INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on December 10, 2020 through December 11, 2020 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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704.11(c)(1) LICENSURE Mandatory Communicable Disease Training
704.11. Staff development program.
(c) General training requirements.
(1) Staff persons and volunteers shall receive a minimum of 6 hours of HIV/AIDS and at least 4 hours of tuberculosis, sexually transmitted diseases and other health related topics training using a Department approved curriculum. Counselors and counselor assistants shall complete the training within the first year of employment. All other staff shall complete the training within the first 2 years of employment.
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Observations
The facility failed to ensure that all staff persons received a minimum of 6 hours of HIV/AIDS training and at least 4 hours of TB/STD and other health related topics within the regulatory timeframe in two of six applicable personnel records reviewed.
Employee #19 was hired as a counselor on July 18, 2019 and was due to have HIV/AIDS training and TB/STD training no later than July 18, 2020; however, the HIV/AIDS training was completed on December 4, 2020 and the TB/STD training was completed on December 1, 2020.
Employee #20 was hired as a counselor on September 12, 2019 and was due to have TB/STD training no later than September 12, 2020; however, the HIV/AIDS training was completed on December 4, 2020 and the TB/STD training was completed on December 1, 2020.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Site Directors will ensure all staff have at least 4 hours of TB/STD & at least 6 hours of HIV/AIDs training within 1 year of hire for clinical staff and 2 years for support staff. Site directors will utilize Relias system to track trainings and ensure completion within regulatory timeframe. Site Directors will utilize online virtual trainings during pandemic |
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
The facility failed to obtain an informed and voluntary consent to release information form prior to the disclosure of information in one of fifteen client records reviewed.
Client # 13 was admitted to the inpatient program on August 19, 2020 and was discharged on August 31, 2020. The release of information form to the funding source was signed and dated by the client on August 19, 2020 and expired on the same date; however, there was evidence of billing to the funding source several times during the course of treatment and no updated consent form was completed prior to the disclosures.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Site Director will re-train staff on how to properly complete a release of information with clients. A QA process will be put in place to ensure consents are completed in their entirety and properly.
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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
The facility failed to keep disclosures of client identifying information within the limits established by 4 Pa. Code 255.5 (b) for releases of information in three of fifteen client records reviewed. Additionally, the facility failed to document the specific information to be disclosed on release of information forms in one of fifteen client records reviewed.
Client #9 was admitted to the inpatient program on November 18, 2020 and was still active at the time of the inspection. There was a consent to release information form to the funding source signed and dated by the client on November 18, 2020 that allowed for the release of admission forms and the ASAM form, which exceeds the limits established by 4 Pa. Code 255.5.
Client #10 was admitted to the inpatient program on November 21, 2020 and was still active at the time of the inspection. There was a consent to release information form to the funding source signed and dated by the client on November 21, 2020 that allowed for the release of admission forms and the ASAM form, whcih exceeds the limits established by 4 Pa. Code 255.5.
Client #11 was admitted to the inpatient program on November 24, 2020 and was still active at the time of the inspection. There was a consent to release information form to the funding source signed and dated by the client on November 24, 2020 that allowed for the release of admission forms and the ASAM form, which exceeds the limits established by 4 Pa. Code 255.5.
Client #15 was admitted to the inpatient program on February 5, 2020 and was discharged on February 26, 2020. There was a consent to release information form to an emergency contact signed and dated by the client on February 18, 2020 and did not include the specific information to be disclosed.
These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
The consent to release will be kept within the bounds of 255.5. Site 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 it's completion and accuracy. Program will be in compliance by 3/01/2021 |
709.28 (c) (6) 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:
(6) Date, event or condition upon which the consent will expire.
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Observations
The facility failed to ensure that all consent to release information forms included the date, event or condition upon which the consent to release information form would expire in one of fifteen client records reviewed.
Client #15 was admitted to the inpatient program on February 5, 2020 and was discharged on February 26, 2020. The release of information forms to the funding source, a government agency, the laboratory, the pharmacy and the emergency contact were all signed and dated on February 5, 2020 and none included an expiration date.
