INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection and methadone monitoring conducted on January 10, 2022 through January 12, 2022 and January 20, 2022 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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704.6(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 ensure that clinical supervisors, who have not functioned for 2 years as supervisors in the provision of clinical services, completed a core curriculum in clinical supervision in one of one applicable personnel records reviewed.
Employee # 5 was hired as a clinical supervisor on May 7, 2021. There was no documentation of clinical supervision experience prior to being hired and no documentation that the clinical supervision core curriculum training was completed as of the date of the inspection.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
Clinical Supervisor will schedule the required 30 hours of supervisory training and attend all core curriculum classes within three months of POC submission. The Program Director will monitor Clinical Supervisor's attendance in registered classes and will review training content with Clinical Supervisor during monthly supervisory meetings. This monthly supervisory follow-up will be implemented to ensure compliance with training requirement as well as provide additional supervisory support. The Clinical Supervisor will complete all required training hours no later than 5/20/22. |
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 experiential qualifications of the position in one of eight applicable personnel records reviewed.
Employee #10 was hired on August 23, 2021 and was still in the position at the time of the inspection. The employee had an Associate ' s Degree in Applied Science, with over 2 years of clinical experience; However, the degree major is non-qualifying as it is in chemical dependency, psychology, social work, counseling, nursing or another related field.
This finding was reviewed with facility staff during the licensing inspection.
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Plan of Correction
Counselor # 10 has been re-assigned to Counselor Assistant as of 2/10/22 and will receive the required amount of direct supervision by the clinical supervisor as per the state regulations. Counselor # 10's training plan has been revised to reflect this change. The Senior Director will retrain HR recruitment staff of 704 staffing regulations; specific attention will be made to degrees that are acceptable prior to initiating or scheduling employment interviews. Counselor # 10 also plan to return to school and obtain her bachelor's degree in the related field, she plans on enrolling in a program no later the fall semester. |
704.11(c)(2) LICENSURE CPR CERTIFICATION
704.11. Staff development program.
(c) General training requirements.
(2) CPR certification and first aid training shall be provided to a sufficient number of staff persons, so that at least one person trained in these skills is onsite during the project's hours of operation.
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Observations
Based on a review of personnel records and staff schedules, the facility failed to ensure that CPR certification and first aid training was provided to a sufficient number of staff persons, so that at least one person trained in these skills is onsite during the project's hours of operations.
There was no staff person, currently certified in CPR and first aid, working at the facility during the following dates and times:
October 25, 2021 from 4pm-12am; October 26, 2021 from 12am-6am; October 27, 2021 from 12am-6am; October 28, 2021 from 12am-7am and 10pm-12am; October 29, 2021 from 12am-7am; October 30, 2021 from 12am-6am and 8pm-12am; October 31, 2021 from 12am-6am and 2pm-12am; November 1, 2021 12am-6am and 4pm-12am; November 2, 2021 from 12am-6am; November 3, 2021 from 12am-6am; November 4, 2021 from 12am-7am and 10pm-12am; November 5, 2021 from 12am-7am; November 6, 2021 from 12am-6am and 8pm-12am; November 7, 2021 from 12am-6am and 2pm-12am; November 8, 2021 from 12am-6am and 3pm-12am; November 9, 2021 from 12am-6am; November 10, 2021 from 12am-6am and 3pm-4pm; November 11, 2021 from 12am-7am and 10pm-12am; November 12, 2021 from 12am-7am; November 13, 2021 from 12am-6am and 8pm-12am; November 14, 2021 from 12am-6am and 2pm-12am; November 15, 2021 from 12am-6am and 3pm-12am; November 16, 2021 from 12am-6am; November 17, 2021 from 12am-6am and 3pm-4pm; November 18, 2021 from 12am-7am and 10pm-12am; November 19, 2021 from 12am-7am; November 20, 2021 from 12am-6am and 8pm-12am; November 21, 2021 from 12am-6am and 2pm-12am.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
All staff at Wharton Center have current CPR certifications which are valid for the next two years. The Director will maintain a log for all staff CPR certifications and stay connected to our training director to ensure that all staff remain CPR certified. All new employees are required to participate in CPR training as part of their hire onboarding. Please see the attached Updated CPR Policy distributed to all NET staff effective 2/20/22. |
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 ensure that each counselor completed at least 25 clock hours of training annually during the facility's January 1, 2021 through December 31, 2021 training year in one of one applicable personnel records reviewed.
