INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection and methadone monitoring inspection conducted on June 7, 2022 through June 9, 2022 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 Health Care, 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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704.11(e)(2) LICENSURE Annual Trng Req-Clin Sup
704.11. Staff development program.
(e) Training requirements for clinical supervisors.
(2) Each clinical supervisor shall complete at least 12 clock hours of training annually in areas such as:
(i) Supervision and evaluation.
(ii) Counseling techniques.
(iii) Substance abuse trends and treatment methodologies in the field of addiction.
(iv) Confidentiality.
(v) Codependency/Adult Children of Alcoholics (ACOA) issues.
(vi) Ethics.
(vii) Interaction of addiction and mental illness.
(viii) Cultural awareness.
(ix) Sexual harassment.
(x) Developmental psychology.
(xi) Relapse prevention.
(xii) Disease of addiction.
(xiii) Principles of Alcoholics Anonymous and Narcotics Anonymous.
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Observations
Based on a review of personnel records, the facility failed to document the completion of 12 clock hours of annual training required for clinical supervisors during the facility's January 2021 through December 2021 training year in one of one applicable personnel record reviewed.
Employee #3 was hired as a clinical supervisor on March 23, 2020. The personnel file documented 4 hours of annual training during the training year reviewed.
These findings were reviewed with facility staff as part of the inspection process.
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Plan of Correction
The Executive Director reviewed the citation. Northeast Family Healthcare will ensure that the DDAP training requirements are met for each employee with in the timeframe spcified in 704.11. The Executive Director will provide oversight to ensure this is completed. This will be implemented immediately and will be addressed by providing a list of required trainings to all staff to include expected timeframe. Staff member in question is no longer on staff at NEFHC. A new Clinical Supervisor was hired May 31, 2022 and has completed 3 hours thus far of training thus far in Counseling Techniques |
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 the facility's June 2021 through May 2022 fire drill logs, the facility failed to conduct unannounced fire drills at least once a month during the months of April 2022 and May 2022.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Executive Director reviewed the citation. As per regulation 705.26, Northeast Family Healthcare will conduct unannounced fire drill at least one time monthly. Person responsible is the Executive Director, last drill completed 6/8/22 and next is schedule 7/8/22. |
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 disclosure on release of information forms in one of seven client records reviewed.
Client #2 was admitted on August 24, 2021 and was active at time of inspection. A release of information form to a probation and parole agency was signed and dated by the client on September 3, 2021; however, the form did not indicate the purpose of disclosure.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Executive Director reviewed the citation. A record-keeping retraining to include a review o confidentiality standards will be facilitated on July 27, 2022 to ensure that all staff adhere to confidentiality standards per DDAP Policy 709.28. All Realease of Information Forms will be reviewed and monitored during the monthly Supervision meetings for compliance, completion and ensure timeline is followed. This will be completed by the Clinical Supervisor by 7/27/22 |
709.28 (c) (5) 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:
(5) Dated signature of witness.
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Observations
Based on a review of client records, the facility failed to document the dated signature of a witness on release of information forms in one of seven client records reviewed.
Client #2 was admitted on August 24, 2021 and was active at time of inspection. A release of information form to a probation and parole agency was signed and dated by the client on September 3, 2021; however, the witness signed and dated the form on September 7, 2021.
This is a repeat citation from the June 30, 2021 annual licensing renewal inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Executive director reviewed the citation, Northeast Family Healthcare will ensure proper and completed releases are noted to patients chart. Wilness will complete a signature following patients permission on the same day of release. This will be update via the counselor by 7/27/2022. The Clincal Supervisor will be responsible to ensure the plan is implemented. |
709.28 (c) (6) 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:
(6) Date, event or condition upon which the consent will expire.
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Observations
Based on a review of client records, the facility failed to document the date, event or condition upon which the consent will expire in one of seven client records reviewed.
Client #2 was admitted on August 24, 2021 and was active at time of inspection. A release of information form to a probation and parole agency was signed and dated by the client on September 3, 2021; however, there was no date, event or condition upon which the consent will expire documented on the form.
This is a repeat citation from the June 30, 2021 annual licensing renewal inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Executive Director reviewed the citation. All staff completing releases will ensure that each release has documented the date, event, or condition upon which the consent upon which the consent will expire. Director and clinica supervisor will ensure confidentiality and release of information training is conducted as review for all staff by 7/27/22 and in all staff team meetings moving forward. |
709.34 (c) (4) LICENSURE Reporting of unusual incidents
§ 709.34. Reporting of unusual incidents.
(c) To the extent permitted by State and Federal confidentiality laws, the project shall file a written unusual incident report with the Department within 3 business days following an unusual incident involving:
(4) Event at the facility requiring the presence of police, fire or ambulance personnel.