These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
Site Director will retrain staff on how to properly complete consents to release information. A QA process will be put in place to ensure consents for completed in their entirety and properly. |
715.15(a) LICENSURE Medication Dosage
(a) The narcotic treatment physician shall review the dosage levels at least twice a year, with each review occurring at least 2 months apart, to determine a patient 's therapeutic dosage.
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Observations
The facility failed to ensure that a narcotic treatment physician reviewed medication dosage levels at least twice a year in one of eight applicable patient records reviewed.
Patient # 6 was admitted October 31, 2018 and was discharged August 19, 2020. The last dosage review was documented in October 2019 and no reviews were completed prior to discharge.
These findings were reviewed with facility staff during the licensing process
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Plan of Correction
The Medical Director will review the deficiency where a bi-annual dose review was not conducted on a client twice per year, no less than 2 months apart. The Site Director/ QA specialist will generate a report monthly for those where a bi-annual dose review is due, and alert the staff physicians. The Medical Director will monitor for compliance monthly. |
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
The facility failed to ensure that an annual physical examination was given by the narcotic treatment program, which is to include an annual reevaluation by the narcotic treatment physician, in one of eight records reviewed.
Patient #8 was admitted on July 9, 2016 and was discharged November 10, 2020. The last documented physical examination was dated July 10, 2019.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The physician will complete annual physicals within the regulatory time frames. The administrative assistant will inform the physicians of all scheduled annual physicals daily. The QA department will audit the patient's charts on a weekly basis for compliance and communicate to the physicians physicals that are out of compliance. |
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
The facility failed to ensure that an annual clinical evaluation of each patient's status was documented in three of eight patient records reviewed.
Patient #4 was admitted on July 5, 2008 and was discharged February 3, 2020. There was no annual evaluation documented for the patient's admission anniversary date of July 5, 2019.
Patient # 6 was admitted October 31, 2018 and was discharged August 19, 2020. There was no annual evaluation documented for the patient's admission anniversary date of October 31, 2019.
Patient #8 was admitted on July 9, 2016 and was discharged November 10, 2020. There was no annual evaluation documented for the patient's admission anniversary date of July 9, 2020.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Site Director in conjunction with the QA Specialist will conduct chart audits on each patient record on a quarterly basis to ensure that annual clinical evaluations are completed in a timely manner. Currently, the missing clinical evaluations noted in the citation will be completed within 14 days. A report will be run weekly to ensure that all upcoming evaluation are completed within the regulatory timeframe. |
709.92(b) LICENSURE Treatment and rehabilitation services
709.92. Treatment and rehabilitation services.
(b) Treatment and rehabilitation plans shall be reviewed and updated at least every 60 days.
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Observations
The facility failed to ensure that treatment and rehabilitation plans were reviewed and updated at least every 60 days in four of eight outpatient client records reviewed.
Patient #2 was admitted on January 8, 2018 and was active at the time of inspection. A treatment plan update was completed on August 6, 2020 and another update was due no later than October 6, 2020. However, the update was not completed at the time of inspection.
Patient #4 was admitted on July 5, 2008 and was discharged February 3, 2020. A treatment plan update was completed on November 5, 2019 and another update was due no later than January 5, 2020. However, the update was not completed prior to discharge.
Patient # 6 was admitted October 31, 2018 and was discharged August 19, 2020. A treatment plan update was completed on April 26, 2020 and another update was due no later than June 26, 2020. However, the update was not completed until July 11, 2020.
Patient #8 was admitted on July 9, 2016 and was discharged November 10, 2020. A treatment plan update was completed on May 26, 2020 and another update was due no later than July 26, 2020. However, the update was not completed prior to discharge.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The deficiencies stating that clients failed to have their treatment plan updates completed within the 60 day time frame will be reviewed with the Clinical Supervisors by the Site Director. The Clinical Supervisors will review the deficiencies as well as the regulation with the counseling staff and retrain on how to complete treatment plans and the new electronic health record. The QA Department will generate and submit a list of all due dates for treatment plans one month in advance and submit to the counselors for follow up. The Record Management Supervisor will monitor for compliance.Program will be in compliance by 3/01/2021. |