Employee # 15 was hired as a counselor on June 27, 2016. The personnel record documented 23.25 hours of training received during the training year reviewed.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
The Program Manager will track each counselor's annual training hours on a quarterly basis to see if counselors are complying with obtaining annual training. The counselor who was deficient will be placed on a success plan to ensure all required training hours are met prior to the end or the training year. Senior Director will review quarterly the generate training status report and submit then to the Clinical Supervisors to follow up with their counseling staff. |
704.12(a)(3)(i) LICENSURE NonHosp Rehab
704.12. Full-time equivalent (FTE) maximum client/staff and client/counselor ratios.
(a) General requirements. Projects shall be required to comply with the client/staff and client/counselor ratios in paragraphs (1)-(6) during primary care hours. These ratios refer to the total number of clients being treated including clients with diagnoses other than drug and alcohol addiction served in other facets of the project. Family units may be counted as one client.
(3) Inpatient nonhospital treatment and rehabilitation (residential treatment and rehabilitation).
(i) Projects serving adult clients shall have one FTE counselor for every eight clients.
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Observations
Based on a review of personnel records and the Staffing Requirements Facility Summary Report, the facility failed to ensure that there was one FTE counselor for every eight clients in the Inpatient nonhospital activity.
The counselor Full Time Equivalent (FTE) is determined by dividing the total number of hours devoted to clients by the facility's workweek. Then, the total number of clients are divided by the FTE.
The FTE counselor ratio calculation was as follows: 47.5/37.5 = 1.2667; 12/1.2667 = 9.4737, which equals to a client/counselor FTE ratio of 9:1.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
The FTE ratio has been adjusted from 9:1 to 8:1 per the clinical caseload ratio regulation. Additional clinical staff will be utilized as needed to ensure that the ratio remains 8:1 based on the hours of dedicated clinical work. The Clinical Supervisor will monitor the ratio weekly and report the findings to the Director to remain in compliance with the 8:1 FTE effective 2-20-22. |
705.10 (d) (5) LICENSURE Fire safety.
705.10. Fire safety.
(d) Fire drills. The residential facility shall:
(5) Conduct a fire drill during sleeping hours at least every 6 months.
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Observations
Based on a review of the facility's December 2020 through November 2021 fire drill log, the facility failed to ensure that a fire drill was conducted during sleeping hours at least one time every six months. There were no fire drills conducted during sleeping hours during a six-month period from January 2021 through June 2021.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
The facility will conduct fire drills during sleeping hours at least one time every six months. The facility's Emergency Manager will schedule all monthly fire drills in collaboration with the maintenance department. The Emergency Manager is responsible to ensure that the schedule includes "during sleep hours" at least one time every six months. The Emergency Manager will maintain the fire drill logbook and will provide ongoing reports to the Program Director as part of their supervisory process effective 2-22-22. |
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 two of fourteen client records reviewed.
Client # 2 was admitted to the inpatient non-hospital activity on December 13, 2021 and was still active at the time of the inspection. The release of information form to the funding source was signed by the client and witness on December 13, 2021 and it expired on December 13, 2021. There was evidence of disclosures to the funding source after the release of information form expired; however, there was no updated consent to release information form signed by the client documented in the record prior to any of the disclosures after December 13, 2021.
Client # 11 was admitted to the outpatient maintenance activity on August 29, 2019 and was discharged on July 19, 2021. There was evidence 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 any of the disclosures.
This is a repeat citation from the December 11, 2020 annual licensing renewal inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
All staff are trained to complete an informed, voluntary consent to release information form, prior to the disclosure of client information. All staff will receive refresher training on Confidentiality and how to accurately complete the Release of Information form to ensure that the time frame for Release of Information consent covers the time period of the requested release. Release of Information consent forms will be reviewed by the Clinical Supervisor for accuracy and completeness effective 3-1-22. Client #11 was discharge on July 19, 2021, and the ROI is not able to be updated. Client #2 has been discharged on 1-10-22. |
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 keep consent forms for the disclosures of client identifying information within the limits established by 4 Pa. Code 255.5 (a) for releases of information in two of fourteen client records reviewed.
