INITIAL COMMENTS
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This report is a result of an on-site provisional license follow-up inspection conducted on July 27, 2022 through July 28, 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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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 five of fifteen client records reviewed.
The facility policy and procedure manual stated that the comprehensive treatment plan is to be completed within 15 days of admission. Additionally, the facility policy and procedure manual stated that a discharge summary is to be documented within 24 hours of discharge and that follow-up contact is to be documented within 30 days of discharge.
Client # 1 was admitted on May 5, 2022 and was still active at the time of the inspection. The comprehensive treatment plan was due to be completed no later than May 20, 2022; however, the treatment plan was completed on June 16, 2022.
Client # 2 was admitted on April 18, 2022 and was still active at the time of the inspection. The comprehensive treatment plan was due to be completed no later than May 2, 2022; however, the treatment plan was completed on June 14, 2022.
Client # 3 was admitted on April 28, 2022 and was still active at the time of the inspection. The comprehensive treatment plan was due to be completed no later than May 13, 2022; however, the treatment plan was completed on June 23, 2022.
Client # 6 was admitted on December 6, 2021 and was discharged on February 16, 2022. The discharge summary was due to be completed no later than February 17, 2022; however, the summary was completed on May 18, 2022. Additionally, follow-up information/contact was due to be completed no later than March 16, 2022; however, follow-up contact was documented on July 27, 2022.
Client # 7 was admitted on August 21, 2021 and was discharged on March 8, 2022. The discharge summary was due to be completed no later than March 9, 2022; however, the summary was completed on July 27, 2022. Additionally, follow-up information/contact was due to be completed no later than April 8, 2022; however, follow-up contact was documented on July 27, 2022.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
Senior Director and Director of operations will work in conjunction with the QA department in reviewing our internal policy and procedure manuals to change the comprehensive treatment plans. The current treatment plans with a protocol of 15 days will now reflect a more achievable 30-day standard. In addition, the program will ensure that all policy and procedural manuals are current and updated to reflect the discharge summary, as well as the discharge follow-up process. The program manager will then provide training to all clinical staff on the new policy manuals no later then 10/17/2022. The new change to the policy will ensure that all clients are able to receive a continuum of care and remain in compliance with our internal policy and procedures. |
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 release of information forms in two of fifteen client records reviewed.
Client # 10 was admitted on June 22, 2022 and was still active at the time of the inspection. The release of information form to a religious organization was signed and dated by the client on July 10, 2022, but the release form did not include the purpose of the disclosure.
Client # 11 was admitted inpatient non-hospital activity on June 8, 2022 and was still active at the time of the inspection. The release of information form to a probation officer was signed and dated by the client on June 8, 2022, but the release form did not include the purpose of the disclosure.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
All Wharton staff will be retrained on Confidentiality Standards and Release of Information (ROI) documentation requirements. This training will emphasize the need to fully complete the ROI form, specifically the purpose for the disclosure. Leadership will review all ROIs to ensure that the release is completed in its entirety. This will be completed by 9/12/2022. There will be ongoing monitoring to ensure compliance through monthly audits. |
709.28 (c) (5) 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:
(5) Dated signature of witness.
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Observations
Based on a review of client records, the facility failed to document the dated signature of the witness at the same time as the client on release of information forms in three of fifteen client records reviewed.
Client # 1 was admitted on May 5, 2022 and was still active at the time of the inspection. The release of information forms to several government agencies, a funding source, an emergency contact, and a probation officer were all signed by the client on May 5, 2022; however, all the release forms were signed by the witness on May 12, 2022.
Client # 3 was admitted on April 28, 2022 and was still active at the time of the inspection. The release of information forms to several government agencies, a funding source, an emergency contact, a laboratory, a transportation company, and a probation officer were all signed by the client on April 28, 2022; however, all the release forms were signed by the witness on May 5, 2022.
Client # 11 was admitted on June 8, 2022 and was still active at the time of the inspection. The release of information form to another treatment provider was signed by the witness on July 20, 2022; however, the release form was signed by the witness on July 21, 2022.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
All staff will be reoriented on Confidentiality Standards and Release of Information (ROI) documentation requirements. Specific emphasis will be focused on the witness signing the ROI at the same time as the client. Leadership will review all ROIs to ensure same time signatures by the client and witness. This training will be completed by 9/12/2022. There will be ongoing monitoring to ensure compliance through monthly audits. The program will be in compliance by 10/17/2022 |
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 two of three applicable client records reviewed.
