INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on January 10, 2018 through January 12, 2018 by staff from the Department of Drug and Alcohol Programs, Bureau of Quality Assurance for Prevention and Treatment, Program Licensure Division. 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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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 the Staffing Requirements Facility Summary Report (SRFSR) and personnel records, the facility failed to document the completion of 25 clock hours of annual training required for counselors in 1 of 4 applicable personnel records.
Employee #14 was hired as a counselor on 08/31/2016. The facility's training year that was reviewed was from 01/01/17 - 12/31/17. Employee #14's personnel/training record only documented 20 hours of annual training for the training year reviewed.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Director of Clinical Operations will track each counselor's annual training hours on a quarterly basis to see if counselors are complying with obtaining annual training. In the event that a counselor has not obtained the required annual training, the Director of Clinical Operations will commence with disciplinary action for that counselor. |
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 15 client records, the facility failed to document an annual clinical evaluation of the patient in 2 of 3 applicable client records.
Client #8 was admitted on 6/10/2015 and was still active at the time of the inspection. The most recent annual evaluation was due no later than 6/10/17; however, it was not documented as of the date of the inspection.
Client #13 was admitted on 3/14/2015 and was discharged on 8/07/17. The most recent annual evaluation was due no later than 3/14/17; however, it was not documented 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
In the future, the Director of Clinical Operations in conjunction with the Director of Operations will conduct chart audits on each patient record on a quarterly basis to ensure that annual clinical evaluations are completed in a timely manner. Currently, the missing clinical evaluations noted in the citation will be completed within 14 days. A report can by run with the electronic health record by each counselor to make sure that no other clinical evaluations are missed. |
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 15 client records, 2 of 4 applicable client records had comprehensive treatment plans that were missing the type/frequency of treatment and rehabilitation services, as well as missing documented support services.
Client #9 was admitted on 3/27/2017 and was still active at the time of the inspection. The comprehensive treatment plan was dated 5/04/17.
Client #11 was admitted on 5/09/2017 and was still active at the time of the inspection. The comprehensive treatment plan was dated 6/08/17.
The findings were reviewed with facility staff during the licensing inspection process.
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Plan of Correction
In the future, the Director of Clinical Operations in conjunction with the Director of Operations will conduct chart audits on each patient record on a quarterly basis to ensure that treatment plan updates and comprehensive treatment plans are completed in a timely manner. Currently, each treatment plan will be reviewed by a clinical supervisor to ensure that the type/frequency of treatment and rehabilitation services, as well as support services are documented before approving the plan. |
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 15 client records, the facility failed to document treatment plan updates within the regulatory timeframe in 6 of 6 applicable client records.
Client #8 was admitted on 6/10/2015 and was still active at the time of the inspection. A treatment plan update was completed on 4/21/17 and the next update was due no later than 6/21/17; however, the update was documented on 7/13/17. Additionally, another treatment plan update was due no later than 9/13/17; however, the update was not documented until 10/4/17.
Client #9 was admitted on 3/27/2017 and was still active at the time of the inspection. A treatment plan update was completed on 7/16/17 and the next update was due no later than 9/16/17; however, the update was not documented until 10/08/17.
Client #11 was admitted on 5/09/2017 and was still active at the time of the inspection. The comprehensive treatment plan was completed on 6/08/17 and an update was due no later than 8/08/17; however, the update was not documented until 8/30/17.
Client #12 was admitted on 2/21/2006 and was discharged on 8/29/2017. A treatment plan update was completed on 4/07/17 and the next update was due no later than 6/07/17; however, the update was not documented until 8/16/17.
Client #13 was admitted on 3/14/2015 and was discharged on 8/07/2017. A treatment plan update was completed on 2/22/17 and the next update was due no later than 4/22/17; however, the update was not documented until 5/26/17.
Client #15 was admitted on 6/12/2008 and was still active at the time of the inspection. A treatment plan update was completed on 3/28/17 and the next update was due no later than 5/28/17; however, the update was documented on 7/09/17. Additionally, another treatment plan update was completed on 9/28/17 and the next update was due no later than 11/28/17; however, the update was not documented until 12/14/17.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
In the future, the Director of Clinical Operations in conjunction with the Director of Operations will conduct chart audits on each patient record on a quarterly basis to ensure that comprehensive treatment plans and treatment plan updates are completed in a timely manner. Currently, each clinical supervisor will run a report for what treatment plans are due each week and ensure that all plans are being completed by counselors in the time frame required. |