Client # 9 was admitted to the outpatient maintenance activity on November 18, 2021 and was still active at the time of the inspection. There was a release of information form to a government agency, signed and dated by the client and witness on November 18, 2021 that allowed for the release of the entire health record, which exceeded the limits established by 4 Pa. Code 255.5.
Client # 10 was admitted to the outpatient maintenance activity on March 15, 2021 and was still active at the time of the inspection. There was a release of information form to a government agency, signed and dated by the client and witness on March 15, 2021 that allowed for the release of medical history, assessment/diagnostic information, and psychological or psychiatric assessments, all of which exceeded the limits established by 4 Pa. Code 255.5.
This is a repeat citation from the January 23, 2020 and the December 11, 2020 annual licensing renewal inspections.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The consent to release will be kept within the bounds of 255.5. Senior Director will provide training on confidentiality and information that can be released to government officials, law enforcement units and insurance providers. A QA process will be put in place to review intake paperwork for its completion and accuracy. Client #9 have a new ROI in the system and will sign new ROI no later then 2/24/2022, client # 10 also have a new ROI in the system and will sign new ROI no later then 2/24/2022. Program will be in compliance by 3/01/2022 |
709.28 (d) LICENSURE Confidentiality
§ 709.28. Confidentiality.
(d) A copy of a client consent shall be offered to the client and a copy maintained in the client record.
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Observations
Based on a review of client records, the facility failed to document that a copy of a client consent to release information form was offered to the client in six of fourteen client records reviewed.
Client # 2 was admitted to the inpatient non-hospital activity on December 13, 2021 and was still active at the time of the inspection. A release of information form to a care coordinator was signed and dated by the client on December 13, 2021; however, there was no documentation that a copy of the consent was offered to the client.
Client # 3 was admitted to the inpatient non-hospital activity on December 14, 2021 and was still active at the time of the inspection. A release of information form to a care coordinator was signed and dated by the client on December 14, 2021; however, there was no documentation that a copy of the consent was offered to the client.
Client # 4 was admitted to the inpatient non-hospital activity on March 12, 2021 and was discharged on June 26, 2021. A release of information form to a care coordinator was signed and dated by the client on March 12, 2021; however, there was no documentation that a copy of the consent was offered to the client.
Client # 5 was admitted to the inpatient non-hospital activity on May 1, 2021 and was discharged on June 2, 2021. A release of information form to a care coordinator was signed and dated by the client on May 1, 2021; however, there was no documentation that a copy of the consent was offered to the client.
Client # 6 was admitted to the inpatient non-hospital activity on May 13, 2021 and was discharged on June 28, 2021. A release of information form to a care coordinator was signed and dated by the client on May 13, 2021; however, there was no documentation that a copy of the consent was offered to the client.
Client # 7 was admitted to the inpatient non-hospital activity on September 18, 2021 and was discharged on January 6, 2022. A release of information form to a care coordinator was signed and dated by the client on September 18, 2021; however, there was no documentation that a copy of the consent was offered to the client.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
All staff will receive refresher training on Confidentiality. As part of this training, it will be emphasized that clients must be offered a copy of all Consent forms. Staff will be instructed to note on the consent forms that the client was offered a copy, with an "accept" or "decline" of the offered consent. All consents will be maintained in the client's record. The Clinical Supervisor will monitor all consents to ensure compliance with regulatory requirements effective 3-1-22. Client's #2 discharged 1-10-22, #3 discharged 1-31-33, #4 discharged 6-26-21, #5 discharged 6-2-21, #6 discharged 6-28-21 & #7 discharged 1-6-22. |
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, including the reason for termination, in one of one applicable client records reviewed.
