INITIAL COMMENTS
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This report is a result of an on-site licensure renewal, methadone and buprenorphine monitoring inspection conducted on June 4-6, 2024 by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, New Directions Treatment Services 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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705.24 (5) LICENSURE Bathrooms.
705.24. Bathrooms.
The nonresidential facility shall:
(5) Ventilate bathrooms by exhaust fan or window.
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Observations
Based on a physical plant inspection, the facility failed to ventilate bathrooms by exhaust fan or window as the downstairs men's restroom exhaust fan was not working.
The finding was reviewed with facility staff during the licensing inspection.
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Plan of Correction
As of 7/29/2024, the fan has been replaced and is now fully operational. Ongoing compliance with the regulation will be the responsibility of the Facility Manager who will be notified by maintenance staff when any of the bathroom fans are not operating. The facility Manager will be responsible for arranging for the replacement of any fan that is not operating. |
709.28 (b) LICENSURE Confidentiality
§ 709.28. Confidentiality.
(b) The project shall secure hard copy client records within locked storage containers. Electronic records must be stored on secure, password protected data bases.
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Observations
Based on a physical plant inspection, the facility failed to secure hard copy of client records within locked storage containers, as documents with client identifying information were found on desks in vacant offices.
The findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
On 6/13/2024, the Program Director reminded staff during the weekly team meeting of the confidentiality requirement to secure all clinical documentation in locked storage containers. The Clinical Supervisor will be responsible for ongoing compliance with the regulatory requirements through regular reminders to the clinical staff during weekly team meetings and individual clinical supervision. The HR Manager will ensure that confidential client information is not left unsecured in any unoccupied location after staff departure from the facility. |
709.29 (a) LICENSURE Retention of client records
§ 709.29. Retention of client records.
(a) Client records, regardless of format, shall be readily accessible for a minimum of 4 years following the discharge of a client.
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Observations
During the licensing inspection, the facility failed to have records readily accessible as it took over 1.5 hours to locate a discharged client's paper record.
The finding was reviewed with facility staff during the licensing inspection.
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Plan of Correction
Effective August 1st 2024, Clinical and Medical staff have been notified that all electronic clinical documentation must be printed upon completion and must be stored in a hard copy file that will be readily available for a minimum of four years following the discharge of the client. Ongoing compliance with the regulation will be the responsibility of the Clinical Supervisor and the Nursing Director through regular audits of a random sample of all Clinical and Medical records maintained at the facility. |
709.30 (2) LICENSURE Client rights
§ 709.30. Client rights.
The project shall develop written policies and procedures on client rights and document written acknowledgement by clients that they have been notified of those rights.
(2) The project may not discriminate in the provision of services on the basis of age, race, creed, sex, ethnicity, color, national origin, marital status, sexual orientation, handicap or religion.
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Observations
Based on the review of the facility's policy and procedures manual and client handbook, the facility failed to include the project may not discriminate in the provision of services on the basis of age, race, creed, sex, ethnicity, color, national origin, marital status, sexual orientation, handicap or religion in their policy and procedures manual. In addition, the clients were not notified they may not be discriminated against based on creed, sex, color, national origina, marital status, and religion, in eight out of eight records reviewed.
The finding was reviewed with facility staff during the licensing inspection.
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Plan of Correction
On July 18, 2024 the Facility Director revised the Clients' Rights and Responsibilities Policy in the Policy and Procedure Manual and in the Clients' Rights and Responsibilities outlined in the Client Handbook to document that the project does not discriminate in the provision of services on the basis of age, race, creed, sex, ethnicity, color, national origin, marital status, sexual orientation, handicap or religion. The revised notification has been posted in the Client Waiting room.
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709.30 (3) LICENSURE Client rights
709.30. Client rights.
The project shall develop written policies and procedures on client rights and document written acknowledgement by clients that they have been notified of those rights.
(3) Clients have the right to inspect their own records. The project, facility or clinical director may temporarily remove portions of the records prior to the inspection by the client if the director determines that the information may be detrimental if presented to the client. Reasons for removing sections shall be documented in the record.
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Observations
Based on the review of the client's handbook, the facility failed to notify clients that reasons for removing sections of their record shall be documented in the record in eight out of eight records reviewed.
The finding was reviewed with facility staff during the licensing inspection.
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Plan of Correction
On July 18, 2024 the Facility Director revised the Clients' Rights and Responsibilities Policy in the Policy and Procedure Manual and in the Clients' Rights and Responsibilities outlined in the Client Handbook to document that reasons for removing sections of their record shall be documented in the record.