Client # 12 was admitted on January 15, 2022 and was administratively discharged on February 5, 2022. There was no documentation in the record indicating that the client was notified of the facility's decision to involuntarily terminate the client's treatment at the project.
Client # 13 was admitted on June 7, 2022 and was administratively discharged on June 24, 2022. There was no documentation in the record indicating that the client was notified of the facility's decision to involuntarily terminate the client's treatment at the project.
This is a repeat citation from the January 20, 2022 annual licensing renewal inspection.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
Wharton has developed and implemented the use of the Administrative Discharge letter to notify all clients involuntary discharged, the reason for their termination. The letter is given to the client upon discharge. Wharton staff have been trained on the standard and on the use of the administrative letter. Effective immediately. There will be ongoing monitoring to ensure compliance through monthly audits. |
709.33 (b) LICENSURE Notification of termination.
§ 709.33. Notification of termination.
(b) The client shall have an opportunity to request reconsideration of a decision terminating treatment.
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Observations
Based on a review of client records, the facility failed to provide an involuntarily terminated client with an opportunity to request reconsideration of the facility's decision to terminate treatment in two of three applicable client records reviewed.
Client # 12 was admitted on January 15, 2022 and was administratively discharged on February 5, 2022. There was no documentation in the record indicating that the client was given the opportunity to request reconsideration of the facility's decision to terminate treatment.
Client # 13 was admitted on June 7, 2022 and was administratively discharged on June 24, 2022. There was no documentation in the record indicating that the client was given the opportunity to request reconsideration of the facility's decision to terminate treatment.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
Wharton has developed and implemented the use of the Administrative Discharge letter. This letter provides clients with the necessary information to request reconsideration of termination. This letter is given to the client upon involuntary termination. Wharton staff have been trained on the standard and the use of the Administrative Discharge letter. Effective Immediately. There will be ongoing monitoring to ensure compliance through monthly audits.
*Please note clients identified under 0333 and 0335 have been sent Administrative Discharge letters to last know location
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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 2022 through July 2022 unusual incident logs, the facility failed to file a written unusual incident report with the Department within 3 business days following several incidents that required the presence of police, fire and/or ambulance personnel at the facility on February 11, 2022, February 20, 2022, April 2, 2022, April 4, 2022, and May 22, 2022.
This is a repeat citation from the January 20, 2022 annual licensing renewal inspection.
This finding was 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 filed within the allotted timeframe of 3 business days of the incident. The Program Director will provide staff training on critical incidents and the reporting requirements. The New DDAP Electronic Reporting System (ERS) was introduced to the team as a new way to submit critical incidents. The program was able to create an account and began using the DDAP ERS system, as of August 5, 2022. The program also designated program managers as the only permissible staff person to submit critical incident reports. This will ensure that all incident reports have been enters correctly in the system.
The program manager will review the critical incidents with the Director of operation and Senior Director. The incidents reports will be used as part of the QA process as a vehicle to identify operational or staff performance issues.
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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, including at least 1 hour of individual psychotherapy, during the patient's first 2 years in treatment in one of five applicable patient records reviewed.
Patient # 4 was admitted on May 11, 2021 and was still active at the time of the inspection. The record of service and progress notes documented that less than 2.5 hours of psychotherapy per month was provided to the patient for the following months: 1.5 hours of psychotherapy for the month of June 2022 and 1 hour of psychotherapy for the month of May 2022. Additionally, during the months of March 2022 and April 2022, there was 2.5 hours of group psychotherapy but there were 0 hours of individual psychotherapy documented.
This is a repeat citation from the January 20, 2022 annual licensing renewal inspection.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
The program has worked with our IT department alongside side of the QA department in creating a power BI report. In addition, there is also a weekly caseload report submitted to the clinical supervisor and program manager on a weekly basis. The program manager and clinical supervisor are expected to review the weekly report to ensure all members 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 will take place at the end of each week. The counselor will use the report to place holds on clients who needs or have missed their individual sessions to ensure these individual sessions are completed weekly or as need. At the end of the week, the clinical supervisor will review each counselor caseload and place new hold on clients who missed to discuss with supervisor the importance of attending their scheduled sessions. The program continues to struggle with limited staff members to support the plan of correction. The program plans to be in compliance by 10/17/2022 |
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 2 months after 4 years of treatment in one of two applicable patient records reviewed.
Patient # 8 was admitted on May 12, 2016 and was discharged on July 7, 2022. The record of service and progress notes showed that only 1 hour of group or individual psychotherapy was provided for the months of February 2022 through June 2022.
