INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on November 2-3, 2014 by staff from the Division of Drug and Alcohol 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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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. The consent shall be in writing and include, but not be limited to:
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Observations
Based on a review of client records, the facility failed to obtain informed and voluntary consents in four of twenty-four records reviewed.
The findings include:
Twenty-four client records were reviewed on December 2-3, 2014. All were reviewed for informed and voluntary consent forms. The facility failed to document informed and voluntary consents in four client records, specifically record, #1, 5, 7, and 9.
Client #1 - Consent to release form dated October 14, 2014 for the client's family didn't have the staff signature on the consent form.
Client #5 - Consent to release form dated October 7, 2014 for the client's emergency contact didn't have the date when the client signed the consent to release form.
Client #7 - Consent to release form dated February 4, 2014 for a laboratory used by the agency didn't have the date when staff signed the consent to release form.
Client #10 - Consent to release form dated May 30, 2014 for the client's parole officer had the date of May 20, 2014 when the client signed and the date of May 30, 2014 when staff signed. Another consent to release form dated May 30, 2014 for the client's family didn't have the date when staff signed the consent to release form. Additionally, consent to release form dated May 30, 2014 for the client's funding source had the date of May 3, 2014 when the client signed and the date of May 30, 2014 when staff signed.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Residential Program Citation: The Residential Program Director has conducted Confidentiality training with staff on 12/11/14 in order to ensure that all consents are completed properly and include all of the required information to avoid future infractions regarding licensure standard 709.28. In addition, the Clinical Supervisor and Residential Program Director will train all new staff within 30 days as well as conduct annual staff training to ensure that all staff understand the importance of client confidentiality, proper consents and compliance with the regulations.
The Residential Program Director will continue to review all consents to verify that all applicable signatures & dates are documented on an on going basis to make sure that the residential program complies with the requirements for this standard. |
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 a decision to involuntarily terminate the client's treatment at the project, in one of one client record reviewed.
The findings include:
Twenty-four client records were reviewed on December 2-3, 2014. Ten of the client records reviewed were reviewed from the inpatient rehabilitation activity, #1-10. One of the discharged clients was involuntarily terminated from treatment at the facility. The facility failed to notify the client, in writing, of a decision to involuntarily terminate the client's treatment at the facility, in client record # 10.
Client # 10 was admitted into treatment on May 30, 2014 and was involuntarily terminated from the project on July 29, 2014. There was no documentation of written notification provided as of the date of the licensing inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Residential Program Citation: The Residential Program Director has conducted a training with the clinical staff on 12/10/14 regarding the discharge documentation and the requirements for Notification of Termination in order to avoid future infractions regarding licensure standard 709.33.
The Residential Program Director will continue to review all discharge documentation to ensure that all involuntary discharges include a notification of termination letter so that we continue to meet the requirements for this standard. |
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 the review of patient records, the facility failed to ensure provision of at least one hour of individual psychotherapy a month for two of eight patient records. Patients are required to receive at least one hour per month of individual psychotherapy during the first year of treatment.
The findings include:
Twenty-four patient records were reviewed December 2-3, 2014. Eight patient records were reviewed for at least one hour of therapy per month, or as ongoing assessment indicated, #17, 18, 19, 20, 21, 22, 23 and 24.
Patient #17 was admitted on September 4, 2014 and the facility failed to document at least one hour of individual psychotherapy for the month of November 2014.
Patient #24 was admitted on July 10, 2014 and the facility failed to document at least one hour of individual psychotherapy for the month of November 2014.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Narcotic Program Monitoring Citation: In Patient # 17, the individual received 37+ hours of group and 1 hour of Individual and for patient #24, the patient received 35+ hours of group and 1.25 hours of individual counseling for November 2014 but in both cases the respective therapists neglected to submit chart documentation for the individual counseling in a timely manner.
The NET Steps Director of Performance Improvement/Quality Assurance will implement an improved accountability system that will identify specific therapists with their supervisors as having "documents past due". All Therapists will be instructed in the requirements for Documents Due, verify their understanding by signature and thereafter held accountable by the respective Supervisor & the Director of PI/QA. This will be implemented by 1/1/15. |
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 provide documentation of TB/STD training in one of fourteen personnel records reviewed.
The findings include:
Fourteen personnel records were reviewed on December 2, 2014 for documentation of HIV/AIDS and TB/STD training. The facility did not provide documentation of the required HIV/AIDS and TB/STD training in personnel record #.
Employee # 14, a counselor, was hired September 7, 2013. HIV/AIDS and TB/STD training was due to be completed no later than September 7, 2014. The facility failed to provide documentation of HIV/AIDS and TB/STD training as of the date of this inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Residential Program Citation: The Residential Program Director will coordinate a scheduled TB/STD and HIV/AIDS training to be conducted where Employee #14, will attend. The TB/STD and HIV/AIDS training are scheduled for January 22, 2015 and January 27 2015 respectively.
The Program Director will review and monitor personnel files monthly to ensure all employees receive TB/STD and HIV/AIDS training within one year or hire date to avoid future infractions regarding licensure standard 704.11. TB/STD and HIV/AIDS trainings will be scheduled accordingly, by the Program Director to meet the training requirements for this standard. |