INITIAL COMMENTS
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This report is a result of an on-site provisional license follow-up and methadone monitoring inspection conducted on December 17-18, 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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709.28 (c) LICENSURE Confidentiality
§ 709.28. Confidentiality.
(c) The project shall obtain an informed and voluntary consent from the client for the disclosure of information contained in the client record.
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Observations
Based on a review of client records, the facility failed to obtain a current signed consent to release information form prior to releasing information in one out of fourteen records reviewed. There was no consent to release information form for the funding source. Facility staff confirmed billing had occurred.
Client #13 was admitted on May 6, 2016 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 1/27/2025, during weekly team meeting, all clinicians will be reminded of the requirement to obtain a Consent to Release confidential information for the funding source and to update the releases prior to billing when a funding source has been changed.
The Primary therapist will meet with Client #13 to obtain consent for the current funding source. Ongoing compliance with the requirement will be the responsibility of the QA/UR staff who will monitor compliance through random and scheduled audits of the Releases for disclosure of confidential information. |
709.28 (c) (1) 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:
(1) Name of the person, agency or organization to whom disclosure is made.
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Observations
Based on a review of client records, the facility failed to document a completed consent to release information form to include name of the person, agency or organization to whom disclosure is made in two out of fourteen records reviewed.
Client #4 was admitted on November 14, 2024 and was still active at the time of the inspection. The form without the required information was dated November 14, 2024.
Client #10 was admitted on September 16, 2024 and was still active at the time of the inspection. The form without the required information was dated September 16, 2024.
These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
By 1/27/2025, during the weekly treatment team meeting clinicians will be reminded to ensure that the name of the person, agency or organization to whom the disclosure is made is included in the consent to release confidential information. The primary therapist will complete the required information in the releases of confidential information for client #4. The Clinical Supervisor will be responsible for ensuring compliance with the regulation through random record review and during individual supervision meetings with the clinicians.
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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 the review of client records, the facility failed to document a completed consent to release information form to include purpose of disclosure in one out of fourteen records reviewed.
Client #5 was admitted on August 21, 2024 and was still active at the time of the inspection. An August 27, 2024 form to a government agency had "other" checked without specifying an additional purpose.
The finding was reviewed with facility staff during the licensing inspection.
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Plan of Correction
0281: During Treatment Team Meeting on 1/13/2025, the Facility Director reminded staff that the purpose of disclosure must be specified on any consent to release confidential information signed by a client. The QA Manager will be responsible for auditing signed releases on an ongoing basis to ensure the purpose of the release is specified and documented. Ongoing compliance with the standard will be the responsibility of the Clinical Supervisor through random record review and during individual supervision. |
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
Based on a request for client records, the facility failed to maintain a system for readily accessibility of records for four years following discharge of a client. All or parts of several clients records, both active and discharged clients, took up to four hours to locate once requested by the auditor.
This is a repeat citation from the June 6, 2024 licensing inspection.
This finding was reviewed with facility staff during the licensing inspection.
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Plan of Correction
On 01/14/2025, the Facility Director met with supervisory staff to review procedures for record retention. Supervisors will ensure that support staff maintain copies of records in a secure location for timely retrieval during an audit until the transition to a new EMR is completed. Ongoing compliance will be the responsibility of the QA Manager through weekly review of the appropriate maintenance and storage of all clinical records at the facility. |
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 data provided during the licensing inspection, the facility failed to develop a system that allows for efficient retrieval of data so the Department can measure the project's performance. Several requested lists of patients took over two hours to be provided to the auditor and did not contain all of the requested data.
This is a repeat citation from the June 6, 2024 licensing inspection.
This finding was reviewed with facility staff during the licensing inspection.
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Plan of Correction
0311: As of 1/22/2025, the Nursing Director oversaw creation of a tracking list of all the patients in the various categories requested by the Department for pre-submission prior to an audit. Beginning on 1/27/2025, during weekly team meetings, the Nursing Director and/or his/her designee will update the tracking list on an ongoing basis. The updated list will be available for presentation upon request by department auditors. Ongoing compliance will be the responsibility of the Clinical Supervisor through regular review of the tracking data collected during team meetings.
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709.34 (c) (2) 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:
(2) Death or serious injury due to trauma, suicide, medication error or unusual circumstances.
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Observations
Based on a review of client records, the facility failed to inform the Department of an unusual incident within the required three days. It was discovered that the facility became aware of an an unusual incident on October 22, 2024 which involved a recent death of a client. The incident was not reported to the Department.
