INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on December 12, 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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705.28 (d) (6) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(6) Conduct fire drills on different days of the week, at different times of the day and on different staffing shifts.
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Observations
Based on a review of the facility's January 2024 through November 2024 fire drill logs, the facility failed to conduct fire drills on different days of the week, at different times of the day and on different staffing shifts.
The facility's hours of operation are posted as Monday through Thursday 9:00AM - 9:00PM and Friday 9:00AM - 5:00PM. Most of the fire drills conducted during the reviewed period were completed during the time of 9:00AM through 3:00PM. There were no fire drills conducted during the facility's evening/night hours of operation.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The facility has updated the fire drill schedule so that fire drills will be held on different days of the week and at different times of the day. The fire drill schedule has also been updated to ensure that there are fire drills happening on each shift that the facility is open. The new fire drill schedule begins 1/8/25. The fire drill schedule will be monitored by the OP director. |
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 review of the facility's January 2024 through November 2024 fire drill logs, the facility failed to set off the fire alarm or a smoke detector during each fire drill.
There was no documentation indicating the facility set off the fire alarm or smoke detectors during the completed June, September, and October 2024 fire drills.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The facility is unable to set off the fire alarm each month although we do have monthly fire drills. We are unable to set off the alarm monthly because we lease space and it would be disruptive to the other businesses inthe building. The director uses a blowhorn to notify all clients and staff that they must immediately evacuate the building. The blow horns are loud so that everyone can hear them. This process is taken very seriously, and all staff and clients are directed to evacuate the building by using the nearest exit to where they are located. All staff and clients evacuate the building and we follow all of the protocols that we would follow if the alarm had actually gone off. Director applied for an exception,however, director was notified on 12/24/24 that an exception is not needed but approval is granted for the use of an alternate means of announcing fire drills. A copy of this letter and documentation that the alarm sysytem is working will be available to licensing specialist.
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709.25 LICENSURE Fiscal Management
§ 709.25. Fiscal management.
The project shall obtain the services of an independent certified public accountant for an annual financial audit of activities associated with the project ' s drug/alcohol abuse services, in accordance with generally accepted accounting principles which include reference to the drug and alcohol treatment activities.
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Observations
Based on an administrative review, the project failed to obtain the services of an independent certified public accountant for the completion of an annual financial audit of activities associated with the project's drug/alcohol abuse services, in accordance with generally accepted accounting principles which include reference to the drug and alcohol treatment activities, for the project's fiscal year ending June 2023.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
NET did obtain the services of an independent certified public accounting firm for the Fiscal period ending June 2023 however the audit has not yet been completed. The audit is taking so long because NET (although they were searching/recruiting) was without a CFO for a period for over a year. NET has had a new CFO for the past year and has been able to manage and put safeguards in place so that this does not happen again. NET's CFO, and NETs fiscal department has been working closely with the public accounting firm to complete this audit. The audit will be completed by March 31st, 2025. NET will send the results of the audit to DDAP by 3/31/25. |
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 obtain a written informed and voluntary consent from the client for the disclosure of information contained in the client record in one of seven client records reviewed.
Client #2 was admitted on June 20, 2024 and was active at the time of the inspection. There was documentation of disclosures to the funding source during the client's treatment episode; however, there was no consent to release information form signed by the client documented in the record prior to the disclosures.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
The care manager was re-trained by the Outpatient director on 12/17/24 on confidentiality. The care manager was also given a success plan on the importance of confidentiality. The training included the importance of obtaining written and informed consent for disclosure of information that is in the client record. In this instance, the release of information was to the funding source, however, the training focused on all information that might be released. Consents to release information will be reviewed by the clinical supervisor weekly. |
709.28 (c) (1) 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:
(1) Name of the person, agency or organization to whom disclosure is made.
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Observations
Based on a review of client records, the facility failed to document the name of the person, agency, or organization to whom a disclosure was to be made to on a release of information form in one of seven client records reviewed.
Client #5 was admitted on May 21, 2024 and was discharged on September 4, 2024. A release of information form to a treatment officer was signed and dated by the client on May 21, 2024; however, there was no specific name of the person, agency, or organization to whom the disclosure was to be made included on the release form.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
The care manager was re-trained on 12/17/24 on confidentiality. This training covered detailed information including the importance of documenting the name of the person, agency and/or organization to who a disclosure was made to on a release of information form in the electronic health record. This will be monitored by the clinical supervisor on a weekly basis. |
709.28 (c) (2) 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:
(2) Specific information disclosed.
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Observations
Based on a review of client records, the facility failed to document the specific information to be released on consent to release information forms in five of seven client records reviewed.
Client #1 was admitted on April 25, 2024 and was active at the time of the inspection. There was a release of information form to a transportation agency signed and dated by the client on April 25, 2024; however, there was no specific information to be disclosed included on the release form.