By 8/06/2024, all clients will receive a copy of the revised Client Rights and Responsibilities policy and will verify receipt of the revised Client Rights and Responsibilities policy. |
709.30 (4) LICENSURE Client rights
§ 709.30. Client rights.
The project shall develop written policies and procedures on client rights and document written acknowledgement by clients that they have been notified of those rights.
(4) Clients have the right to appeal a decision limiting access to their records to the director.
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Observations
Based on a review of the facility's policy and procedures manual, the facility failed to include in their policy that clients have the right to appeal a decision limiting access to their records.
The finding was reviewed with facility staff during the licensing inspection.
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Plan of Correction
On July 18, 2024 the Facility Director revised the Clients' Rights and Responsibilities Policy in the Policy and Procedure Manual and in the Clients' Rights and Responsibilities outlined in the Client Handbook to document that the clients have the right to appeal a decision limiting access to their records. By 8/06/2024, all clients will receive a copy of the revised Rights and Responsibilities and will verify receipt of the revised Client Rights and Responsibilities policy. |
709.30 (5) LICENSURE Client rights
§ 709.30. Client rights.
The project shall develop written policies and procedures on client rights and document written acknowledgement by clients that they have been notified of those rights.
(5) Clients have the right to request the correction of inaccurate, irrelevant, outdated or incomplete information in their records.
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Observations
Based on a review of the facility's policy and procedures manual, the facility failed to include in their policy that clients have the right to request the correction of inaccurate, irrelevant, outdated or incomplete information in their records.
The finding was reviewed with facility staff during the licensing inspection.
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Plan of Correction
On July 18, 2024 the Facility Director revised the Clients' Rights and Responsibilities Policy in the Policy and Procedure Manual and in the Clients' Rights and Responsibilities outlined in the Client Handbook to document that clients have the right to request the correction of inaccurate, irrelevant, outdated or incomplete information in their records. By 8/06/2024, all clients will receive a copy of the revised Rights and Responsibilities and will verify receipt of the revised Client Rights and Responsibilities policy. |
709.30 (6) LICENSURE Client rights
§ 709.30. Client rights.
The project shall develop written policies and procedures on client rights and document written acknowledgement by clients that they have been notified of those rights.
(6) Clients have the right to submit rebuttal data or memoranda to their own records.
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Observations
Based on a review of the facility's policy and procedures manual, the facility failed to include in their policy that clients have the right to submit rebuttal data or memoranda to their own records.
The finding was reviewed with facility staff during the licensing inspection.
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Plan of Correction
On July 18, 2024 the Facility Director revised the Clients' Rights and Responsibilities Policy in the Policy and Procedure Manual and in the Clients' Rights and Responsibilities outlined in the Client Handbook to document that Clients have the right to submit rebuttal data or memoranda to their own records.
By 8/06/2024, all clients will receive a copy of the revised Client Rights and Responsibilities and will verify receipt of the revised Client Rights and Responsibilities policy. |
709.31 (a) LICENSURE Data collection system
§ 709.31. Data collection system.
(a) A data collection and recordkeeping system shall be developed that allows for the efficient retrieval of data needed to measure the project ' s performance in relationship to its stated goals and objectives.
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Observations
Based on a review of patient records, the facility failed to develop a recordkeeping system that allowed for the efficient retrieval of data.
Patient #3 was admitted on December 10, 2018 and had an estimated discharge date of August 2023; however, there was no documentation in the record of the actual discharge date. When the patient's record was opened in the electronic system, it contained no documentation, with the exception of one progress note and one case consultation. It was reported that the electronic system was implemented in March 2023.
The finding was reviewed with facility staff during the licensing inspection.
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Plan of Correction
During weekly team meeting on 8/01/2024 staff will be notified by the Program Director of a revised process of clinical record keeping and retrieval. As of 08/06/2024, a back-up copy of all electronic clinical and medical records will be printed in hard copy and filed in a record binder for every client enrolled in the program. The Clinical Supervisor will be responsible for monitoring ongoing compliance with clinical documentation and the Nursing Director will be responsible for monitoring ongoing compliance with medical records. The facility Manager will ensure that records are stored and maintained securely to ensure timely retrieval during audit and/or program evaluation. |
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 and emergency contact in three out of eight records reviewed.
Patient #4 was admitted on February 1, 2024 and was still active at the time of the inspection. There was no documentation of identity and emergency contact.
