INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection and methadone monitoring conducted on July 21, 2022 through July 22, 2022 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 complete an informed and voluntary consent to release information form prior to the disclosure of information in three of seven client records reviewed.Client # 1 was admitted on November 18, 2021 and was still active at the time of the inspection. There was evidence of a disclosure to another treatment provider on November 23, 2021; however, there was no consent to release information form signed by the client documented in the record prior to the disclosure. Client # 4 was admitted on September 18, 2020 and was discharged on February 3, 2022. The release of information forms to the funding source and the laboratory were signed by the client and witness on September 15, 2020 and they expired on September 15, 2021. There was evidence of disclosures to the funding source and the laboratory after the release of information forms expired; however, there were no updated consent to release information forms signed by the client documented in the record prior to any of the disclosures after September 15, 2021. Client # 6 was admitted on July 1, 2015 and was discharged on March 16, 2022. The release of information forms to the funding source and the laboratory were signed by the client and witness on May 1, 2020 and they expired on May 1, 2021. There was evidence of disclosures to the funding source and the laboratory after the release of information forms expired; however, there were no updated consent to release information forms signed by the client documented in the record prior to any of the disclosures after May 1, 2021. This is a repeat citation from the October 28, 2021, May 12, 2021, and November 20, 2019 annual licensing renewal inspections.This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
On 07/28/22 the Clinical Supervisor met with clinical staff and reviewed confidentiality regulations and the requirement to obtain client's written consent prior to disclosure of protected treatment information and to update all consents annually. Beginning on 08/23/2022 the Clinical Supervisor will be responsible for addressing failure to follow requirements during individual supervision with staff who have not consistently followed the regulation. Ongoing compliance with the requirement will be monitored and addressed by the Clinical Supervisor during bi-weekly individual supervision and random record review. |
715.19(1) LICENSURE Psychotherapy services
A narcotic treatment program shall provide individualized psychotherapy services and shall meet the following requirements:
(1) A narcotic treatment program shall provide each patient an average of 2.5 hours of psychotherapy per month during the patient 's first 2 years, 1 hour of which shall be individual psychotherapy. Additional psychotherapy shall be provided as dictated by ongoing assessment of the patient.
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Observations
Based on a review of patient records, the facility failed to provide an average of 2.5 hours of psychotherapy per month during the patient's first 2 years in treatment in two of four applicable patient records reviewed. Patient # 3 was admitted on February 7, 2022 and was still active at the time of the inspection. The record of service and progress notes documented that during the following months less than 2.5 hours of psychotherapy per month was provided to the patient: March 2022: 0 hours of psychotherapy; April 2022: 30 minutes of psychotherapy; May 2022: 0 hours of psychotherapy; and June 2022: 1 hour of psychotherapyPatient # 4 was admitted on September 18, 2020 and was discharged on February 3, 2022. The record of service and progress notes documented that less than 2.5 hours of psychotherapy per month was provided to the patient in December 2021, when only 1 hour of psychotherapy was documented in the record.This is a repeat citation from the October 28, 2021 and May 12, 2021 annual licensing renewal inspections.This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
Beginning on 8/01/2022, billing staff will audit monthly counseling hours for compliance with the regulatory requirement of 2.5 hours of counseling for individuals enrolled in the program for less than two years. Monthly reports of counseling hours will be provided to the Clinical Supervisor. The Clinical Supervisor will be responsible for ensuring ongoing compliance through addressing staff compliance with the regulation and reviewing staff interventions to meet the counseling requirement during bi-weekly individual supervision.
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715.19(3) LICENSURE Psychotherapy services
A narcotic treatment program shall provide individualized psychotherapy services and shall meet the following requirements:
(3) After 4 years of treatment, a narcotic treatment program shall provide each patient with at least 1 hour of group or individual psychotherapy every 2 months. Additional psychotherapy shall be provided as dictated by ongoing assessment of the patient.