This is a repeat citation from the January 20, 2022 annual licensing renewal inspection.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
The program has worked with our IT department alongside side of the QA department in creating a power BI report. In addition, there is also a weekly caseload report submitted to the clinical supervisor and program manager on a weekly basis. The program manager and clinical supervisor are expected to review the weekly report to ensure all members 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 will take place at the end of each week. The counselor will use the report to place holds on clients who needs or have missed their individual sessions to ensure these individual sessions are completed weekly or as need. At the end of the week, the clinical supervisor will review each counselor caseload and place new hold on clients who missed to discuss with supervisor the importance of attending their scheduled sessions. The program continues to struggle with limited staff members to support the plan of correction. The program plans to be in compliance by 10/17/2022 |
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 two of three applicable patient records reviewed.
Patient # 4 was admitted on May 11, 2021 and was still active at the time of the inspection. An annual physical examination was due in May 2022; however, there was no annual physical examination given by the narcotic treatment program documented in the record as of the date of the inspection.
Patient # 8 was admitted on May 12, 2016 and was discharged on July 7, 2022. An annual physical examination was due in May 2022; however, there was no annual physical examination given by the narcotic treatment program documented in the record prior to discharge.
This is a repeat citation from the December 11, 2020 and January 20, 2022 annual licensing renewal inspections.
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 audit the patient's chart on a weekly basis for compliance and communicate to the physicians' physicals that are out of compliance. The QA department will send out the list weekly to the clinical supervisor and doctor. Patients who are non-compliant with scheduled appointments will meet with their counselor to obtain a new appointment. The Operational Director will monitor and ensure that the caseload report list is being sent out, as indicated in the beginning of each month, as well on a weekly basis. Client #4 was scheduled for an Annual physical for August 8th, 2022, client #4 failed to present for appointment. Client #4 was rescheduled for August 29, 2022. The program will be in compliance by 10/17/2022 |
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 of the patient in two of three applicable patient records reviewed.
Patient # 1 was admitted on May 5, 2022 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 # 2 was admitted to the outpatient maintenance activity April 18, 2022 and was still active at the time of the inspection. The psychosocial evaluation was due to be completed within 15 days of admission, thus no later than May 2, 2022; however, the psychosocial evaluation was completed on June 9, 2022.
This is a repeat citation from the January 20, 2022 annual licensing renewal inspection.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
The Intake Department initially managed the completion of Biopsychosocial evaluations on all new admissions. Effective 2/1/2022, all new Biopsychosocial evaluations are now assigned to the primary counselors to complete once assigned a new patient. The restructuring of how the Biopsychosocial process will be completed, will now allow the program and the Clinical Supervisor an opportunity to track the completion of the Biopsychosocial process. This process will also allow the Power BI report to track missing and past due documents. In addition, the program is reviewing their internal policy and will make the necessary changes from 15 days to 30 days for all Biopsychosocial to be completed. Client #1 was a transfer from our State Rd location and had his BIO completed on February 4, 2021, at the time of this transfer to the Bridge Street location, the BIO was transferred over with his transfer packet. Client #2 had the Biopsychosocial evaluation completed in the system; however, it was entered past the 15-day required from our policy. The program will be in compliance by 10/17/22 |
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 two of three applicable patient records reviewed.
Patient # 4 was admitted on May 11, 2021 and was still active at the time of the inspection. An annual evaluation of the patient's status was due in May 2022; however, there was no annual evaluation documented in the record as of the date of the inspection.
Patient # 8 was admitted on May 12, 2016 and was discharged on July 7, 2022. An annual evaluation of the patient's status was due in May 2022; however, there was no annual evaluation documented in the record prior to discharge.
This is a repeat citation from the December 11, 2020 and January 20, 2022 annual licensing renewal inspections.
This finding was 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 to all clinical staff on this standard by 10-1-2022. In addition, the QA department will ensure the annual evaluation is added to the caseload report that will be sent out to the supervisor on a weekly basis. The QA supervisor will monitor compliance into our ongoing QA process, address non-compliance and report outcomes by way of the monthly QA report. Client #4 Annual evaluation was completed on August 23, 2022. Client #8 was discharged from the program and unable to complete annual. |
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 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.
Patient # 4 was admitted on May 11, 2021 and was still active at the time of the inspection. A treatment plan update was completed on February 24, 2022 and the next update was due no later than April 24, 2022; however, the update was not completed until May 23, 2022.