Patient #5 was admitted on May 23, 2024 and was still active at the time of the inspection. There was no documentation of identity.
Patient #9 was admitted on June 16, 2016 and was still active at the time of the inspection. There was no documented emergency contact.
These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
During weekly team meeting on 08/01/2024, the Program Director will remind clinical and medical staff of the requirement to verify client identity and record an Emergency Contact for every client admitted to the program. Beginning on 08/02/2024, Intake staff will scan the required Photo Identification Card into the clinical record for each enrolled client. Intake staff will be responsible for obtaining an Emergency Contact with a signed Consent to Release protected health information from each applicant seeking admission to treatment. The QA Manager will be responsible for ensuring compliance with the regulation through a review of all Intake documentation, prior to the client's admission to treatment. Ongoing compliance with the requirement will be the responsibility of the Clinical Supervisor through random record review and during Individual Supervision with clinicians. |
715.10(a)(2) LICENSURE Pregnant patients
(a) A narcotic treatment program may place a pregnant patient, regardless of age, who has had a documented narcotic dependency in the past and who may return to narcotic dependency, on a comprehensive maintenance regime.
(2) Evidence of all findings and the criteria used to determine the findings shall be recorded in the patient's record by the admitting narcotic treatment physician before the initial dose is administered to the patient.
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Observations
Based on a review of patient records, the facility failed to document evidence of all findings and the criteria used to determine the findings by the narcotic treatment physician in two out of two applicable records. The two applicable records contained no documentation of patient's pregnancy by the narcotic treatment physician. Documentation of pregnancy was only included in clinical progress notes and verified by facility staff.
Patient #1 was admitted on October 24, 2022 and was still active at the time of the inspection.
Patient #2 was admitted on January 25, 2022 and was still active at the time of the inspection.
These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
As of 8/01/2024, the Narcotic Treatment Physician will document evidence of the pregnancy, the findings and the criteria used to determine medical justification for treatment before the initial dose is administered to any pregnant woman without physiological dependence who has had a documented narcotic dependency in the past and who may return to narcotic dependency. Ongoing compliance with the regulation will be the responsibility of the Nursing Director through a review of the NTP Provider's documentation of criteria used for medical justification for treatment for pregnant women without physiological dependence prior to administration of the first dose. |
715.10(b) LICENSURE Pregnant patients
(b) A narcotic treatment program shall give pregnant patients the opportunity for prenatal care either by the narcotic treatment program or by referral to appropriate health-care providers.
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Observations
Based on the review of patient records, the facility failed to document the opportunity for pregnant patients to receive prenatal care either by the narcotic treatment program or by referral to appropriate health-care providers in two out of two applicable records reviewed.
Patient #1 was admitted on October 24, 2022 and was still active at the time of the inspection.
Patient #2 was admitted on January 25, 2022 and was still active at the time of the inspection.
These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
On August 1, during the weekly team meeting, the Program Director reminded clinicians of the requirement to document that the patient has been referred to a pre-natal healthcare provider and to document the collaboration with the pre-natal provider and the pre-natal support being provided by the clinician. Ongoing compliance with the regulation will be the responsibility of the Clinical Supervisor through regular review of the clinical record for all pregnant women in the program until after the pregnancy has ended.
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715.10(d) LICENSURE Pregnant patients
(d) Within 3 months after termination of pregnancy, the narcotic treatment physician shall enter an evaluation of the patient 's treatment status into her record and state whether she should remain in comprehensive maintenance treatment or receive detoxification treatment.
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Observations
Based on the review of patient records, the facility failed to document an evaluation by the narcotic treatment physician within three months after termination of pregnancy status and whether the patient should remain in maintenance treatment or receive detoxification treatment in one out of one applicable records reviewed.
Patient #1 was admitted on October 24, 2022 and was still active at the time of the inspection.
The finding was reviewed with facility staff during the licensing inspection.
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Plan of Correction
Beginning on August 1, 2024, within 3 months after termination of pregnancy, the Narcotic Treatment Physician will document an evaluation of all pregnant patients' treatment status into the record and will document whether she should remain in comprehensive maintenance treatment or receive detoxification treatment Ongoing compliance with the regulation will the responsibility of the Nursing Director who will maintain a record of all pregnant women in the program and will notify the narcotic treatment physician when the post-natal evaluation of continuing treatment must be documented. |
715.13(b) LICENSURE Patient identification
(b) A narcotic treatment program shall maintain onsite a photograph of each patient which includes the patient 's name and birth date. The narcotic treatment program shall update the photograph every 3 years.