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Observations
Based on a review of patient records, the facility failed to provide at least 1 hour of group or individual psychotherapy every 2 months after 4 years of treatment in two of three applicable patient records reviewed. Patient # 2 was admitted on June 28, 2017 and was still active at the time of the inspection. The record of service and progress notes showed that only 1 hour 30 minutes of group or individual psychotherapy was provided during the months of March 2022 through June 2022.Patient # 6 was admitted on July 1, 2015 and was discharged on March 16, 2022. The record of service and progress notes showed that only 1 hour of group or individual psychotherapy was provided during the months of November 2021 through March 2022.This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
Beginning on 8/01/2022 billing staff will audit counseling hours for compliance with the regulatory requirement of at least 1 hour of counseling every two months for individuals enrolled in the program for four years. Monthly reports of counseling hours will be provided to the Clinical Supervisor. The Clinical Supervisor will be responsible for ensuring ongoing compliance through addressing staff compliance with the regulation and reviewing staff interventions to meet the counseling requirement during bi-weekly individual supervision. |
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 a review of patient records, the narcotic treatment program failed to document, in writing, that it notified the transferring narcotic treatment program of the date of the admission of the patient and the date of the initial dose given to the patient in one of one applicable patient records reviewed. Patient # 1 was transferred in and admitted on November 18, 2021 and was still active at the time of inspection. There was documentation in the record that the transferring narcotic treatment program was notified of the date of admission on November 23, 2021; however, the documentation did not include the date the initial dose was given. This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
On 08/22/2022, the Nursing Director reminded nursing staff to document in the electronic record that confirmation of the date of admission and the date of the first dose given to individuals transferred in to the clinic has been provided to the transferring clinic. The Nursing Director will be responsible for ensuring ongoing compliance with the requirement by reviewing the record of all clients transferred in to the program on the date of transfer, to ensure that the date of admission and the date of first dose has been provided to the referring clinic and that the confirmation has been documented in the client record. |
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 ensure that an annual evaluation of the patient's status was completed by the patient's counselor and was reviewed, dated and signed by the medical director in one of four applicable patient records reviewed. Patient # 2 was admitted on June 28, 2017 and was still active at the time of the inspection. The annual evaluation of the patient's status was completed by the counselor on June 30, 2022; however, the evaluation did not address the client's legal standing, fulfillment of treatment objectives, family and community support and the evaluation was not signed by the medical director. This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
On 07/28/2022, the Clinical Supervisor reminded staff that the Annual Evaluation of each client's status must include all of the required criteria including the client's legal standing, fulfillment of treatment objectives and the client's family and community supports. The Clinical Supervisor also reminded staff that the Annual Review must be reviewed, dated and signed by the Medical Director.
The Facility Director revised the Annual Review template used by the clinicians to ensure that the evaluation included all of the components required by the regulation. The Clinical Supervisor will be responsible for distribution of the revised Annual Review template to all clinicians and ensuring ongoing compliance with the regulation through random record review and during bi-weekly individual supervision. The revised Annual Review for Patient #2 will be completed by the counselor and reviewed and signed by the Medical Director by 08/26/2022. |
709.17(a)(3) LICENSURE Subchapter B.Licensing Procedures.Refusal/rev
709.17. Refusal or revocation of license.
(a) The Department may revoke or refuse to issue a license for any of the following reasons:
(3) Failure to comply with a plan of correction approved by the Department, unless the Department approves an extension or modification of the plan of correction.
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Observations
Based on a review of administrative documents, the facility failed to comply with plans of correction that were approved by the Department. A plan of correction for failing to complete an informed and voluntary consent to release information form prior to the disclosure of information was submitted and approved by the Department for the October 28, 2021, May 12, 2021 and November 20, 2019 annual licensing inspections. Failing to complete an informed and voluntary consent to release information form prior to the disclosure of information was again found to be a deficiency in the July 21, 2022 through July 22, 2022 licensing inspection.Additionally, a plan of correction for failing to provide an average of 2.5 hours of psychotherapy per month during the patient's first 2 years in treatment was submitted and approved by the Department for the October 28, 2021 and May 12, 2021 annual licensing inspections. Failing to provide an average of 2.5 hours of psychotherapy per month during the patient's first 2 years in treatment was again found to be a deficiency in the July 21, 2022 through July 22, 2022 licensing inspection.This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
As of 8/23/2022, the Facility Director has advised the Clinical Supervisors that failure to complete informed and voluntary consent to release confidential information prior to disclosure of information has been a repeated non-compliance with plans of correction approved by the Department. The Supervisors were also advised of repeated non-compliance with plans of correction approved by the Department to ensure that counseling hour requirements were met.
The updated plans of correction to address the non-compliance with these standards were reviewed by the Facility Director with the supervisors. The Facility Director will provide quarterly training for clinical staff to review the regulations as well as to review strategies to ensure compliance. The Clinical Supervisors will be responsible for monitoring ongoing compliance through regular record review and during individual clinical supervision.
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