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Observations
Based on review of the facility's unusual incident reports, the facility failed to notify the Department within 3 business days of an event at the facility requiring the presence of police, fire or ambulance personnel.
On August 24, 2021, an emergency medical team was called to the facility; however, there was no documentation that the incident was reported to the Department within 3 business days.
On October 22, 2021, police were called to the facility; however, there was no documentation that the incident was reported to the Department within 3 business days.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Executive Director reviewed the citation. A training will be conducted on 7/27/22 reviewing the DDAP Unusual Incident Reporting policy 709.34 (c)(4) by the Executive Director and Clinical Supervisor. DDAP will be notified of all unusual incednet per 709.34 (c) (4) within 72 hours following an unusual incident. Executive Director will be responsible for ensuring the plan is implemented and completed by 7/27/22 |
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 an administrative review, the facility failed to ensure that time provided by the certified registered nurse practitioner did not exceed two-thirds of the required narcotic treatment physician time.
During the week of February 13, 2022, the patient census was 300, which required 30 total narcotic treatment physician hours, and no more than 20 of those hours were to be provided by the mid-level practitioner. The narcotic treatment physician provided 8.50 of the required hours and the certified registered nurse practitioner provided 21.50 of the required hours.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The executive Director reviewed the citation. Physician was hired 6/23/22 andwill work 10 hours weekly and CRNP was hired 4.25.2022 and is staffed for 40 hours weekly in NEFHC to cover hours needed per the census. |
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 seven patient records reviewed.
Patient #4 was admitted on April 20, 2016 and was discharged on April 23, 2022. There was no documented drug screen urinalysis for the month of February 2022.
Patient #7 was admitted on November 15, 2019 and was discharged on May 17, 2022. There was no documented drug screen urinalysis for the month of January 2022.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Executive Director reviewed the citation. As of July 1, 2022 the Clinical Supervisor will run a patient without a drug screen report from the EMR twice monthly to identify the patients who have not completed the minimum urine drug screen requirements. patients identified by this method shall be place on hold to do so. Patients who refuse to complete a screening shall have a non billable note placed in their EMR record to to document as such and serve as proof that attempts for screeening were made by the staff. The process will be ongoing and will be monitored by the Clinical Supervisor and overseen by the Executive Director to ensure completion. |
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 that the counselor completed an annual evaluation of each patient's status, which is to be reviewed, dated and signed by the medical director, in one of four applicable patient records reviewed.
Patient #7 was admitted on November 15, 2019 and was discharged on May 17, 2022. An annual evaluation of the patient's status was completed on December 3, 2020, and the next was due no later than December 3, 2021; however, there was no annual evaluation documented in the patient record prior to discharge.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
The Executive Director reviewed the citation. As of July 10, 2022 a EMR tracking reort is established to track and flag annuals reviews. The Clinical Supervidor will indentify any outstanding reports weekly and along with the executive Director, monthly will complete an audit for all reviews to be completed. |
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 that treatment and rehabilitation plans are reviewed and updated at least every sixty days in four of seven client records reviewed.
Client #2 was admitted on August 24, 2021 and was active at time of inspection. A treatment plan update was completed on October 1, 2021, and the next update was due no later than December 1, 2021; however, the update was completed on February 25, 2022. Additionally, the next update was due no later than April 25, 2022; however, the update was completed on May 9, 2022.
Client #3 was admitted on September 8, 2021 and was active at time of inspection. The comprehensive treatment plan was completed on September 21, 2021, and the first update was due no later than November 21, 2021; however, the update was completed on December 23, 2021.
Client #4 was admitted on April 20, 2016 and was discharged on April 23, 2022. A treatment plan update was completed on August 3, 2021, and the next update was due no later than October 3, 2021; however, the update was completed on October 11, 2021. Additionally, a treatment plan update was completed on January 25, 2022, and the next update was due no later than March 25, 2022, however, the update was completed on April 4, 2022.
Client #7 was admitted on November 15, 2019 and was discharged on May 17, 2022. A treatment plan update was completed on October 1, 2021, and the next update was due no later than December 1, 2021; however, the update was completed on December 21, 2021. Additionally, a treatment plan update was completed on February 21, 2022, and the next update was due no later than April 21, 2022; however, the update was completed on May 2, 2022.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Executive Director reviewed the citation. The Clinical Supervisor will conduct a staff training on DDAP regulations 709.92 and specifice to policy and procedure for Treatment Plans. The training will be specific to Treatment and Rehabilitation plans, ensuring they are reviewed and updated within a 60 day timeframe. The Executive Director and Clinical Supervisor will utilize weekly record reviews to monitor and ensure compliance. |