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Observations
Based on a review of patient records, the facility failed to maintain onsite a photograph of each patient in one out of eight records reviewed.
Patient #8 was admitted on April 29, 2021 and was still active at the time of the inspection.
The finding was reviewed with facility staff during the licensing inspection.
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Plan of Correction
By August 5, 2024, the Nursing Director will direct the Nursing staff to review all client records in the dispensing system to verify that each record has a photograph that has been updated every three years prior to dispensing of medication. The patient dispensing record will include the patient's name and date of birth. Ongoing compliance with the regulation will be the responsibility of the Nursing Director by creation of a reminder system to ensure that a photograph of every patient is included in the record and that every photograph is updated no later than three years after the date of patient's admission. |
715.14(a) LICENSURE Urine testing
(a) A narcotic treatment program shall complete an initial drug-screening urinalysis for each prospective patient and a random urinalysis at least monthly thereafter.
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Observations
Based on the review of patient records, the facility failed to complete a random urinalysis at least monthly in one out of seven applicable records reviewed.
Patient #9 was admitted on June 16, 2016 and was still active at the time of the inspection. The patient did not have a urinalysis in December 2023.
The finding was reviewed with facility staff during the licensing inspection.
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Plan of Correction
By 8/02/2024, the Nursing Director will create a list of all active patients to track UDS testing results on a monthly basis. The Nursing Director will delegate responsibility to the dispensing staff to monitor the tracking list to ensure that all patients provide a specimen for testing every month. Ongoing compliance with the regulation will be the responsibility of the Nursing Director who will review the tracking list prior to the end of each month and will schedule any patient who has failed to provide at least one specimen during the month as required. |
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
Based on the review of patient records, the facility failed to document dosage level reviews by the narcotic treatment physician at least twice a year in five out of five applicable records reviewed. In all applicable records reviewed, there was no documentation of dosage reviews occurring.
Patient #1 was admitted on October 24, 2022 and was still active at the time of the inspection.
Patient #2 was admitted on January 25, 2022 and was still active at the time of the inspection.
Patient #4 was admitted on February 1, 2024 and was still active at the time of the inspection.
Patient #8 was admitted on April 29, 2021 and was still active at the time of the inspection.
Patient #9 was admitted on June 16, 2016 and was still active at the time of the inspection.
These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
On 8/04/2024, the Program Director will remind the Narcotic Treatment Physician to document that all doses must be reviewed at least twice a year with each review being no more than two months apart. The physician will include documentation that the dose has been reviewed whenever a dose is changed and will document that the dose has been reviewed twice a year for individuals who do not require a change in dose. Ongoing compliance will be the responsibility of the Nursing Supervisor who will verify documentation of the minimum of the twice yearly dose reviews with each review occurring at least two months apart. |
715.16(a)(1) LICENSURE Take-home privileges
(a) A narcotic treatment program shall determine whether a patient may be provided take-home medications.
(1) A narcotic treatment program may give take-home medications only to a patient who the narcotic treatment physician has determined is responsible and able to handle narcotic drugs outside the narcotic treatment program.
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Observations
Based on a review of patient records, the facility failed to show the narcotic treatment physician has determined a patient is responsible and able to handle narcotic drugs outside the narcotic treatment program in five out of five applicable records.
Patient #1 was admitted on October 24, 2022 and was still active at the time of the inspection.
Patient #2 was admitted on January 25, 2022 and was still active at the time of the inspection.
Patient #4 was admitted on February 1, 2024 and was still active at the time of the inspection.
Patient #6 was admitted on January 16, 2024 and was still active at the time of the inspection.
Patient #7 was admitted on October 2, 2020 and discharged on October 30, 2023.
The findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
M127: Effective 08/05/2024, the Narcotic Treatment Physicians will demonstrate that they considered and exercised reasonable clinical judgment that a patient is responsible for handling narcotic drugs through documentation of their determination which patients may receive unsupervised doses and how many unsupervised doses they will receive. The physician's documentation will include consideration of the following criteria: (a) whether the therapeutic benefits of unsupervised doses outweigh the risks (b) Absence of active substance use disorders, other physical or behavioral health conditions that increase the risk of patient harm as it relates to the potential for overdose, or the ability to function safely;(c) Regularity of attendance for supervised medication administration;(d) Absence of serious behavioral problems that endanger the patient, the public or others;(e) Absence of known recent diversion activity; (f) Whether take home medication can be safely transported and stored and (g) Any other criteria that the narcotic treatment physician considers relevant to the patient's safety and the public's health.Ongoing compliance will be the responsibity of the Nursing Director through random record review of the prescriber's Take Home Approval Documentation in the record. |
715.16(a)(2) LICENSURE Take-home privileges
(a) A narcotic treatment program shall determine whether a patient may be provided take-home medications.
