INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on January 20 -22, 2009 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Northeast Treatment Centers - NET STEPS 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 and a plan of correction is due on February 24, 2009.
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Plan of Correction
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704.6(c) LICENSURE Core Curriculum - Supervisor Training
704.6. Qualifications for the position of clinical supervisor.
(c) Clinical supervisors and lead counselors who have not functioned for 2 years as supervisors in the provision of clinical services shall complete a core curriculum in clinical supervision. Training not provided by the Department shall receive prior approval from the Department.
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Observations
Based on a review of personnel records, the facility failed to document that the clinical supervisor completed the core curriculum in clinical supervision in three of five personnel records.
Findings:
Five personnel records for the clinical supervisor position were reviewed on January 13 and 14, 2009. The core curriculum in clinical supervision training was required for five of five staff reviewed.. The facility did not document core curriculum training in clinical supervision in personnel records #5, 8 and 10. The facility did not document that the clinical supervisors functioned for two years as a supervisor in the provision of clinical services before being hired as clinical supervisors. Employee #5 was hired as a clinical supervisor on 11/21/07. Employee #8 was hired as a clinical supervisor on 1/15/08. Employee #10 was hired as a clinical supervisor on 2/15/07.
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Plan of Correction
The program has contracted with a certified training to provide this curriculum on site to the persons cited.
The training will be initiated 3/1 and continue until 7/1/2009 |
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 nineteen client records, the facility failed to include within the informed and voluntary consent forms the right for clients to verbally revoke the consent.
Findings:
Sixteen client records were reviewed between January 20 and 21, 2009. Informed and voluntary consent forms were required in eight client records. The consent to release information form only indicated that the client could revoke the consent in writing in eight of -eight client records, #1, 2, 3, 4, 5, 6, 7 and 8.
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Plan of Correction
All informed and voluntary consent forms have been revised to state the client's right to verbally revoke the consent. The PI/QA Director will train staff on the use of this form and monitor for compliance with the policy |
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 shall 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 disclosed met the requirements in Pa Code 255.5 in five of eight client records.
Findings:
Sixteen client records were reviewed on January 20 and 21, 2009. The specific information to be disclosed was required to be documented according to Pa Code 255.5 in eight client records. The facility exceeded Pa Code 255.5 in specific information to be disclosed in five of eight client records, #1, 2, 3, 4 and 7. The facility released "client reports using 5 bags today and smoking marijuana yesterday" in the Pennsylvania Client Placement Criteria (PCPC) report in client record #1. The facility released "at present time he reports using 4 to 8 bags of heroin today. He has used today." in the PCPC report in client record #2. The facility released "at present time he is using 15 bags of heroin a day" in the PCPC report in client record #3. The facility released "reports using between 2 to 3 oxy's a day, last used this a.m." in the PCPC report in client record #4. The facility released "at present time he is using 2 bags of heroin a day" in the PCPC report in client record #7.
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Plan of Correction
The Pi/QA Director will re-train all clinical staff in Pa Code 255.5 10(b) 1-5
Pi/QA Director will monitor the PCPC for compliance during the clinical record QA process. |
709.32(c)(1) LICENSURE Medication Control
709.32. Medication control.
(c) The project shall have a written policy regarding all medications used by clients which shall include, but not be limited to:
(1) Administration of medication.
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Observations
Based on the review of medication administration records, the facility failed to follow their own policy regarding the administration of medications used by clients in two of two client records.
Findings:
Client medication administration records were reviewed on January 21, 2009. Two client records were required to have medication administration records, #2 and 4. As per facility policy for supervised self-administration of medications, the medication administration records should document the client's refusal to take medication. The facility failed to document in client record #2 that the client refused his divalproex medication on 1/20/09. The facility failed to document in client record #2 that the client refused his Seroquel medication from 1/8/09 through 1/16/09. The facility failed to document in client record #4 that the client refused cephalexin, which was to be taken every six hours, and only documented that it was taken two times a day on 12/30 and 12/31/08, and 1/3/09 and then failed to document supervision of self-administration of this medication after 1/3/09.
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Plan of Correction
Program Director has retrained all responsible on proper completion of all medication logs as per Divisional policy. Program Director will review and monitor compliance of the completion of medication logs. |
709.91(b)(6) LICENSURE Intake and admission
709.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(6) Psychosocial evaluation.
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Observations
Based on a review of client records, the facility failed to document a psychosocial evaluation that included evaluative statements in six of six client records.
Findings:
Sixteen client records were reviewed on January 20 and 21, 2009. Psychosocial evaluations were required in six client records. The facility failed to document a psychosocial evaluation that included evaluative comment in the areas of assets/strengths, support systems, coping mechanisms, negative factors and counselor conclusions/impressions in client records #1,2, 3, 4, 5 and 6.
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Plan of Correction
All current and new intake staff will be trained on this standard by the PI/QA Director. The Intake coordinator and PI/QA Director will QA the medical record including the psychosocial evlauation for compliance after the inatke is complete. All new admissions will be reviewed within 14 days or less of the admission date.
PI/QA Director will provide intake staff with targeted supervision on the psychosocial evaluation standard and compliance from 3-15-09 on going.
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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 sixteen client records, the facility failed to document that counseling services are provided according to the individual treatment plan in eight client records.
Findings:
Sixteen client records were reviewed on January 20 and 21, 2009. Counseling services provided according to the individual treatment plan were required in 8 client records.
The facility failed to provide counseling services once per week as prescribed in the individual treatment plan in eight of eight client records. Based on a review of the progress notes and the record of services in client records #1, 2, 3, 4, 5, 6, 7 and 8, the facility failed to document that counseling services were provided as prescribed in the treatment plan.
Individual counseling sessions for client #1 were only documented for the following dates: 11/10, 12/12 and 12/23/08.
Individual counseling sessions for client #2 were only documented for the following dates: 11/5, 11/10, 11/24, 12/2, 12/8 and 12/18/08.
Individual counseling sessions for client #3 were only documented for the following dates: 10/3, 10/13, 11/13 and 12/3/08.
Individual counseling sessions for client #4 were only documented for the following dates: 10/1, 10/20, 10/31, 12/4, 11/6, 11/20, 12/4, 12/12 and 12/22/08.
Individual counseling sessions for client #5 were only documented for the following dates: 10/1, 10/8 and 10/29/08.
Individual counseling sessions for client #6 were only documented for the following dates: 10/20 and 11/7/08.
Individual counseling sessions for client #7 were only documented for the following dates: 10/16, 10/21, 10/22, 11/11, 11/24, 12/10 and 12/17/08.
Individual counseling sessions for client #8 were only documented for the following dates: 10/13, 11/14, 11/19 and 12/1/08.
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Plan of Correction
The PI/QA Director will creat a form for the client record that documents the time for the scheduled session, the reason the session was not held, whether the missed session was due tot he counselor or client' activity, and follow up/ disposition.
The PI/QA Director will train staff on the this form and monitor for compliance. |