INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection and methadone and buprenorphine monitoring inspection conducted on January 8, 2024 through January 9, 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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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, the facility failed to ensure that all counselors met the educational and/or experiential qualifications in two of six applicable personnel records reviewed.
Employee #12 was hired as a counselor on October 10, 2022. The employee has a bachelor's degree in English, which is not a qualifying degree for the position of counselor.
Employee #15 was hired as a counselor on December 27, 2022. The employee record did not have documentation of a qualifying degree; therefore, verification that the employee meets the educational qualifications of the position could not be completed.
This is a repeat citation from the January 11, 2023 annual licensing renewal inspection.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
We will be requesting a waiver from DDAP by 3/1/24 in regard to Employee #12 bachelor's degree in English.
As of 2/9/2024, Employee #15 will no longer employed with NET Bridge.
On 1/23/2024 The recruiting department within Human Resources was re-educated on the employment requirements for clinical staff to ensure we are within the DDAP guidelines. Moving forward, we will be ensuring that during the hiring process, the hiring manager will be provided a copy of the candidate's transcript and degree prior to onboarding. |
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 that a copy of a client consent to release information form was offered to the client in two of eight client records reviewed.
Client #2 was admitted on May 7, 2007 and was active at the time of inspection. A release of information form to a hospital was signed and dated by the client on November 14, 2023; however, there was no documentation indicating that a copy of the release form was offered to the client.
Client #3 was admitted on March 8, 2023 and was discharged on November 21, 2023. There were release of information forms to an outside individual and a physician that were signed and dated by the client on October 12, 2023; however, there was no documentation indicating that a copy of either release form was offered to the client. Additionally, there was a release of information form to another treatment provider that was signed and dated by the client on November 7, 2023; however, there was no documentation indicating that 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
On December 5, 2023, the quality assurance department updated the release of information form to adhere to the DDAP guidelines. The updated form now includes a section that indicates a copy of the ROI was offered to the client, which prompts the client to accept or deny a copy.
Effective Immediately, releases of information will be monitored upon completion by the QA department and clinical management team to ensure all clients were offered a copy of their ROI. |
715.21(2) LICENSURE Patient termination
A narcotic treatment program shall develop and implement policies and procedures regarding involuntary terminations. Involuntary terminations shall be initiated only when all other efforts to retain the patient in the program have failed.
(2) A patient terminated involuntarily, except a patient who commits or threatens to commit acts of physical violence, shall be afforded the opportunity to receive detoxification of at least 7 days. The detoxification may take place at the facility or the patient may be referred to another narcotic treatment program or hospital licensed and approved by the Department for detoxification.
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Observations
Based on a review of patient records, the facility failed to provide an involuntarily terminated patient with the opportunity to receive detoxification of at least 7 days in one of one applicable patient records reviewed.
Patient #6 was admitted on July 30, 2021 and was administratively discharged on August 17, 2023. The patient was administratively discharged due to continuous absence from the narcotic treatment program and failing to follow treatment plan objectives. There was no documentation, in the record, that the patient was afforded the opportunity to receive detoxification of at least 7 days.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
On 2/6/2024, The administrative discharge letter was revised that is given to clients that will be discharged due to continuous absence from the program and failing to follow treatment plan objectives. The letter has been updated to include the statement:
"You have the option to opt in to a 7-day detox at this time, which will begin today. Your last day of dosing would be (date of last day of dosing)."
Effective Immediately, the clinical management team and clinical staff will monitor the content of each letter provided to clients who are being discharged due to non-compliance. |
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 were reviewed and updated at least every sixty days in six of eight client records reviewed.
Client #1 was admitted on June 24, 2019 and was active at the time of inspection. A treatment plan update was completed on June 27, 2023, and the next update was due no later than August 27, 2023; however, the update was completed on December 20, 2023.
Client #2 was admitted on May 6, 2007 and was active at the time of inspection. A treatment plan update was completed on August 1, 2023, and the next update was due no later than October 1, 2023; however, the update was completed on October 24, 2023.
Client #3 was admitted on March 8, 2023 and was discharged on November 21, 2023. The individual treatment and rehabilitation plan was completed on April 7, 2023, and the first update was due no later than June 7, 2023; however, the update was completed on June 20, 2023.
Client #4 was admitted on July 18, 2023 and was active at the time of inspection. A treatment plan update was completed on October 5, 2023, and the next update was due no later than December 5, 2023; however, the update was not completed at the time of inspection.
Client #7 was admitted on October 1, 2021 and was discharged on October 2, 2023. A treatment plan update was completed on June 28, 2023, and the next update was due no later than August 28, 2023; however, the update was not completed prior to discharge.
Client #8 was admitted on May 19, 2017 and was discharged on August 5, 2023. A treatment plan update was completed on May 11, 2023, and the next update was due no later than July 11, 2023; however, the update was not completed prior to discharge.
This is a repeat citation from the January 11, 2023 annual licensing renewal inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Effective 2/1/24, all treatment plan updates will be completed every 45 days to ensure plans are completed within the required timeframe. The leadership team will continue to work in conjunction with the QA department to monitor the clinical staff's progress in completing treatment plan updates within the required timeframe.
Client #4 had a treatment plan update completed on January 9, 2023. |
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 maintain a complete client record, which is to include follow-up information, in two of three applicable client records reviewed.
Client #3 was admitted on March 8, 2023 and was discharged on November 21, 20323. There was no follow-up information regarding the client documented in the record at the time of the inspection.
Client #8 was admitted on May 19, 2017 and was discharged on August 5, 2023. There was no follow-up information regarding the client documented in the record at the time of the inspection.
This is a repeat citation from the January 11, 2023 annual licensing renewal inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The program manager and senior program director met with the QA department to implement a process to ensure all outreaches are completed within 2 weeks after discharges are completed. The QA department will continue to work in conjunction with the clinical supervisor and program manager to provide feedback on incomplete follow-up.
Effective immediately, counselors will begin conducting outreaches within 2 weeks after a successful discharge.
Effective immediately, all discharged patients will receive a follow-up letter regarding their discharge within 7 days after discharge. |