Client #3 was admitted on May 7, 2024 and was active at the time of the inspection. There was a release of information form to a transportation agency signed and dated by the client on May 7, 2024; however, there was no specific information to be disclosed included on the release form.
Client #4 was admitted on March 20, 2024 and was discharged on August 23, 2024. There was a release of information form to a transportation agency signed and dated by the client on May 7, 2024; however, there was no specific information to be disclosed included on the release form.
Client #6 was admitted on April 17, 2024 and was discharged on July 26, 2024. There was a release of information form to a transportation agency signed and dated by the client on April 17, 2024; however, there was no specific information to be disclosed included on the release form.
Client #7 was admitted on May 14, 2024 and was discharged on September 23, 2024. There was a release of information form to a transportation agency signed and dated by the client on May 14, 2024; however, there was no specific information to be disclosed included on the release form.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The care manager was re-trained on 12/17/24 on confidentiality. This training covered detailed information including the importance of documenting the specific disclosure that was made on a release of information form in the electronic health record. The director reviewed the importance of being specific on what information can be released. The care manager was aslo given a success plan. This will be monitored by the clinical supervisor on a weekly basis. |
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 the disclosure consent to release information forms in six of seven client records reviewed.
Client #1 was admitted on April 25, 2024 and was active at the time of the inspection. There were release of information forms to a funding source, a urinalysis laboratory, and a government agency signed and dated by the client on April 25, 2024; however, there was no purpose of the disclosure included on any of the release forms.
Client #3 was admitted on May 7, 2024 and was active at the time of the inspection. There were release of information forms to a funding source, an emergency contact, a urinalysis laboratory, and a government agency signed and dated by the client on May 7, 2024; however, there was no purpose of the disclosure included on any of the release forms.
Client #4 was admitted on March 20, 2024 and was discharged on August 23, 2024. There were release of information forms to a funding source, an emergency contact, a urinalysis laboratory, an outside individual, a physician, and a government agency signed and dated by the client on March 20, 2024; however, there was no purpose of the disclosure included on any of the release forms.
Client #5 was admitted on May 21, 2024 and was discharged on September 4, 2024. There were release of information forms to a funding source, an outside individual, a transportation agency, a urinalysis laboratory, and a government agency signed and dated by the client on May 21, 2024; however, there was no purpose of the disclosure included on any of the release forms.
Client #6 was admitted on April 17, 2024 and was discharged on July 26, 2024. There were release of information forms to a funding source, a urinalysis laboratory, and a government agency signed and dated by the client on April 17, 2024; however, there was no purpose of the disclosure included on any of the release forms.
Client #7 was admitted on May 14, 2024 and was discharged on September 23, 2024. There were release of information forms to a funding source, a urinalysis laboratory, and a government agency signed and dated by the client on May 14, 2024; however, there was no purpose of the disclosure included on any of the release forms.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The care manager was re-trained by the director on 12/17/24 on confidentiality. During the training they specifically discussed the importance of adding the purpose of the disclosure of the records that are being released. This citation applies to releases of information pertaining to funding sources, urinalasis labratory and a governement agency. However, this trainng included any disclosures being made to any entity. The care manager was given a success plan to improve. This will be monitored by the clinical supervisor. |
709.28 (c) (4) 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:
(4) Dated signature of client or guardian as provided for under 42 CFR 2.14(a) and (b) and 2.15 (relating to minor patients; and incompetent and deceased patients).
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Observations
Based on a review of client records, the facility failed to document the dated signature of a client on consent to release information forms in three of seven client records reviewed.
Client #1 was admitted on April 25, 2024 and was active at the time of the inspection. There were release of information forms to a funding source and a government agency signed and dated by facility staff on April 25, 2024; however, there was no dated signature of the client included on either release form.
Client #4 was admitted on March 20, 2024 and was discharged on August 23, 2024. There were release of information forms to a government agency and a urinalysis laboratory signed and dated by facility staff on March 20, 2024; however, there was no dated signature of the client included on either release form.
Client #5 was admitted on May 21, 2024 and was discharged on September 4, 2024. There was a release of information form to a funding source signed and dated by facility staff on May 21, 2024; however, there was no dated signature of the client included on the release form.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
There was a gliche on the consent form that clients sign to release information to the funding source. The gliche was that the date for the information to be released disappeared from the form. A ticket was submitted to the IT department on 12/26/24 to have this form corrected. The form will be updated on 1/8/25 to re-include that box to the form so that the client signature and date can be recorded. The care manager was re-trained on 12/17/24 by the OP director that if she notices that this box is missing to inform the director. The director also re-trained the care manager on 12/17/24 the importance of including that date on the form. This will be monitored by the clincial supervisor. |
709.31 (b) LICENSURE Data collection system
§ 709.31. Data collection system.