This finding was reviewed with facility staff during the licensing inspection.
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Plan of Correction
On 01/13/2025, the Facility Director met with the treatment team to remind staff that all deaths, including deaths from ill health that are not due to serious injury, trauma, suicide, medication error or unusual circumstances, must be reported to the Department as an Unusual Incident. Clinical staff will notify the Nursing Director and/or the Facility Director of all patient deaths, including deaths due to illness, immediately upon receipt of notification of an active patient's death. On 2/03/2025 an Unusual Incident Report was submitted to the electronic portal for the death that occurred on 10/22/2024.Ongoing compliance with the reporting requirement will be the responsibility of the Facility Director and/or the Nursing Director.
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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 in one out of ten applicable records.
Patient #3 was admitted on October 10, 2024 and was still active at the time of the inspection.
This is a repeat citation from the June 6, 2024 licensing inspection.
The finding was reviewed with facility staff during the licensing inspection.
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Plan of Correction
The Facility Director has reminded Intake staff that evidence of the means used to verify a patient's identity, prior to admission, must be retained in the patient record. Beginning on 01/06/2025, Intake staff will scan the photo identification used to verify the applicant's identity and retain the verification in the patient record. Ongoing compliance with the requirement will be the responsibility of the nursing staff who will confirm that identity verification is included in the medical record prior to administration of the patient's first dose of medication. |
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 nine applicable records.
Patient #10 was admitted on September 16, 2024 and was still active at the time of the inspection.
This is a repeat citation from the June 6, 2024 licensing inspection.
The finding was reviewed with facility staff during the licensing inspection.
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Plan of Correction
On 01/10/2025, the Nursing Director reminded nursing staff of the requirement to maintain a photograph of each patient onsite. Dispensing staff will ensure that prior to administration of the first dose of medication, a current photograph of the patient will be taken and uploaded in the EMR. Ongoing compliance will be the responsibility of the Nursing Director through random review of dispensing screens to ensure that patient photographs are accurately included and updated every three years in the dispensing screen of the medical record.
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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 one out of five applicable records. The manual states the exam shall be completed within seven days after admission.
Patient #5 was admitted on August 21, 2024 and was still active at the time of the inspection. An initial physical examination was due by August 28, 2024; however, it was completed on September 20, 2024.
This is a repeat citation from the June 6, 2024 licensing inspection.
The finding was reviewed with facility staff during the licensing inspection.
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Plan of Correction
Beginning on 1/24/25 the Nursing Director will enter appointment reminders in the dispensing record and dispensing staff will remind clients of upcoming physicals scheduled for new admissions. Medical staff will document all "No Shows" for initial physical examinations to ensure that initial physical examinations are completed within the agency policy requirement. Monitoring ongoing compliance with the regulation will be the responsibility of the Nursing Director through review of the medical records of all new admissions. |
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 facility failed to document an annual physical examination within the timeframe stated in the facility's policy and procedures manual in four out of seven applicable records. The manual states the annual exam be conducted "during the anniversary month of admission throughout treatment".
Patient #6 was admitted on July 12, 2017 and was still active at the time of the inspection. An annual physical exam was due no later than July 31, 2024; however, it was completed on August 9, 2024.
Patient #12 was admitted on August 26, 2022 and discharged on October 2, 2024. An annual physical exam was due no later than August 31, 2024; however, none was completed.
Patient #13 was admitted on May 6, 2016 and was still active at the time of the inspection. An annual physical exam was due no later than May 31, 2024; however, it was completed on September 19, 2024.
Patient #14 was admitted on October 21, 2014 and was still active at the time of the inspection. An annual physical exam was due no later than October 31, 2024; however, none was completed.
These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
As of 1/24/25 the QA Manager will share due dates of upcoming annual physical examinations with the Nursing Director and/or his/her designee who will enter appointment reminders in the dispensing screen. Dispensing staff will remind clients of upcoming annual physicals scheduled. Medical staff will document all "No Shows" for annual physical examinations to ensure that annual physical examinations are completed within the agency policy requirement. Monitoring ongoing compliance with the regulation will be the responsibility of the QA Manager through review of the medical records of all active clients. |
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 facility failed to document an annual evaluation within the timeframe stated in the facility's policy and procedures manual in four out of five applicable records. The manual states the annual review be conducted "during the anniversary month of admission to treatment".
Patient #7 was admitted on November 24, 2004 and was still active at the time of the inspection. An annual evaluation was due on November 30, 2024; however, it was completed on December 11, 2024.
