, the informed, voluntary, written consent was not signed in the patient record.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
All medical and nursing staff to be retrained on medication consent required by ED no later than 12/8/2023. Nursing staff will ensure that no patient is administered medication without written consent being present in the chart. Compliance will be monitored through intake chart audits completed by clinical leadership. |
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 patient records, the narcotic treatment program failed to complete a random urinalysis at least monthly in two of ten patient records reviewed.Patient # 1 was admitted on February 6, 2020 and was active at the time of the inspection. There was no documented drug screen urinalysis for the month of October 2023.Patient # 10 was admitted on September 19, 2022 and was active at the time of the inspection. There was no documented drug screen urinalysis for the months of July 2023 or October 2023.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Patients without drug screen reports will be run by nursing staff on the second and fourth weeks of the month to ensure that all patients have drug screens scheduled and completed every month. ED to review updated protocol for drug screens with nursing team by 12/8/2023. |
715.15(a) LICENSURE Medication Dosage
(a) The narcotic treatment physician shall review the dosage levels at least twice a year, with each review occurring at least 2 months apart, to determine a patient 's therapeutic dosage.
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Observations
Based on a review of patient records, the narcotic treatment physician failed to review the dosage levels at least twice per year in one of four applicable records reviewed.Patient # 1 was admitted on February 6, 2020 and was active at the time of the inspection. The most recent dose evaluation documented was on February 8, 2022.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Medical staff will be retrained in dose review policy by ED by 12/8/2023. Medical and nursing staff will run reports weekly to ensure that all patients who need a dose review have appointments to see medical within the timeframe required |
715.17(c)(1)(i-vi)) LICENSURE Medication control
(c) A narcotic treatment program shall develop and implement written policies and procedures regarding the medications used by patients which shall include, at a minimum:
(1) Administration of medication.
(i) A narcotic treatment physician shall determine the patient 's initial and subsequent dose and schedule. The physician shall communicate the initial and subsequent dose and schedule to the person responsible for the administration of medication. Each medication order and dosage change shall be written and signed by the narcotic treatment physician.
(ii) An agent shall be administered or dispensed only by a practitioner licensed under the appropriate Federal and State laws to dispense agents to patients.
(iii) Only authorized staff and patients who are receiving medication shall be permitted in the dispensing area.
(iv) There shall be only one patient permitted at a dispensing station at any given time.
(v) Each patient shall be observed when ingesting the agent.
(vi) Administering and dispensing shall be conducted in a manner that protects the patient from disruption or annoyance from other individuals.
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Observations
Based on a review of patient records, the facility failed to ensure that medication orders were complete according to the facility's policy and procedures in one of ten records reviewed. According to the Project's policy on medication orders, complete medication orders contain the signature of the physician. Patient # 4 was admitted on August 15, 2023 and was active at the time of the inspection. A medication order was entered on August 15, 2023, and was not signed by the prescriber until August 22, 2023. Additionally, during an observation of medication administration on November 6, 2023, two nurses were observed preparing for subsequent medication doses or take-home medication, instead of observing patients when ingesting the agent. These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Medical staff to be retrained on signature timeframes by ED by 12/8/2023. ED to run signature report every other day to ensure that verbal orders are being signed as expected according to policy.
Nursing staff to be retrained on dosing procedures by ED by 12/8/2023. ED to randomly observe dosing to ensure 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.