(b) The recordkeeping system must allow for the identification of clients' admissions and discharges within a specific time period.
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Observations
Based on an administrative review, the facility failed to maintain a recordkeeping system that allowed for the identification of clients' admission dates and discharge dates within a specific time.
The facility was unable to produce a discharged client list upon request as it took approximately two hours to generate a complete, and accurate, discharge client list with admit and discharge dates.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
The facility maintains a caseload report for all active and discharged clients in excel format. This caseload report is used daily by all clinical staff and was always availble to see on the computer. The director attempted to print it the morning of the inspection and had a technical gliche. She needed to get assistance from NETs IT department to have it printed. It was printed for the licensing specialist. For all inspections, the OP director will have the admitted/discharged list from the caseload report printed the day before the inspection. |
709.33 (a) LICENSURE Notification of termination.
§ 709.33. Notification of termination.
(a) Project staff shall notify the client, in writing, of a decision to involuntarily terminate the client ' s treatment at the project. The notice shall include the reason for termination.
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Observations
Based on a review of client records, the facility failed to notify the client, in writing, of the decision to involuntarily terminate the client's treatment at the project, which is to include the reason for termination, in one of one applicable client record reviewed.
Client #7 was admitted on May 14, 2024 and was administratively discharged on September 23, 2024. There was no documentation, in the record, indicating that the client was notified in writing of the facility's decision to involuntarily terminate the client's treatment at the project.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
A training will be held by the OP director for all clinical staff on 1/9/25. The training will include the importance of documenting in the electronic health record the notification to the client if they have been involuntarilty or administratively discharged. The reason for the discharge will always be included in the notification. The clinical supervisor will monitor all discharges weekly to ensure that notification and reason why is always documented. |
709.92(a)(2) 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:
(2) Type and frequency of treatment and rehabilitation services.
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Observations
Based on a review of client records, the facility failed to document the type and frequency of treatment and rehabilitation services on an individual treatment and rehabilitation plan in four of six applicable client records reviewed.
Client #1 was admitted on April 25, 2024 and was active at the time of the inspection. The individual treatment and rehabilitation plan was completed on May 20, 2024; however, the plan did not include the frequency of treatment and rehabilitation services being provided to the client.
Client #2 was admitted on June 20, 2024 and was active at the time of the inspection. The individual treatment and rehabilitation plan was completed on August 7, 2024; however, the plan did not include the frequency of treatment and rehabilitation services being provided to the client.
Client #4 was admitted on March 20, 2024 and was discharged on August 23, 2024. The individual treatment and rehabilitation plan was completed on May 17, 2024; however, the plan did not include the frequency of treatment and rehabilitation services being provided to the client.
Client #5 was admitted on May 21, 2024 and was discharged on September 4, 2024. The individual treatment and rehabilitation plan was completed on July 12, 2024; however, the plan did not include the frequency of treatment and rehabilitation services being provided to the client.
This is a repeat citation from the January 22, 2024 annual licensing renewal inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The OP director will hold a training on documentation for all clinical staff on 1/9/25. During this training, staff will be re-trained on the importance of documenting the type, and frequency of treatment and rehabilitation services on a treatment plan. If the the type and frequency of treatment changes, the treatment plan will be updated. If the client misses the appointments, it will be documented in the progress note to show why the frequency did not occur. This will be monitord by the clinical supervisor on a weekly basis. |
709.92(c) LICENSURE Treatment and rehabilitation services
709.92. Treatment and rehabilitation services.
(c) The project shall assure that counseling services are provided according to the individual treatment and rehabilitation plan.
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Observations
Based on a review of client records, the facility failed to assure counseling services were being provided to the client according to the individual treatment and rehabilitation plan in two of two applicable client records reviewed.
Client #3 was admitted on May 7, 2024 and was active at the time of the inspection. The individual treatment and rehabilitation plan dated June 5, 2024 and the treatment plan update dated July 24, 2024 indicated individual counseling sessions were to be provided twice per month. There was only one individual counseling session on August 23, 2024 documented for the month of August 2024.
Client #7 was admitted on May 14, 2024 and was discharged on September 23, 2024. The individual treatment and rehabilitation plan dated July 10, 2024 indicated individual counseling sessions were to be provided weekly. There was no documentation, in the record, indicating individual counseling sessions occurred during the weeks of July 14, 2024 through August 17, 2024.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The OP director will hold a training on documentation for all clinical staff on 1/9/25. During this training, staff will be re-trained on the importance of providing the counseling services that have been included in the recommended type and frequency portion of the treatment plan. If the frequency of treatment changes, the treatment plan will be updated. If the client misses the appointment, it will be documented in the progress note to show why the frequency did not occur. This will be monitord by the clinical supervisor on a weekly basis. |