(2) The narcotic treatment physician shall make this determination after consultations with staff involved in the patient's care.
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Observations
Based on a review of patient records, the facility failed to show the narcotic treatment physician has determined a patient is responsible and able to handle narcotic drugs outside the narcotic treatment program after consultations with staff involved in the patient's care in five out of five applicable records.
Patient #1 was admitted on October 24, 2022 and was still active at the time of the inspection.
Patient #2 was admitted on January 25, 2022 and was still active at the time of the inspection.
Patient #4 was admitted on February 1, 2024 and was still active at the time of the inspection.
Patient #6 was admitted on January 16, 2024 and was still active at the time of the inspection.
Patient #7 was admitted on October 2, 2020 and discharged on October 30, 2023.
The findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
As of 8/06/2024, The Narcotic Treatment Physician will consult with the staff involved in the patient's care to determine whether the patient is responsible and able to handle take home medications safely and will document the physician's rationale for permitting take home medication in the record. The clinical staff will be responsible for documentation of the consultation in the Case Consultation Notes. Ongoing compliance with the regulation will be the responsibility of the Clinical Supervisor through random record review of the Take Home approval rationale and the Case Consultation Notes and during group and individual supervision. |
715.16(a)(3) LICENSURE Take-home privileges
(a) A narcotic treatment program shall determine whether a patient may be provided take-home medications.
(3) The narcotic treatment physician shall document in the patient record the rationale for permitting take-home medication.
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Observations
Based on a review of patient records, the facility failed to show documentation for the narcotic treatment physician's rationale for permitting take-home medication in five out of five applicable records reviewed.
Patient #1 was admitted on October 24, 2022 and was still active at the time of the inspection.
Patient #2 was admitted on January 25, 2022 and was still active at the time of the inspection.
Patient #4 was admitted on February 1, 2024 and was still active at the time of the inspection.
Patient #6 was admitted on January 16, 2024 and was still active at the time of the inspection.
Patient #7 was admitted on October 2, 2020 and discharged on October 30, 2023.
The findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
As of 8/06/2024, The Narcotic Treatment Physician will document the physician's rationale for permitting take home medication in the record. Ongoing compliance with the regulation will be the responsibility of the Nursing Supervisor through record review of the Take Home approval rationale for all patients receiving Take Home medication. |
715.16(b)(1-8) LICENSURE Take-home privileges
(b) The narcotic treatment physician shall consider the following in determining whether, in exercising reasonable clinical judgment, a patient is responsible in handling narcotic drugs:
(1) Absence of recent abuse of drugs (narcotic or non-narcotic), including alcohol.
(2) Regular narcotic treatment program attendance.
(3) Absence of serious behavioral problems at the narcotic treatment program.
(4) Absence of known recent criminal activity.
(5) Stability of the patient 's home environment and social relationships.
(6) Length of time in comprehensive maintenance treatment.
(7) Assurance that take-home medication can be safely stored within the patient 's home.
(8) Whether the rehabilitative benefit to the patient derived from decreasing the frequency of attendance outweighs the potential risks of drug diversion.
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Observations
Based on a review of patient records, the facility failed to show the narcotic treatment physician considered and exercised reasonable clinical judgment that a patient is responsible for handling narcotic drugs in five out of five applicable records.
Patient #1 was admitted on October 24, 2022 and was still active at the time of the inspection.
Patient #2 was admitted on January 25, 2022 and was still active at the time of the inspection.
Patient #4 was admitted on February 1, 2024 and was still active at the time of the inspection.
Patient #6 was admitted on January 16, 2024 and was still active at the time of the inspection.
Patient #7 was admitted on October 2, 2020 and discharged on October 30, 2023.
The findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
Effective 08/06/2024, the Narcotic Treatment Physicians will demonstrate that they considered and exercised reasonable clinical judgment that a patient is able to be responsible for handling narcotic drugs through documentation of their determination which patients may receive unsupervised doses and how many unsupervised doses they will receive. The physician's documentation will include consideration of the following criteria: (a) whether the therapeutic benefits of unsupervised doses outweigh the risks (b) Absence of active substance use disorders, other physical or behavioral health conditions that increase the risk of patient harm as it relates to the potential for overdose, or the ability to function safely;(c) Regularity of attendance for supervised medication administration;(d) Absence of serious behavioral problems that endanger the patient, the public or others;(e) Absence of known recent diversion activity; (f) Whether take home medication can be safely transported and stored and (g) Any other criteria that the narcotic treatment physician considers relevant to the patient's safety and the public's health.Ongoing compliance will be monitored by the Nursing Director through random review of the Take Home approval documentation in the record. |
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 patients with 2.5 hours of psychotherapy per month during the patient's first two years of treatment, one hour of which shall be individual psychotherapy, in three out of three applicable records reviewed.
Patient #1 was admitted on October 24, 2022 and was still active at the time of the inspection. In March 2024 and May 2024, the patient had 60 minutes of individual therapy and no group therapy sessions. In April 2024, the patient had 30 minutes of individual therapy and no group sessions.
Patient #4 was admitted on February 1, 2024 and was still active at the time of the inspection. In February 2024, the patient received sixty minutes of therapy. In March 2024, there were no therapy sessions documented. In April 2024, the patient received one hours of individual therapy and one hour of group therapy.
Patient #6 was admitted on January 16, 2024 and was still active at the time of the inspection. In March 2024, there were no therapy sessions documented. In April 2024, the patient received sixty minutes of individual therapy and no group therapy sessions.
These findings were reviewed with facility staff during the licensing inspection.
This is a repeat citation from the July 19, 2023, July 21, 2022, May 21, 2021 and October 28, 2021 licensing inspections.
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Plan of Correction
As of 08/06/2024, the patient Consent to Methadone Treatment will be revised to include patient agreement to attend a minimum of 2.5 hour of counseling per month for the first two years in treatment, 1.0 hours of counseling per month between two years and four years in treatment and 1.0 hour of counseling per month after four years of treatment in order to remain in the program. Meeting counseling attendance requirements will be included as a goal in all Treatment Plans throughout treatment. Ongoing compliance with meeting regulatory requirement will be the responsibility of the Clinical Supervisor and will be monitored by the QA Manager through regular record audits and reported to all clinicians and to the Clinical Supervisors on a monthly basis. The Clinicians will be responsible for implementing interventions to ensure patient compliance with the counseling attendance requirements in the treatment plan throughout treatment. |
715.20(1) LICENSURE Patient transfers
A narcotic treatment program shall develop written transfer policies and procedures which shall require that the narcotic treatment program transfer a patient to another narcotic treatment program for continued maintenance, detoxification or another treatment activity within 7 days of the request of the patient.
(1) The transferring narcotic treatment program shall transfer patient files which include admission date, medical and psychosocial summaries, dosage level, urinalysis reports or summary, exception requests, and current status of the patient, and shall contain the written consent of the patient.
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Observations
Based on the review of patient records, the facility failed to document the transfer of patient files to the receiving narcotic treatment program in one out of one applicable record.
Patient #7 was admitted on October 2, 2020 and discharged on October 30, 2023.
The finding was reviewed with facility staff during the licensing inspection.
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Plan of Correction
During weekly team meeting on 8/01/2024, the Program Director reminded staff of the requirements to document the transfer of patient files to the receiving program during patient transfers to another narcotic treatment provider. The Transfer Documentation Packet that included the sample of the File Transfer document list that will be sent to the receiving program, was provided to staff. Ongoing compliance with the regulation will be the responsibility of the Clinical Supervisor who will review the records of all patient transfers to ensure all documentation required is included in the record.
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715.20(4) LICENSURE Patient transfers
A narcotic treatment program shall develop written transfer policies and procedures which shall require that the narcotic treatment program transfer a patient to another narcotic treatment program for continued maintenance, detoxification or another treatment activity within 7 days of the request of the patient.
(4) The receiving narcotic treatment program shall document in writing that it notified the transferring narcotic treatment program of the admission of the patient and the date of the initial dose given to the patient by the receiving narcotic treatment program.
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Observations
Based on the review of patient records, the facility failed to document that it notified the transferring narcotic treatment program of the admission of the patient and the date of the initial dose given in one out of one applicable record reviewed.
Client #4 was admitted on February 1, 2024 and was still active at the time of the inspection.
The finding was reviewed with facility staff during the licensing inspection.