Client # 4 was admitted to the inpatient non-hospital activity on March 12, 2021 and was administratively discharged on June 26, 2021. There was 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 on June 29, 2021; however, the documentation listed the incorrect reason for termination.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
The facility will notify clients in writing when there is a decision to involuntarily terminate client's treatment, including the reason for termination. The assigned clinician will be responsible for notifying the client in writing about the involuntary discharge, including termination reason. The clinician will be responsible for maintaining this documentation in the client's record. The Clinical Supervisor will monitor all terminations to ensure that the notification and documentation protocols are maintained as required effective 2-20-22. |
709.34 (c) (4) 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:
(4) Event at the facility requiring the presence of police, fire or ambulance personnel.
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Observations
Based on a review of the facility's January 2021 through December 2021 unusual incident logs, the facility failed to file a written unusual incident report with the Department within 3 business days following a September 19, 2021 event that required the presence of police, fire and/or ambulance personnel at the facility.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Senior Director will ensure Program compliance with 709.34 (c) (4), by making sure all unusual incidents are completed and file within the allotted timeframe of 3 business days of the incident. The program will create a tracking system to track all unusual incident, who submit them to the State and the timeframe of submission. The unusual incident report will be submitted to DDAP no later then 2/24/2022. The program will be in compliance by 4/1/2022 |
715.9(a)(2) LICENSURE Intake
(a) Prior to administration of an agent, a narcotic treatment program shall screen each individual to determine eligibility for admission. The narcotic treatment program shall:
(2) Verify the individual 's identity, including name, address, date of birth, emergency contact and other identifying data.
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Observations
Based on a review of patient records, the facility failed to verify the individual's identity including the name, address and date of birth prior to the administration of an agent in one of two applicable patient records reviewed.
Patient # 9 was admitted to the outpatient maintenance activity on November 18, 2021 and was still active at the time of the inspection. There was no documentation that the verification of the patient's identity was completed in the patient record prior to the administration of an agent.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Senior Director will provide a training to the intake department, as a refresher on the 715.9 (a) (2) regulation for intake. A QA process will be put in place to review intake paperwork for its completion and accuracy. Program will be in compliance by 3/01/2022 |
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 one of four applicable patient records reviewed.
Patient # 9 was admitted to the outpatient maintenance activity on November 18, 2021 and was still active at the time of the inspection. The record of service and progress notes documented that during the month of December 2021, there was 30 minutes of psychotherapy provided to the patient.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
The program has work with our IT department alone side the QA department in creating a power BI report, The program managers and clinical supervisor are expected to review the report weekly to ensure all member of the program receives the appropriate service for their current level of care. All counselors will be sent this report on a weekly basis by their direct supervisor and a follow-up with take place at the end of each week. The program has already implemented this process as of 2/1/2022. |
715.19(3) LICENSURE Psychotherapy services
A narcotic treatment program shall provide individualized psychotherapy services and shall meet the following requirements:
(3) After 4 years of treatment, a narcotic treatment program shall provide each patient with at least 1 hour of group or individual psychotherapy every 2 months. 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 at least 1 hour of group or individual psychotherapy every two months after 4 years of treatment in two of three applicable patient records reviewed.
Patient # 8 was admitted to the outpatient maintenance activity on August 28, 2017 and was still active at the time of the inspection. The record of service and progress notes documented that during the month of November 2021 and December 2021, there were zero minutes of psychotherapy provided to the patient.
Patient # 13 was admitted to the outpatient maintenance activity on January 27, 2014 and was discharged on November 24, 2021. The record of service and progress notes documented that during the month of September 2021 and October 2021, there were zero minutes of psychotherapy provided to the patient.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The program has work with our IT department alone side the QA department in creating a power BI report, The program managers and clinical supervisor are expected to review the report weekly to ensure all member of the program receives the appropriate service for their current level of care. All counselors will be sent this report on a weekly basis by their direct supervisor and a follow-up with take place at the end of each week. The program has already implemented this process as of 2/1/2022. |
715.23(b)(5) LICENSURE Patient records
(b) Each patient file shall include the following information:
(5) The results of all annual physical examinations given by the narcotic treatment program which includes an annual reevaluation by the narcotic treatment physician.
