INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on January 14 - 16, 2019 by staff from the Department of Drug and Alcohol Programs, Bureau of Quality Assurance for Prevention and Treatment. 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(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 personnel and training records, the facility failed to document TB/STD training within one year of hire for a counselor. Employee #11 was hired as a counselor on 2/24/17. TB/STD training was due to be completed by 2/24/18, but it was not completed 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
NET will utilize the Behavioral Health Training and Education Network (BHTEN) to provide the counselor, employee #6, with the required 6 hours of HIV/AIDS training . Trainings will be scheduled by the Site Director. Compliance with the regulation will be monitored by the Program Director. The facility will be in full compliance by May 30, 2019. |
705.24 (3) LICENSURE Bathrooms.
705.24. Bathrooms.
The nonresidential facility shall:
(3) Have hot and cold water under pressure. Hot water temperature may not exceed 120F.
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Observations
Based on a physical plant inspection conducted on January 14, 2019, the hot water in the men's staff bathroom exceeded 120 degrees. The water temperature measured 131 degrees at the time of inspection.
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Plan of Correction
The Director of Facilities Management will regulate the hot water heater to heat the water to no more than 120 degrees Fahrenheit. The Director of Facilities Management will monitor the water temperature for ongoing compliance. The facility will be in compliance by 4/15/2019. |
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 a review of personnel records, the facility failed to ensure that the facility director, hired January 8, 2018, received an annual performance evaluation.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The facility director ended employment at NET on 1/17/2019. An evaluation was not completed prior to the 1/17/2019. The Human Resources Information Systems Coordinator will monitor personnel files for compliance with the regulation. |
709.28 (a) (1) LICENSURE Confidentiality
§ 709.28. Confidentiality.
(a) A written procedure shall be developed by the project director which shall comply with 4 Pa. Code § 255.5 (relating to projects and coordinating bodies: disclosure of client-oriented information). The procedure must include, but not be limited to:
(1) Confidentiality of client identity and records. Procedures must include a description of how the project plans to address security and release of electronic and paper records and identification of the person responsible for maintenance of client records.
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Observations
Based on a review of outpatient detoxification client records, the facility failed to document informed consent to release information in accordance with 4 Pa. Code 255.5 in client records # 1, 2, 3 and 5.Client #1 was admitted on 4/3/18. A consent to release information from to an insurance company documented the release of " Assessments; Treatment Plans and Recommendations; Discharge and Aftercare Plans; Discharge Summary; Physical Health Assessments and Recommendations; Medication History; Treatment recommendations. "Client #2 was admitted on 4/3/18. A consent to release information form to an insurance company documented the release of " Entire Health Record. "Client #3 was admitted on 5/9/18. A consent to release information form to an insurance company documented the release of " Assessments; Treatment Plans and Recommendations; Discharge and Aftercare Plans; Discharge Summary; Physical Health Assessments and Recommendations; Medication History; Treatment recommendations. "Client #5 was admitted on 5/7/18. A consent to release information form to an insurance company documented the release of " Assessments; Treatment Plans and Recommendations; Discharge and Aftercare Plans; Discharge Summary; Physical Health Assessments and Recommendations; Medication History; Treatment recommendations. "
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Plan of Correction
The Director of Quality and Compliance will amend the Release of Information form for the insurance company to comply with 4 Pa. Code 255.5. The Director of Quality and Compliance will provide training to the staff regarding the new form and compliance with 4 Pa. Code 255.5. Oversight for compliance will be conducted by the Quality Assurance Department. The facility will be in full compliance by 4/30/19. |
709.30 (1) LICENSURE Client rights
§ 709.30. Client rights.
The project shall develop written policies and procedures on client rights and document written acknowledgement by clients that they have been notified of those rights.
(1) A client receiving care or treatment under section 7 of the act (71 P. S. § 1690.107) shall retain civil rights and liberties except as provided by statute. No client may be deprived of a civil right solely by reason of treatment.
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Observations
Based on a review of outpatient detoxification client records, the facility failed to document written acknowledgement, in records # 1, 2, 3, 4, and 5, that the clients were notified of the following rights: Clients have the right to appeal a decision limiting access to their records to the director. Clients have the right to request the correction of inaccurate, irrelevant, outdated or incomplete information in their records.Clients have the right to submit rebuttal data or memoranda to their own records.
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Plan of Correction
The Director of Quality and Compliance will amend the Client Rights form to comply with section 7 of the act (71 P. S. § 1690.107). The Client Rights form will include language explaining that: Clients have the right to appeal a decision limiting access to their records to the director; Clients have the right to request the correction of inaccurate, irrelevant, outdated or incomplete information in their records; and Clients have the right to submit rebuttal data or memoranda to their own records. The Director of Quality and Compliance will provide training to the staff regarding the new form and compliance with section 7 of the act (71 P. S. § 1690.107). Oversight for compliance will be conducted by the Quality Assurance Department. The facility will be in full compliance by 4/30/19. |