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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, 1 hour of which shall be individual psychotherapy in one of one applicable record.Patient # 10 was admitted on September 19, 2022 and was active at the time of the inspection. The patient did not receive any individual psychotherapy hours for the month of September 2023, and only 1.25 hours of psychotherapy for the month of July 2023. These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Counselors were retrained on counseling requirements in July 2023. Counselors have been provided cheat sheet on required counseling hours based on amount of time in treatment. Counseling requirements are reviewed by ED and Clinical Supervisor monthly and addressed in individual and group supervisions at least once per month. |
715.19(2) LICENSURE Psychotherapy services
A narcotic treatment program shall provide individualized psychotherapy services and shall meet the following requirements:
(2) A narcotic treatment program shall provide each patient at least 1 hour per month of group or individual psychotherapy during the third and fourth year of treatment. 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 at least 1 hour per month of group or individual psychotherapy during the third and fourth year of treatment in one of two applicable records reviewed.Patient # 1 was admitted on February 6, 2020 and was active at the time of the inspection. The patient only received 0.5 hours of psychotherapy in September 2023 and 0.75 hours in July 2023. These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Counselors were retrained on counseling requirements in July 2023. Counselors have been provided cheat sheet on required counseling hours based on amount of time in treatment. Counseling requirements are reviewed by ED and Clinical Supervisor monthly and addressed in individual and group supervisions at least once per month. |
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 ensure an annual physical examination was given by the narcotic treatment program which includes an annual reevaluation by the narcotic treatment physician in two of two applicable records reviewed.Patient # 1 was admitted on February 6, 2020 and was active at the time of the inspection. The annual physical examination was due no later than February 6, 2023; however, the most recent annual physical was completed on February 8, 2022. Patient # 10 was admitted on September 19, 2022 and was active at the time of the inspection. The annual physical examination was due no later than September 19, 2023; however, the record did not contain an annual physical. The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
All staff to be retrained in services required and timeframes for delivery by 12/8/2023 by the ED. ED to run reports weekly to ensure all medical services due are scheduled and completed |
715.23(c)(1-7) LICENSURE Patient records
(c) An annual evaluation of each patient 's status shall be completed by the patient 's counselor and shall be reviewed, dated and signed by the medical director. The annual evaluation period shall start on the date of the patient 's admission to a narcotic treatment program and shall address the following areas:
(1) Employment, education and training.
(2) Legal standing.
(3) Substance abuse.
(4) Financial management abilities.
(5) Physical and emotional health.
(6) Fulfillment of treatment objectives.
(7) Family and community supports.
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Observations
Based on a review of patient records, the facility failed to ensure an annual evaluation of each patient's status was completed by the patient's counselor in one of two applicable records reviewed. Patient # 10 was admitted on September 19, 2022 and was active at the time of the inspection. An annual evaluation was due to be completed by September 19, 2023, however, the record did not contain documentation of annual evaluation.This is a repeat citation from the May 22, 2023 through May 23, 2023 annual renewal licensing inspection. These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
All staff to be retrained in services required and timeframes for delivery by 12/8/2023 by the ED. ED and/or Clinical Supervisor to run reports weekly to ensure all clinical services due are scheduled and completed |
709.91(b)(7) LICENSURE Intake and admission
709.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(7) Preliminary treatment and rehabilitation plan.
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Observations
Based on a review of client records and the facility's policies and procedures, the facility failed to document a preliminary treatment plan within seven days of admission, per policy, in three of six applicable records reviewed. Client # 3 was admitted on October 20, 2023 and was active at the time of the inspection. The record did not contain a preliminary treatment plan.Client # 9 was admitted on July 6, 2023 and was active at the time of the inspection. The preliminary treatment plan was not completed until August 8, 2023.Client # 8 was admitted on March 27, 2023 and was discharged on August 10, 2023. The preliminary treatment plan was not completed until April 21, 2023.These finding were discussed with facility staff during the licensing process.
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Plan of Correction
all staff to be retrained on intake and admission procedures by 12/8/2023 by the ED and Clinical Supervisor. ED and Clinical Supervisor to complete intake checklist within 7 days of the patient's admission. |
709.92(a) LICENSURE Treatment and rehabilitation services
709.92. Treatment and rehabilitation services.
(a) An individual treatment and rehabilitation plan shall be developed with a client. This plan shall include, but not be limited to, written documentation of:
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Observations
Based on a review of client records and the facility's policies and procedures, the facility failed to document an individual treatment and rehabilitation plan within 30 days of admission, per policy, in one of one applicable record reviewed. Client # 2 was admitted on June 30, 2023 and was active at the time of the inspection. The individual treatment and rehabilitation plan was not completed until October 27, 2023.These finding were discussed with facility staff during the licensing process.
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Plan of Correction
All staff to be retrained on documentation timeframes by ED and Clinical Supervisor by 12/8/2023. Compliance will be monitored during individual supervisions with the Clinical Supervisor as well as chart audits completed by ED and QI |
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 eleven client records, the facility failed to document treatment plan updates within the regulatory timeframe in four of four applicable records reviewed.Client # 1 was admitted on February 6, 2020 and was active at the time of the inspection. A treatment plan update was completed on January 23, 2023, and the next update was due no later than March 23, 2023; however, the next treatment plan update was not completed until August 17, 2023. The next treatment plan update was due to be completed by October 17, 2023; however, no additional treatment plan updates were completed prior to the date of the inspection. Client # 5 was admitted on January 17, 2019 and was active at the time of the inspection. A treatment plan update was completed on June 22, 2023, and the next update was due no later than August 22, 2023; however, no additional treatment plan updates were completed prior to the date of the inspection. Client # 8 was admitted on January 20, 2023 and was discharged on July 20, 2023. A treatment plan update was completed on March 9, 2023, and the next update was due no later than May 9, 2023; however, no additional treatment plan updates were completed prior to the date of the inspection. Client # 10 was admitted on September 19, 2022 and was active at the time of the inspection. A treatment plan update was completed on July 7, 2023, and the next update was due no later than September 7, 2023; however, no additional treatment plan updates were completed prior to the date of the inspection. This is a repeat citation from the May 22, 2023 through May 23, 2023 and June 7, 2022 through June 9, 2022 annual renewal licensing inspections. These findings were discussed with facility staff during the inspection process.
