INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection and methadone monitoring conducted on October 26, 2021 through October 28, 2021 by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, New Directions Treatment Services 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 records, the facility failed to ensure that all staff persons received a minimum of 6 hours of HIV/AIDS training and at least 4 hours of TB/STD and other health related topics training within the regulatory timeframe in two of six applicable personnel records reviewed. Employee # 4 was hired as a counselor on August 27, 2020 and was due to have TB/STD training no later than August 27, 2021. The TB/STD training was not completed at the time of the inspection.Employee # 7 was hired as a counselor on January 27, 2020 and was due to have HIV/AIDS training and TB/STD training no later than January 27, 2021. The HIV/AIDS training was not completed until February 12, 2021 and the TB/STD training was not completed until March 30, 2021.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
By 11/25/2021, the Facility Director will collaborate with the agency's Advanced Nurse Practitioner to develop a training curriculum that meets the Department's six -hour HIV/AIDS and four-hour TB/STD requirements. Training will be provided on-site at least annually to ensure that both Clinical and Support Staff meet the regulatory standard within twelve and twenty four months, respectively, of hire date. The Clinical Supervisor will be responsible for scheduling and ensuring that participation in and documentation of trainings have been completed within the required time- frames. Ongoing compliance will be monitored by the Facility Director through regular review of training records. |
705.28 (d) (7) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(7) Set off a fire alarm or smoke detector during each fire drill.
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Observations
Based on a review of the facility's August 2020 through September 2021 fire drill logs, the facility failed to ensure that a fire alarm or a smoke detector was set off during the March 2021 and April 2021 fire drills.This is a repeat citation from the August 25, 2020 annual licensing renewal inspection. This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
As of 11/01/2021, staff responsible for conducting the monthly fire drills has been reminded to ensure that activation of the fire alarm/smoke detector during the fire drill has been completed and documented in the Health & Safety Record Manual. Ongoing compliance will be monitored by the Nursing Director and/or the Safety Committee staff through a review of the Health & Safety Records during the regularly scheduled Safety Committee meetings. |
709.28 (c) 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.
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Observations
Based on a review of client records, the facility failed to complete an informed and voluntary consent to release information form prior to the disclosure of information in one of ten client records reviewed.Client # 6 was admitted on February 14, 2020 and was discharged on September 14, 2021. The release of information forms to the funding source and the urinalysis laboratory were signed by the client and witness on January 23, 2020 and both forms expired on January 23, 2021. There was evidence of disclosures to both entities after the release of information forms expired; however, there were no updated consent to release information forms signed by the client documented in the record prior to any of the disclosures made after January 23, 2021.This is a repeat citation from the May 12, 2021 and the November 20, 2019 annual licensing renewal inspections. These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
During clinical staff meeting on 11/03/2021, Clinicians were reminded of the requirement to update all active Consents to Release Confidential Information annually at time of completion of the Annual Review of treatment. The Clinical Supervisor will be responsible for monitoring ongoing compliance with the regulatory requirement during individual supervision and through random record review. |
709.30 (2) 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.
(2) The project may not discriminate in the provision of services on the basis of age, race, creed, sex, ethnicity, color, national origin, marital status, sexual orientation, handicap or religion.