Patient #11 was admitted on September 22, 2021 and discharged on October 22, 2024. An annual evaluation was due on September 30, 2024; however, none was completed.
Patient #12 was admitted on August 26, 2022 and discharged on October 2, 2024. An annual evaluation was due on August 31, 2024; however, it was completed on September 16, 2024.
Patient #14 was admitted on October 21, 2014 and was still active at the time of the inspection. An annual evaluation was due on October 30, 2024; however, none was completed.
These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
On 01/24/2025, the Facility Director revised the Policy & Procedure manual to require that an Annual Evaluation of each patient's status in treatment will be completed by the counselor and will be reviewed, dated and signed by the Narcotic Treatment Physician within thirty days of the anniversary date of the patient's admission to treatment. Clinicians were notified of the requirement during treatment team meeting on 1/27/2025. Ongoing compliance will be the responsibility of the QA Manager through tracking of the completion of the documentation during ongoing audits of the clinical records. |
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 twelve applicable records reviewed.
Client #2 was admitted on July 10, 2024 and discharged on October 21, 2024. The September 30, 2024 treatment plan did not contain type of service.
Client #4 was admitted on November 14, 2024 and was still active at the time of the inspection. The December 5, 2024 comprehensive treatment plan did not list frequency of individual sessions.
Client #7 was admitted on November 24, 2004 and was still active at the time of the inspection. The November 6, 2024 treatment plan did not list type and frequency of service.
Client #14 was admitted on October 21, 2014 and was still active at the time of the inspection. The September 18, 2024 treatment plan did not indicate type or frequency of service.
This is a repeat citation from the June 6, 2024 licensing inspection.
These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
By 2/03/2025,The Clinical Supervisor will review the Treatment Plan template with clinicians during treatment team meeting to remind staff of the treatment plan requirement to include written documentation of type and frequency of treatment services outlined in the plan. The Clinical Supervisor will be responsible for ensuring ongoing compliance with the regulation during regular audit and approval of treatment plans submitted by clinicians. |
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 four out of thirteen applicable records.
Client #5 was admitted on August 21, 2024 and was still active at the time of the inspection. A treatment plan update was completed on September 25, 2024 and the next update was due no later than November 25, 2024; however, none was completed.
Client #6 was admitted on July 12, 2017 and was still active at the time of the inspection. A treatment plan update was completed on September 3, 2024 and the next update was due no later than November 3, 2024; however, none was completed.
Client #8 was admitted on November 7, 2018 and was still active at the time of the inspection. A treatment plan update was completed on July 10, 2024 and the next update was due no later than September 10, 2024; however, none was completed.
Client #11 was admitted on September 22, 2021 and discharged on October 22, 2024. A treatment plan update was completed on August 2, 2024 and the next update was due no later than October 2, 2024; however, none was completed.
This is a repeat citation from the June 6, 2024 and July 19, 2023 licensing inspections.
These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
The Clinical Supervisor reminded clinicians during Treatment Team meeting on 02/03/2024 of the requirement that treatment plans must be reviewed and updated at least every 60 days. The QA Manager will create a tracking record of Treatment Plan Review and Update due dates and will forward reminders to clinicians when the reviews and updates are due. The QA manager will be responsible for ensuring ongoing compliance with the regulation through audit of the records to verify that Treatment Plan Reviews and Updates have been completed every 60 days and will forward compliance reports to the Clinical Supervisor for ongoing follow up |
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 treatment plan in eight out of nine applicable records.
Client #3 was admitted on October 10, 2024 and was still active at the time of the inspection. A treatment plan dated October 25, 2024 indicated individual sessions twice a month. In November 2024, the client received one individual session.
Client #5 was admitted on August 21, 2024 and was still active at the time of the inspection. An August 27, 2024 treatment plan indicated group sessions weekly and individual sessions daily. Between September 1 - December 18, 2024, there was no group sessions documented. There were no individual sessions September 11-19, September 21-23, September 26-30, October 2-7, October 9-14, October 16-28, October 30-November 5, November 7, and November 9-22, 2024.
Client #6 was admitted on July 12, 2017 and was still active at the time of the inspection. The September 3, 2024 treatment plan indicated individual sessions every two months. Between August 1 - October 31, 2024, the client received one individual session.
Client #9 was admitted on September 20, 2024 and was still active at the time of the inspection. The October 23, 2024 treatment plan indicated 2.5 hours of therapy per month. In October and November, 2024, the client received 60 minutes of individual therapy each of those months.