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Observations
Based on a review of patient records, the narcotic treatment program failed to document the results of all annual physical examinations given by the narcotic treatment program, which is to include an annual reevaluation by the narcotic treatment physician, in one of five applicable patient records reviewed.
Patient # 14 was admitted to the outpatient maintenance activity on January 27, 2014 and was discharged on February 10, 2021. An annual physical examination was due in January 2021; however, there was no annual physical examination given by the narcotic treatment program documented in the record as of the date of the inspection.
This is a repeat citation from the December 11, 2020 annual licensing renewal inspection.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
A list of all annual physicals due will be distributed to the physicians at the beginning of each month. The program scheduler will ensure that all annual physicals are scheduled monthly and will maintain a report. The QA department will send out the list weekly to the clinical supervisor and doctors, Patients who are non-compliant with schedule appointment will meet with their counselor to obtain new appointment. This process has already been implemented by the program as of 2/1/2022 |
715.23(b)(15) LICENSURE Patient records
(b) Each patient file shall include the following information:
(15) Psychosocial evaluations of the patient.
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Observations
Based on a review of patient records, the facility failed to document a psychosocial evaluation in two of two applicable patient records reviewed.
Patient # 9 was admitted to the outpatient maintenance activity November 18, 2021 and was still active at the time of the inspection. There was no completed psychosocial evaluation documented in the patient record at the time of the inspection.
Patient # 10 was admitted to the outpatient maintenance activity March 15, 2021 and was still active at the time of the inspection. There was no completed psychosocial evaluation documented in the patient record at the time of the inspection.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
The Intake Department oversaw the completion of psychosocial evaluation on all new admissions. Effective 2/1/2022, all psychosocial evaluations were transferred back to the primary counselors to complete once assigned a new patient. The restructuring of how the psychosocial are complete will allow the program and the clinical supervisor better opportunity to track the completion of the psychosocial by using the Power BI report created for tracking missing and past due documents. Both client #9 and client #10 had the psychosocial evaluation completed on January 25, 2022 and January 27, 2022. The program will be in compliance by 4/1/2022 |
715.23(b)(23) LICENSURE Patient records
(b) Each patient file shall include the following information:
(23) Discharge summary.
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Observations
Based on a review of patient records, the facility failed to maintain a complete file for each patient, which is to include a discharge summary, in three of four applicable client records.
Patient #11 was admitted to the outpatient maintenance activity on August 29, 2019 and was discharged on July 19, 2021. There was no discharge summary documented in the client record.
Patient #12 was admitted to the outpatient maintenance activity on February 20, 2019 and was discharged on July 28, 2021. There was no discharge summary documented in the client record.
Patient #13 was admitted to the outpatient maintenance activity on April 28, 2017 and was discharged on November 24, 2021. There was no discharge summary documented in the client record.
These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
The program will adhere to the State regs and ensure all discharge patients receive a complete discharge summery. Once a patient has been discharged from the program, the clinic supervisor will email the counselor to complete the discharge summary. A QA process will be put in place to review all recent discharge patient for its completion and accuracy. Senior Direct will receive a weekly report of all discharge patients monthly. Program will be in compliance by 4/01/2022 |
715.23(b)(24) LICENSURE Patient records
(b) Each patient file shall include the following information:
(24) Follow-up information regarding the patient.
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Observations
Based on a review of patient records, the narcotic treatment program failed to maintain a complete patient record, which is to include follow-up information regarding the patient, in two of three applicable patient records reviewed.
Patient #11 was admitted to the outpatient maintenance activity on August 29, 2019 and was discharged on July 19, 2021. There was no follow-up information regarding the patient documented in the record at the time of the inspection.
Patient #12 was admitted to the outpatient maintenance activity on February 20, 2019 and was discharged on July 28, 2021. There was no follow-up information regarding the patient documented in the record at the time of the inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The program will adhere to the State regs and ensure all discharge patients discharge from the program received a follow-up letter or a documented phone call. Senior Director will provide the clinical, intake and medical staff with training on the regulation as well as creating a database to track all discharge follow-up letters being sent to patients 7 days post discharge. The program will be in compliance by 4/1/2022. |
715.23(c)(1-7) LICENSURE Patient records
(c) An annual evaluation of each patient 's status shall be completed by the patient 's counselor and shall be reviewed, dated and signed by the medical director. The annual evaluation period shall start on the date of the patient 's admission to a narcotic treatment program and shall address the following areas:
(1) Employment, education and training.
