INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on January 17, 2023 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 each counselor met the educational and/or the experiential requirements for the position.Employee #10, promoted as a counselor on April 19, 2022, had a bachelor's degree in a qualifying major; however, there was only 6 months of clinical experience in a health or human service agency, documented in the record, prior to promotion.This finding was reviewed with facility staff during the licensing inspection.
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Plan of Correction
Program director will work collaboratively with the human resources department to ensure that the proper amount of clinical experience in a health or human service agancy or educatonal experience has occurred prior to a counselor's assistant being promoted to a counselor. This will be monotered for compliance through our new HRIS system, Paycom and program director. No further action needed with the employee that was promoted because he now has the appropriate amount of clinical experience needed. |
704.11(d)(2) LICENSURE Annual Training Requirements
704.11. Staff development program.
(d) Training requirements for project directors and facility directors.
(2) A project director and facility director shall complete at least 12 clock hours of training annually in areas such as:
(i) Fiscal policy.
(ii) Administration.
(iii) Program planning.
(iv) Quality assurance.
(v) Grantsmanship.
(vi) Program licensure.
(vii) Personnel management.
(viii) Confidentiality.
(ix) Ethics.
(x) Substance abuse trends.
(xi) Developmental psychology.
(xii) Interaction of addiction and mental illness.
(xiii) Cultural awareness.
(xiv) Sexual harassment.
(xv) Relapse prevention.
(xvi) Disease of addiction.
(xvii) 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 the project director and the facility director during the facility's July 2021 through June 2022 training year in two of two applicable personnel records reviewed. Employee #1 was hired as the Project Director on December 1, 2003. The record documented 10 hours of annual training during the training year reviewed.Employee #2 was hired as the Facility Director on February 1, 2020. The record documented 9 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
Both the Project Director and Facility Director did have 12 hours of training completed however it was during the Fiscal year and not during the training calendar year. Moving forward, this will be monitored more carefully for compliance in our Learning Management System, Relias and by the program director. The program director will run a report in Relias to ensure that all mandatory trainings are completed in a timely way and during the correct time frame. Both the Facility Director and Project Director have their 12 hours of trainings completed for the next calendar training year. |
704.11(f)(2) LICENSURE Trng Hours Req-Coun
704.11. Staff development program.
(f) Training requirements for counselors.
(2) Each counselor shall complete at least 25 clock hours of training annually in areas such as:
(i) Client recordkeeping.
(ii) Confidentiality.
(iii) Pharmacology.
(iv) Treatment planning.
(v) Counseling techniques.
(vi) Drug and alcohol assessment.
(vii) Codependency.
(viii) Adult Children of Alcoholics (ACOA) issues.
(ix) Disease of addiction.
(x) Aftercare planning.
(xi) Principles of Alcoholics Anonymous and Narcotics Anonymous.
(xii) Ethics.
(xiii) Substance abuse trends.
(xiv) Interaction of addiction and mental illness.
(xv) Cultural awareness.
(xvi) Sexual harassment.
(xvii) Developmental psychology.
(xviii) Relapse prevention.
(3) If a counselor has been designated as lead counselor supervising other counselors, the training shall include courses appropriate to the functions of this position and a Department approved core curriculum or comparable training in supervision.
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Observations
Based on a review of personnel records, the facility failed to document the completion of 25 clock hours of annual training required for counselors during the facility July 2021 through June 2022 training year in two of five applicable personnel records reviewed.Employee #8 was hired as a counselor on October 21, 2019. The record documented 16.50 hours of annual training during the training year reviewed.Employee #9 was hired as a counselor on June 14, 2021. The record documented 18.75 hours of annual training during the training year reviewed.This is a repeat citation from the December 14, 2021 annual licensing renewal inspection.These findings were reviewed with facility staff as part of the inspection process.
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Plan of Correction
The The program director will use our Learning Management System, Relias to ensure that all staff have completed the correct amount of trainings needed. She will run a report in Relias monthly to ensure that all staff have completed mandatory trainings. If she finds that staff are behind on their trainings , she will meet with them individually to ensure compliance with training regulations. |
709.24 (a) (3) LICENSURE Treatment/rehabilitation management.