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Plan of Correction
All staff to be retrained on documentation timeframes by ED and Clinical Supervisor by 12/8/2023. Compliance will be monitored during individual supervisions with the Clinical Supervisor as well as chart audits completed by ED and QI |
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 eleven client records and the facility's policy and procedure manual, the facility failed to ensure a complete client record included information relative to the client's involvement with the project to include case consultation notes every three months for the first year of treatment and annually thereafter, per the facility's policy, in three of three applicable records reviewed. Client # 2 was admitted on June 30, 2023 and was active at the time of the inspection. The client record did not contain documentation of case consultation notes.Client # 8 was admitted on January 20, 2023 and was discharged on July 20, 2023. The client record did not contain documentation of case consultation notes.Client # 10 was admitted on September 19, 2022 and was active at the time of the inspection. A case consultation was documented on March 17, 2023 and another quarterly consultation was due to be completed by June 17, 2023; however, no subsequent case consultations were documented in the record.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
All staff to be retrained on documentation timeframes by ED and Clinical Supervisor by 12/8/2023. Compliance will be monitored during individual supervisions with the Clinical Supervisor as well as chart audits completed by ED and QI |
709.93(a)(11) 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:
(11) Follow-up information.
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Observations
Based on a review of client records, the facility failed to ensure a complete client record included information relative to the client's involvement with the project to include follow-up information at 30- and 60-days post discharge, per facility policy, in three of three applicable records reviewed. Client # 7 was admitted on January 31, 2019 and was discharged on June 26, 2023. The client record did not contain documentation of follow-up information.Client # 8 was admitted on January 20, 2023 and was discharged on July 20, 2023. The client record did not contain documentation of follow-up information.Client # 11 was admitted on June 28, 2023 and was discharged on August 24, 2023. The client record did not contain documentation of follow-up information.This is a repeat citation from the May 22, 2023 through May 23, 2023 annual renewal licensing inspection. These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
All staff to be retrained on documentation timeframes by ED and Clinical Supervisor by 12/8/2023. Compliance will be monitored during individual supervisions with the Clinical Supervisor as well as chart audits completed by ED and QI |
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 client records and administrative documents, the facility failed to comply with plans of correction that were approved by the Department. A plan of correction for completing treatment plan updates within the regulatory timeframe was submitted and approved by the Department for the May 22, 2023 through May 23, 2023, and June 7, 2022 through June 9, 2022 annual licensing inspections. Completing treatment plan updates was again found to be a deficiency in the November 6, 2023 licensing inspection. A plan of correction for including follow-up information in the client record was submitted and approved by the Department for the May 22, 2023 through May 23, 2023, annual licensing inspection. Completing follow-up information was again found to be a deficiency in the November 6, 2023 licensing inspection. A plan of correction for ensuring narcotic treatment physician services at least 1 hour per week onsite for every ten patients was submitted and approved by the Department for the May 22, 2023 through May 23, 2023 annual licensing inspection. Physician services was again found to be a deficiency in the November 6, 2023 licensing inspection. A plan of correction for ensuring a client was given written notification of termination was submitted and approved by the Department for May 22, 2023 through May 23, 2023 annual licensing inspection. Written notification of termination was again found to be a deficiency in the November 6, 2023 licensing inspection. A plan of correction for completing annual clinical evaluation was submitted and approved by the Department for May 22, 2023 through May 23, 2023 annual licensing inspection. Completing annual clinical evaluations was again found to be a deficiency in the November 6, 2023 licensing inspection. These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Executive Director will evaluate POC implementation with clinical supervisor and medical staff weekly to ensure that all staff are following POC as indicated and counseling staff accordingly. The Executive Director, Quality Improvement Director, and Regional Director will review the POC action step progress for each item monthly to ensure that all staff are following the plan to and counseling/disciplining staff when staff are not completing the action step items. |