(2) Legal standing.
(3) Substance abuse.
(4) Financial management abilities.
(5) Physical and emotional health.
(6) Fulfillment of treatment objectives.
(7) Family and community supports.
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Observations
Based on a review of patient records, the narcotic treatment program failed to ensure an annual evaluation of the patient's status was completed by the patient's counselor and was reviewed, dated and signed by the medical director in four of five applicable patient records reviewed.
Patient # 8 was admitted to the outpatient maintenance activity on August 28, 2017 and was still active at the time of the inspection. There was no 2021 annual evaluation of the patient's status completed by the counselor documented in the patient record at the time of the inspection.
Patient #12 was admitted to the outpatient maintenance activity on February 20, 2019 and was discharged on July 28, 2021. There was no 2021 annual evaluation of the patient's status completed by the counselor documented in the patient record at the time of the inspection.
Patient #13 was admitted to the outpatient maintenance activity on April 28, 2017 and was discharged on November 24, 2021. There was no 2021 annual evaluation of the patient's status completed by the counselor documented in the patient record at the time of the inspection.
Patient # 14 was admitted to the outpatient maintenance activity on January 27, 2014 and was discharged on February 10, 2021. The annual evaluation of the patient's status was completed by the counselor on January 7, 2021; however, the evaluation was not reviewed, dated, and signed by the medical director.
This is a repeat citation from the December 11, 2020 annual licensing renewal inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Clinical Supervisor will audit each supervisee's caseload weekly and communicate all clinical annuals that are due. The Clinical Supervisor will review the timelines for which clinical annuals are due. Furthermore, Program manager will conduct a re-training of all clinical staff on this standard by 4-1-2022. In addition, the QA supervisor will monitor compliance into our ongoing QA process, identify compliance or lack thereof, address non-compliance and report finding via the monthly QA reports. |
715.23(d) LICENSURE Patient records
(d) A narcotic treatment program shall prepare a treatment plan that outlines realistic short and long-term treatment goals which are mutually acceptable to the patient and the narcotic treatment program.
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Observations
Based on a review of patient records, the narcotic treatment program failed to prepare a treatment plan that outlines realistic short and long-term treatment goals which are mutually acceptable to the patient and the narcotic treatment program in one of two applicable patient records reviewed.
Patient # 9 was admitted to the outpatient maintenance activity on November 18, 2021. There was no comprehensive treatment plan documented in the patient record at the time of the inspection.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
The program has created a multilevel approval process in conjunction with the QA department as well as creating a program in our electronic health record program to be able to track and review treatment plans at appear the same or duplicated without any changes. Staff who does not adhere to this stander will be place on success plans and possible corrective action. The program will be in compliance by 4/1/2022 Does not address how the facility will correct the deficiency. New treatment plan was corrected for this patient to outline realistic short and long-term goals and will be complete as of 2/28/22 |
715.23(d)(2) LICENSURE Patient records
(d) A narcotic treatment program shall prepare a treatment plan that outlines realistic short and long-term treatment goals which are mutually acceptable to the patient and the narcotic treatment program.
(2) The narcotic treatment physician or the patient 's counselor shall review, reevaluate, modify and update each patient 's treatment plan as required by Chapters 157, 709 and 711 (relating to drug and alcohol services general provisions; standards for licensure of freestanding treatment activities; and standards for certification of treatment activities which are a part of a health care facility).
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Observations
Based on a review of patient records, the facility failed to review, reevaluate, modify, and update each patient's treatment plan every 60 days in five of six applicable patient records reviewed.
Patient #8 was admitted on August 28, 2017 and was still active at the time of the inspection. A treatment plan update was completed on March 22, 2021 and the next update was due no later than May 22, 2021; however, there was no update completed at the time of the inspection.