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Plan of Correction
During weekly team meeting on 8/01/2024, the Program Director reminded staff of the requirement to document notification to the transferring program of the admission of the patient and the date of the initial dose received by the patient after patient transfers from another narcotic treatment provider. The Transfer In Documentation Packet that included the sample of the Patient Admission and the date of the initial dose that will be sent to the transferring program was provided to staff. Ongoing compliance with the regulation will be the responsibility of the Clinical Supervisor who will review the records of all patient transfers to ensure all documentation required is included in the record. |
715.23(b)(4) LICENSURE Patient records
(b) Each patient file shall include the following information:
(4) The results of an initial intake physical examination.
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Observations
Based on a review of patient records, the facility failed to document an initial physical examination within the timeframe established in their policy and procedures manual, in two out of two applicable records. The manual states the exam shall be completed within seven days after admission.
Patient #4 was admitted on February 1, 2024 and was still active at the time of the inspection. A physical exam was due no later than February 8, 2024; however, it was not completed until April 18, 2024.
Patient #6 was admitted on January 16, 2024 and was still active at the time of the inspection. A physical exam was due no later than January 23, 2024; however, there it was not completed at the time of the inspection.
These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
As of 08/06/2024, the Nursing Supervisor or his/her designee will schedule all new admissions for an initial physical examination within fourteen days of admission in accordance with the agency Policy & Procedure Manual.If a patient does not attend the scheduled appointment, the prescribing physician will complete the physical examination prior to induction of medication. Ongoing compliance with the regulation will be the responsibility of the QA Manager who will review admission documentation to ensure that that the initial physical examination has been completed within the policy time frame. |
709.91(b)(1) LICENSURE Intake and admission
709.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(1) Disclosure to the client of criteria for admission, treatment, completion and discharge.
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Observations
Based on a review of client records, the facility failed to document that client orientation had taken place in one out of three applicable records reviewed.
Client #6 was admitted on January 16, 2024 and was still active at the time of the inspection.
The finding was reviewed with facility staff during the licensing inspection.
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Plan of Correction
Beginning on 8/06/2024, all newly admitted clients will be provided with a complete Patient Orientation within 30 days of admission. The Primary Counselor will be responsible for documentation of the patient orientation and completion of the Patient Orientation Checklist. Ongoing compliance with the regulation will be the responsibility of the QA Manager who will review the clinical record within 30 days after admission to ensure documentation of the patient orientation has been completed. |
709.92(a)(2) LICENSURE Treatment and rehabilitation services
709.92. Treatment and rehabilitation services.
(a) An individual treatment and rehabilitation plan shall be developed with a client. This plan shall include, but not be limited to, written documentation of:
(2) Type and frequency of treatment and rehabilitation services.
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Observations
Based on the review of client records, the facility failed to document type and frequency on treatment plans in four out of five applicable records reviewed.
Client #1 was admitted on October 24, 2022 and was still active at the time of the inspection. There was no type and frequency documented on treatment plans dated December 19, 2023 and May 3, 2024.
Client #4 was admitted on February 1, 2024 and was still active at the time of the inspection. There was no frequency documented on the February 7, 2024 treatment plan.
Client #6 was admitted on January 16, 2024 and was still active at the time of the inspection. There was no type and frequency documented on the January 16, 2024 treatment plan.
Client #8 was admitted on April 29, 2021 and was still active at the time of the inspection. There was no frequency documented on the April 20, 2024 treatment plan.
These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
As of 08/06/2024, the Treatment Plan template in the clinical record will be revised to include the type and frequency of services to be provided. The Clinical Supervisor has reminded clinicians to record the Type and Frequency of services to be provided in the Treatment Plan and will be responsible for monitoring ongoing compliance with the regulation through random record review of Treatment Plans and during Clinical Supervision. |
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
Based on the review of client records, the facility failed to document treatment plan updates within the regulatory timeframe in seven out of eight records reviewed.
Client #1 was admitted on October 24, 2022 and was still active at the time of the inspection. A treatment plan update was completed on December 19, 2023 and the next update was due no later than February 19, 2024; however, it was not completed until May 3, 2024.
Client #2 was admitted on January 25, 2022 and was still active at the time of the inspection. A treatment plan update was completed on December 28, 2023 and the next update was due no later than February 28, 2024; however, it was not completed until March 5, 2024.
Client #4 was admitted on February 1, 2024 and was still active at the time of the inspection. The comprehensive treatment plan was completed on February 7, 2024 with an update due no later than April 7, 2024; however, it was not completed until May 23, 2024.