Patient # 8 was admitted on May 12, 2016 and was discharged on July 7, 2022. The individual treatment and rehabilitation plan was completed on February 22, 2021 and an update was due no later than April 22, 2021; however, the update was not completed until May 16, 2022.
This is a repeat citation from the January 20, 2022 annual licensing inspection.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
The program continues to struggle with staffing concerns and has failed to adhere to the timeliness of the standards. Senior Director will ensure that the program maintains an adequate number of staff within 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 Manager, who will address with clinical staff during weekly supervision. The Program Manager in conjunction with the QA department will maintain a tracking sheet on all upcoming due dates, and assist counselors to collaborate with clients, in completing their plans in a timely manner as indicated by the standard. The program will be in compliance by 10/17/22 |
715.28(c)(1-5) LICENSURE Unusual incidents
(c) A narcotic treatment program shall file a written Unusual Incident Report with the Department within 48 hours following an unusual incident including the following:
(1) Complaints of patient abuse (physical, verbal, sexual and emotional).
(2) Death or serious injury due to trauma, suicide, medication error or unusual circumstances.
(3) Significant disruption of services due to a disaster such as a fire, storm, flood or other occurrence.
(4) Incidents with potential for negative community reaction or which the facility director believes may lead to community concern.
(5) Drug related hospitalization of a patient.
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Observations
Based on a review of the facility's January 2022 through July 2022 unusual incident logs, the facility failed to file a written unusual incident report with the Department within 48 hours following the notification of an off-site death of a patient on July 2, 2022. The incident was not reported to the Department until July 6, 2022.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
POC- The Program Director will provide staff training on critical incidents and the reporting requirements. The New DDAP Electronic Reporting System (ERS) was introduced to the team as a new way to submit critical incidents. The program was able to create their account and started using the DDAP ERS as of August 5, 2022. The program also designated the Program Manager as the only staff to submit critical incident reports, to ensure all incident reports have been enters correctly in the system.
The Program Manager will review the critical incidents with the Director of Operations and Senior Director. The incident reports will be used as part of the QA process as a vehicle to identify operational or staff performance issues.
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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 four applicable client records reviewed.
Client # 10 was admitted to the inpatient non-hospital activity on June 22, 2022 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 # 11 was admitted to the inpatient non-hospital activity June 8, 2022 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.
This is a repeat citation from the January 20, 2022 annual licensing inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Wharton has revised it standard and policy on Case Consultations. Implementation of the updated standard and policy is effective immediately. This process will ensure each individual in the Wharton program will have their case reviewed with members of the treatment team. In addition, the case consultation will serve as a reassessment to monitor an individual progress in treatment, level of care and discharge planning. There will be ongoing monitoring to ensure compliance through monthly audits. |
709.17(a)(3) LICENSURE Subchapter B.Licensing Procedures.Refusal/rev
709.17. Refusal or revocation of license.
(a) The Department may revoke or refuse to issue a license for any of the following reasons:
(3) Failure to comply with a plan of correction approved by the Department, unless the Department approves an extension or modification of the plan of correction.
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Observations
Based on a review of administrative documents, the facility failed to comply with plans of correction that were approved by the Department.
A plan of correction for failing to complete annual physical examinations, which are given by the narcotic treatment program, and is to include an annual reevaluation by the narcotic treatment physician was submitted and approved by the Department for the January 20, 2022 and December 11, 2020 annual licensing inspections. complete annual physical examinations, which are given by the narcotic treatment program, and is to include an annual reevaluation by the narcotic treatment physician was again found to be a deficiency in the July 27, 2022 through July 28, 2022 provisional license follow-up inspection.
A plan of correction for failing 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 was submitted and approved by the Department for the January 20, 2022 and December 11, 2020 annual licensing inspections annual licensing inspections. Failing 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 was again found to be a deficiency in the July 27, 2022 through July 28, 2022 provisional license follow-up inspection.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
The facility failed to comply with its plan of corrections POC to address the deficiencies in the annual physicals by the doctors. Senior Director and Director of Operations has established new measure to ensure the program are able to follow it's own POC. Senior Director will ensure monthly reviews and training are completed around the POC. During these meeting, a list of any upcoming annual physicals will be discussed and schedule for the doctor appointments.
Senior Director and Director of Operation during their bi-weekly meeting continue to Keep the program POC as part of its agenda to review and discuss any progress. This information will be provided and shared with to the QA and scheduling department.
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