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Observations
Based on a review of client records, the facility failed to document the written acknowledgement by clients that they have been notified of their right that the project may not discriminate in the provision of services on the basis of national origin, marital status and handicap in four of four applicable client records reviewed.Client #1 was admitted on June 18, 2021 and was still active at the time of the inspection.Client #2 was admitted on June 19, 2021 and was still active at the time of the inspection.Client #3 was admitted on July 2, 2021 and was still active at the time of the inspection.Client #4 was admitted on August 25, 2021 and was still active at the time of the inspection.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
By 11/25/2021, the Facility Director will revise the Clients' Rights & Responsibilities document provided to individuals receiving services to include notification that the project will not discriminate in the provision of services on the basis of age, race, creed, sex, ethnicity, color, national origin, marital status, sexual orientation, handicap or religion. The revised document will be provided to all enrolled and newly admitted individuals and a copy of each client's acknowledgement of receipt of the revised document will be retained in the client record. Ongoing compliance with the regulatory requirement will be monitored by the Clinical Supervisor during individual supervision and through random record review. |
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 one-third of all required narcotic treatment physician time was provided by a narcotic treatment physician and no more than two-thirds of the required time was provided by a physician assistant or certified registered nurse practitioner. During the week of June 28, 2021, the patient census was 553 which required 56 total narcotic treatment physician hours, with at least 19 of those hours to be provided by a narcotic treatment physician. The narcotic treatment physicians provided only 16.5 hours of the required time while the physician assistant and certified registered nurse practitioner provided 50 hours of required time. These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
On 11/05/2021 the Facility Director reminded Nursing Staff assigned to monitor Physician hours of the regulatory requirement that 1/3 of required physician hours must be provided by NTP Physicians. Beginning on 11/08/2021, the Nursing Director or his/her designee will review the current active MAT census and ensure that sufficient physician hours will be scheduled to meet one third of the regulatory required hours based on the census at the beginning of every week. The Nursing Director will be responsible for modifying the physician hours scheduled as needed to meet the requirement. The Facility Director will monitor ongoing compliance with the regulation through ongoing review of the Physician/Physician Extender/Census tracking record. |
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 an average of 2.5 hours of psychotherapy per month during the patient's first 2 years in treatment in two of seven applicable patient records reviewed. Patient # 6 was admitted on February 14, 2020 and was discharged on September 14, 2021. The record of service and progress notes documented that during the month of June 2021, there were 2 hours of psychotherapy provided to the patient. Additionally, during the month of July 2021, the record of service and progress notes documented that there were zero minutes of psychotherapy provided to the patient.Patient # 7 was admitted on August 26, 2020 and was discharged on August 20, 2021. The record of service and progress notes documented that during the month of June 2021, there were 2 hours of psychotherapy provided to the patient. Additionally, during the month of July 2021, the record of service and progress notes documented that there were zero minutes of psychotherapy provided to the patient.This is a repeat citation from the May 12, 2021 annual licensing renewal inspection.This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
By 11/25/2021, the Facility Director will provide a training to Clinicians outlining the requirement to meet the regulatory minimum number of hours of counseling per month. The training will review recommended interventions to be utilized to support and encourage individuals enrolled in MAT to attend counseling. Staff will be assigned to track monthly counseling hours and the Clinical Supervisor will be responsible for monitoring compliance with the counseling attendance regulatory requirements. |
715.28(c)(1-5) LICENSURE Unusual incidents
(c) A narcotic treatment program shall file a written Unusual Incident Report with the Department within 48 hours following an unusual incident including the following:
(1) Complaints of patient abuse (physical, verbal, sexual and emotional).
(2) Death or serious injury due to trauma, suicide, medication error or unusual circumstances.
(3) Significant disruption of services due to a disaster such as a fire, storm, flood or other occurrence.
(4) Incidents with potential for negative community reaction or which the facility director believes may lead to community concern.
(5) Drug related hospitalization of a patient.
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Observations
Based on a review of the facility's May 2021 through September 2021 unusual incident logs, the facility failed to file a written unusual incident report with the Department within 48 hours following a death due to trauma, suicide, medication error or unusual circumstances. The facility learned of the offsite death of a then-active client on August 31, 2021; however, the incident was not reported to the Department within the regulatory timeframe. This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
As of 11/10/2021, the Nursing Director and/or his/her designee will notify the Facility Director of any Unusual Incidents with 24 hours of an occurrence of incidents required by regulation to be reported to the Department. Beginning on 11/10/2021, the Facility Director will file a written Unusual Incident Report with the Department within 48 hours of a reportable incident. A hard copy of all reported Unusual Incidents will also be maintained on file at the facility to ensure ongoing compliance with the regulation. |