§ 709.24. Treatment/rehabilitation management.
(a) The governing body shall adopt a written plan for the coordination of client treatment and rehabilitation services which includes, but is not limited to:
(3) Written procedures for the management of treatment/rehabilitation services for clients.
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Observations
Based on a review of client records, the facility failed to follow their own written procedures for the management of treatment/rehabilitation services for clients in three of seven client records reviewed. The facility policy and procedure manual stated that the comprehensive treatment plan is to be completed within 30 days of the initial treatment plan.Client #1 was admitted on March 10, 2022 and was active at the time of inspection. The comprehensive treatment plan was due to be completed no later than April 10, 2022, per facility policy; however, the treatment plan was completed on April 30, 2022. Client #2 was admitted on March 31, 2022 and was active at the time of inspection. The comprehensive treatment plan was due to be completed no later than April 30, 2022, per facility policy; however, the treatment plan was completed on May 12, 2022. Client #7 was admitted on March 8, 2022 and was discharged on September 12, 2022. The comprehensive treatment plan was due to be completed no later than April 8, 2022, per facility policy; however, the treatment plan was not completed prior to discharge. This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
The program director and clinical supervisor will review the Caseload report daily to ensure that counselors are following NET policy and completing all mandatory paperwork in a timeley manner. If they see that any documentation is comming due, including the comprehensive treatment plan, they will prompt the counselor to ensure that we remain in compliance with NET policy and DDAP regulations. This will be managed for compliance by the program director and clinical supervisor. |
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 on consent to release information forms in six of seven client records reviewed. Client #1 was admitted on March 10, 2022 and was active at time of inspection. There were release of information forms to a urinalysis laboratory, a funding source, a pharmacy, an attorney, an emergency contact, a transportation service, a government agency, and a physician that were signed and dated by the client on March 10, 2022; however, the purpose of the disclosure was not documented on any of the release forms. ,Client #2 was admitted on March 31, 2022 and was active at time of inspection. There was a release of information form to a urinalysis laboratory that was signed and dated by the client on March 31, 2022; however, the purpose of the disclosure was not documented on the release form. Client #3 was admitted on April 14, 2022 and was active at time of inspection. There were release of information forms to a urinalysis laboratory, a funding source, a pharmacy, an emergency contact, a transportation service, a government agency, and a physician that were signed and dated by the client on April 14, 2022; however, the purpose of the disclosure was not documented on any of the release forms.Client #5 was admitted on May 12, 2022 and was discharged on October 25, 2022. There were release of information forms to a urinalysis laboratory and an emergency contact that were signed and dated by the client on May 12, 2022; however, the purpose of the disclosure was not documented on either release form.Client #6 was admitted on May 24, 2022 and was discharged on October 6, 2022. There were release of information forms to a urinalysis laboratory and an emergency contact that were signed and dated by the client on May 24, 2022; however, the purpose of the disclosure was not documented on either release form.Client #7 was admitted on March 8, 2022 and was discharged on September 12, 2022. There was release of information form to a urinalysis laboratory that was signed and dated by the client on March 8, 2022; however, the purpose of the disclosure was not documented on the release form.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
A training has been scheduled prior to 2/15/23 for all staff that complete releases of infomation. These staff will be re-trained by the clinical supervisor and program director on how to correctly document the purpose of the rlease of information. Client's #1, #2 and #3 will have their existing incorrect ROI's updated so that they have a purpose documented correctly in the release of informatiton form. The clinical supervisor will monitor all ROI's on a daily basis to ensure compliance. |
709.34 (c) (2) 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:
(2) Death or serious injury due to trauma, suicide, medication error or unusual circumstances.