Client #10 was admitted on September 16, 2024 and was still active at the time of the inspection. The September 16, 2024 treatment plan indicated individual and group therapy totaling 2.5 hours per month. In October 2024, the client had two no show appointments scheduled for 60 minutes each with no group sessions.
Client #11 was admitted on September 22, 2021 and discharged on October 22, 2024. An August 2, 2024 progress note indicated weekly counseling sessions. There were no sessions between August 3 - October 22, 2024.
Client #12 was admitted on August 26, 2022 and discharged on October 2, 2024. A July 17, 2024 treatment plan indicated weekly group sessions. There were no group sessions September 8-14, and September 23-28, 2024.
Client #13 was admitted on May 6, 2016 and was still active at the time of the inspection. A July 19, 2024 progress note indicated weekly group sessions. There were no group sessions from August 6-December 18, 2024.
This is a repeat citation from the June 6, 2024 licensing inspection.
These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
By 02/03/2025, the Clinical Supervisor will review the regulatory requirement with the clinical staff to ensure that services are provided in accordance with the service goals outlined in the treatment plan and in the treatment plan updates and amendments. The Clinical Supervisor will remind clinicians of the importance of documenting when a patient is a "no show" for a treatment service as well as ensuring that documentation of any change in the type and/or frequency of the service is documented in the record. Ongoing compliance with the regulation will be the responsibility of the QA Manager who will review treatment plans and the record of service to ensure that services are being provided and documented in accordance with the Individual Treatment Plans, Updates and Amendments. |
709.93(a)(3) 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:
(3) Record of services provided.
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Observations
Based on a review of client records, the facility failed to document a record of services provided, as the record of services were incomplete in three out of three applicable records.
Client #7 was admitted on November 24, 2004 and was still active at the time of the inspection.
Client #11 was admitted on September 22, 2021 and discharged on October 22, 2024.
Client #13 was admitted on May 6, 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 01/27/2025, the Nursing Director reminded staff to complete the Record of Service in the clinical record after any service has been provided. The Clinical Supervisor will be responsible for monitoring ongoing compliance with the requirement through regular audit of the clinical record and by reminding clinicians to meet the requirement during individual and group supervision meetings. |
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 six out of eight applicable records. The manual states a consultation needs to be completed within the first 90 days and annually thereafter.
Client #5 was admitted on August 21, 2024 and was still active at the time of the inspection. A case consultation was due no later than November 21, 2024. There was no consultation documented.
Client #7 was admitted on November 24, 2004 and was still active at the time of the inspection. The case consultation documented on December 11, 2024 only had one person present.
Client #10 was admitted on September 16, 2024 and was still active at the time of the inspection. The case consultation documented on December 5, 2024 only had one person present.
Client #11 was admitted on September 22, 2021 and discharged on October 22, 2024. There was no annual consultation documented within the last year at the time of the inspection.
Client #12 was admitted on August 26, 2022 and discharged on October 2, 2024. The annual consultation only had one person present.
Client #14 was admitted on October 21, 2014 and was still active at the time of the inspection. There was no annual consultation documented within the last year at the time of the inspection.
This is a repeat citation from the June 6, 2024 licensing inspection.
These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
1905: By 01/13/2025, the Clinical Supervisor will review the regulation and the requirement to document a Case Consultation every ninety days during the first year of treatment and annually thereafter as well as the requirement to document all individuals present during the Case Consultation.
The QA Manager will be responsible for monitoring ongoing compliance with the regulation through tracking and sending monthly reminders of upcoming due dates to clinicians on an ongoing basis. The Clinical Supervisor will be responsible for ensuring ongoing compliance with the regulations through random audit of the Case Consultation records and during individual and group supervision.
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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 treatment plan updates was submitted and approved by the Department for the July 19, 2023 and June 6, 2024 licensing inspections. Treatment plan updates were again found to be deficient in the December 18, 2024 licensing inspection.
These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
By 02/03/2025, the Facility Director will meet with the Treatment Team to review the Plans of Correction submitted to the Department in response to the licensing audit on 12/18/2024. The Plans of Correction will also be addressed during individual supervision meetings by the Clinical Supervisor. On 01/30/2025, the Facility Director shared the Plans of Correction with the new QA manager to ensure that staff compliance with the plans will be monitored on an ongoing basis. The Performance Improvement Committee will be responsible for reviewing compliance with the plans during monthly PI Meetings to ensure ongoing compliance with the regulations.
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