Client #6 was admitted on January 16, 2024 and was still active at the time of the inspection. A treatment plan update was completed on March 11, 2024 and the next update was due no later than May 11, 2024; however, it was not completed until May 31, 2024.
Client #7 was admitted on October 2, 2020 and discharged on October 30, 2023. A treatment plan update was completed on June 29, 2023 and the next update was due no later than August 29, 2023; however, it was not completed until September 11, 2023.
Cliient #8 was admitted on April 29, 2021 and was still active at the time of the inspection. A treatment plan update was completed on January 12, 2024 and the next update was due no later than March 12, 2024; however, it was completed April 29, 2024.
Client #9 was admitted on June 16, 2026 and was still active at the time of the inspection. A treatment plan update was completed on February 9, 2024 and the next update was due no later than April 9, 2024; however, it was completed on April 30, 2024.
These findings were reviewed with facility staff during the licensing inspection.
This is a repeat citation from the July 19, 2023 annual licensing inspection.
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Plan of Correction
Beginning on 08/06/2024, the Clinical Supervisor will remind staff of the regulatory requirement to complete Treatment Plan Reviews and Updates every sixty days. Ongoing compliance will be the responsibility of the QA Manager who will alert clinicians before the due dates of each Treatment Plan Review and Update on their caseloads. |
709.92(c) LICENSURE Treatment and rehabilitation services
709.92. Treatment and rehabilitation services.
(c) The project shall assure that counseling services are provided according to the individual treatment and rehabilitation plan.
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Observations
Based on the review of client records, the facility failed to ensure that the client received counseling services according to their individual comprehensive treatment plan in one out of one applicable record.
Client #2 was admitted on January 25, 2022 and was still active at the time of the inspection. A treatment plan update dated May 13, 2024 indicated weekly individual sessions. There were no documented sessions between May 13, 2024 and the date of the inspection.
The finding was reviewed with facility staff during the licensing inspection.
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Plan of Correction
During the Treatment Team Meeting on 8/01/2024, the Facility Director reminded the clinicians that the frequency of services recommended and included in the Treatment Plans must be provided exactly as outlined in the Treatment Plan. Ongoing compliance of the regulation will be the responsibility of the Clinical Supervisor through random review of the treatment plans included in the record and during individual supervision. |
709.93(a)(8) LICENSURE Client records
709.93. 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 case consultations according to the timeline outlined in their policy and procedures manual in two out of five applicable records reviewed. The manual states a consultation needs to be completed within the first 90 days and annually thereafter.
Client #4 was admitted on February 1, 2024 and was still active at the time of the inspection. A case consultation was due no later than May 1, 2024; however, it was not completed until May 20, 2024.
Client #8 was admitted on April 29, 2021 and was still active at the time of the inspection. A case consultation was due no later than April 29, 2024; however, it was not completed until June 4, 2024.
These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
During the Treatment Team Meeting on 8/01/2024, the Facility Director reminded the clinicians of the regulatory requirement to document Case Consultation notes in the record every 90 days for the first year of treatment and annually thereafter.Ongoing compliance of the regulation will be the responsibility of the Clinical Supervisor and the QA Manager through random review of the Case Consultation Notes that are included in the record and during individual supervision. |
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 patient records, the facility failed to comply with plans of correction that were approved by the Department.
A plan of correction for providing patients with 2.5 hours of psychotherapy per month during the patient's first two years of treatment was submitted and approved by the Department for the July 21, 2022, October 28, 2021, May 21, 2021 and July 19, 2023 licensing inspections. Psychotherapy hours were again found to be deficient in the June 6, 2024 licensing inspection.
In addition, a plan of correction for annual clinical evaluation was submitted and approved by the Department for the July 19, 2023 and July 22, 2022 licensing inspections. Annual clinical evaluations were again found to be deficient in the June 6, 2024 licensing inspection.
These findings were reviewed with facility staff during the licensing inspection.
This is a repeat citation from the July 19, 2023 and July 22, 2022 licensing inspections.
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Plan of Correction
By 8/06/2024,the Facility Director will meet with the Treatment Team Supervisors to review the Plans of Correction approved by the department in 2021,2022 and 2023 and to address implementation of the revised Plans of Correction for 2024. The Clinical Supervisors will coordinate with the QA Manager and will be responsible for ongoing compliance with meeting the regulatory requirements through monthly record of service audits and sharing the audit results with staff during group and individual Clinical Supervision. |