Patient # 10 was admitted on March 15, 2021 and was still active at the time of the inspection. The comprehensive treatment plan was completed on April 5, 2021 and an update was due no later than June 5, 2021; however, there was no update completed at the time of the inspection.
Patient # 11 was admitted on August 29, 2019 and was discharged on July 19, 2021. A treatment plan update was completed on October 2, 2020 and the next update was due no later than December 2, 2020; however, the update was not completed until April 19, 2021.
Patient # 12 was admitted on February 20, 2019 and was discharged on July 28, 2021. A treatment plan update was completed on January 25, 2021 and the next update was due no later than March 25, 2021; however, the update was not completed until April 13, 2021.
Patient # 13 was admitted on April 28, 2017 and was discharged on November 24, 2021. A treatment plan update was completed on January 13, 2021 and the next update was due no later than March 13, 2021; however, the update was not completed until April 12, 2021. Additionally, a treatment plan update was completed on April 12, 2021 and the next update was due no later than June 12, 2021; however, the update was not completed at the time of discharge.
This is a repeat citation from the December 11, 2020 annual licensing renewal inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Due to a lack of staff during the pandemic the program failed to adhere to the standers. Senior Director will enjoy the program maintain an adequate number of staff on the program to be able to provide the best quality of care to the patients. The QA department will send out the list weekly to the clinical supervisor and program managers, who will address with clinical staff during weekly supervision. The program will be in compliance by 4/1/2022. Client #11 was discharge on July 19, 2021, and we are unable to update the document. However, both client # 8 and #10 treatment plan will be updated no later then 2/28/22. |
709.52(b) LICENSURE TX Plan update
709.52. Treatment and rehabilitation services.
(b) Treatment and rehabilitation plans shall be reviewed and updated at least every 30 days. For those projects whose client treatment regime is less than 30 days, the treatment and rehabilitation plan, review and update shall occur at least every 15 days.
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Observations
Based on a review of client records, the facility failed to review and update treatment and rehabilitation plans at least every thirty days in two of six applicable client records reviewed.
Client # 1 was admitted to the inpatient non-hospital activity September 24, 2021 and was still active at the time of the inspection. The individual treatment and rehabilitation plan was completed on September 28, 2021 and an update was due no later than October 28, 2021; however, there was no update completed at the time of the inspection.
Client # 7 was admitted to the inpatient non-hospital activity September 18, 2021 and was discharged on January 6, 2022. The individual treatment and rehabilitation plan was completed on September 21, 2021 and an update was due no later than October 21, 2021; however, there was no update completed prior to discharge.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Treatment plans will be updated for all residents in treatment at least every 30 days and for those in treatment less than 30 days every 15 days. Clinical Supervisor will review this regulation with all clinical staff and monitor timeliness of treatment plan updates. Documentation training will be conducted by the Clinical Supervisor to assist with the timely completion of all clinical documents. The Program Director will provide additional oversight during supervisory sessions and random record reviews to ensure compliance with regulation effective 3-1-22. Client's #1 1-19-22 & #7 1-6-22 have been discharged. |
709.53(a)(8) LICENSURE Case Consultation Notes
709.53. Client records.
(a) There shall be a complete client record on an individual which includes information relative to the client's involvement with the project. This shall include, but not be limited to, the following:
(8) Case consultation notes.
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Observations
Based on a review of client records, the facility failed to document a complete client record, which is to include case consultation notes, in two of six applicable client records reviewed.
Client # 1 was admitted to the inpatient non-hospital activity September 24, 2021 and was still active at the time of the inspection. The client record did not document case consultation notes at the time of the inspection.
Client # 7 was admitted to the inpatient non-hospital activity September 18, 2021 and was discharged on January 6, 2022. The client record did not document case consultation notes at the time of the inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Clinical Supervisor will ensure that there is a complete client record including case consultation notes. Case consultation notes will be completed at each weekly group supervision and documented in the client's chart within 48 hours after the group supervision. The Clinical Supervisor will be responsible to complete the weekly group supervision log, listing the clients that were discussed during that supervision and checking for the case consult note in the EHR of each client. Effective 2-22-22 |