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Observations
Based on a review of client records, the facility failed to file a written unusual incident report with the Department within 3 business days following the death of a client.The facility was notified of the off-site death of an active client on April 9, 2022; however, the unusual incident was not reported to the Department as of the date of inspection.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Program director will ensure that all deaths will be reported to DDAP within 3 business days. The program director will review this with all staff in the next scheduled staff meeting on 2/3/23. The VP will monitor this for 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 treatment and rehabilitation plans are reviewed and updated at least every sixty days in four of six applicable client records reviewed.Client #1 was admitted on March 10, 2022 and was active at the time of inspection. A treatment plan update was completed on October 25, 2022, and the next update was due no later than December 25, 2022; however, the update was completed on January 2, 2023.Client #2 was admitted on March 31, 2022 and was active at the time of inspection. The individual treatment and rehabilitation plan was completed on May 12, 2022, and the first update was due no later than July 12, 2022; however, the update was completed on July 19, 2022. Additionally, the next treatment plan update was due no later than September 19, 2022; however, the update was completed on September 30, 2022. Also, the next treatment plan update was due no later than November 30, 2022; however, the update was completed on December 7, 2022. Client #3 was admitted on April 14, 2022 and was active at the time of inspection. A treatment plan update was completed on July 13, 2022, and the next update was due no later than September 13, 2022; however, the update was completed on October 18, 2022.Client #4 was admitted on March 1, 2022 and was discharged on July 22, 2022. The individual treatment and rehabilitation plan was completed on March 23, 2022, and the first update was due no later than May 23, 2022; however, the update was completed on June 23, 2022.This is a repeat citation from the December 14, 2021 annual licensing renewal inspection. These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Ths Clinical Supervisor and Program Director will review the case load report on a daily basis. The caseload report tracks when all mandatory documentation has last been completed and when it is due. If they see that documentation is comming due, they will prompt the counselor to ensure that all documentation is completed. All staff will be re-trained by 2/15/23 on when all documentation is due so that we are not out of compliance. The Program director and clinical supervisor will monitor for compliance on a daily 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 ensure that counseling services were being provided according to the individual treatment and rehabilitation plan in three of six applicable client records reviewed. Client #1 was admitted on March 10, 2022 and was active at the time of inspection. The individual treatment plan dated April 30, 2022 and treatment plan updates dated June 27, 2022, August 23, 2022, and October 25, 2022, all indicated weekly individual counseling services. There was no documentation, in the record, of individual counseling services being provided during the weeks of June 26, 2022 - July 30, 2022, August 7, 2022 - August 20, 2022, September 4, 2022 - September 24, 2022 and October 30, 2022 - November 26, 2022. Client #2 was admitted on March 31, 2022 and was active at the time of inspection. The individual treatment plan dated May 12, 2022 and treatment plan updates dated July 19, 2022, September 30, 2022, and December 7, 2022, all indicated weekly individual counseling services. There was no documentation, in the record, of individual counseling services being provided during the weeks of May 22, 2022 - June 4, 2022, June 12, 2022 - June 18, 2022, July 10, 2022 - July 16, 2022, July 24, 2022 - September 17, 2022, and October 23, 2022 - November 26, 2022. Client #3 was admitted on April 14, 2022 and was active at the time of inspection. The individual treatment plan dated May 12, 2022 and treatment plan updates dated July 13, 2022, October 18, 2022, and December 15, 2022, all indicated weekly individual counseling services. There was no documentation, in the record, of individual counseling services being provided during the weeks of May 15, 2022 - May 28, 2022, June 19, 2022 - June 25, 2022, July 17, 2022 - July 23, 2022, August 14, 2022 - August 27, 2022, September 4, 2022 - September 10, 2022, December 18, 2022 - January 7, 2023.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The program director and clinical supervisor will review the caseload report on a daily basis. The caseload report tracks when mandatory documentation was last completed and when it will be due. If paperwork is comming due, the director and supervisor will prompt staff to ensure that all documents including the treatment plan updates are completed in a timely manner. If in the treatment plan, it is recommended that a client has specific services and the client does not show or cancels for those services, the counselor will document in the outreach note that the services were scheduled but not completed and state the reason why this occurred. If the recommendation for a type or frequency of a service changes, the counselor will update the treatment plan so it is reflected. This will be monitored for compliance by the program director. |