INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection and methadone monitoring conducted on June 28, 2021 through June 30, 2021 by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, Northeast Family Health Care, LLC was found not to be in compliance with the applicable chapters of 28 PA Code which pertain to the facility. The following deficiencies were identified during this inspection:
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Plan of Correction
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704.11(b)(1) LICENSURE Individual training plan.
704.11. Staff development program.
(b) Individual training plan.
(1) A written individual training plan for each employee, appropriate to that employee's skill level, shall be developed annually with input from both the employee and the supervisor.
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Observations
Based on a review of personnel records, the facility failed to document an annual written individual training plan for each employee, appropriate to that employee's skill level, with input from both the employee and the supervisor in one of nine personnel records reviewed.
Employee # 7 was hired as counselor on October 7, 2017. There was no individual training plan documented, for the facility's 2019 training year, in the personnel record at the time of the inspection.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
Currently and moving forward, all staff will complete annual training plan and job descriptions at the time of annual focus reviews every February. Previously this was done on anniversary date of staff. Staff member in question is on leave, should they return, will complete a written training plan at their date of return. To ensure this does not re occur all training plans are conducted annually as part of the focus review requirements. |
704.11(c)(1) LICENSURE Mandatory Communicable Disease Training
704.11. Staff development program.
(c) General training requirements.
(1) Staff persons and volunteers shall receive a minimum of 6 hours of HIV/AIDS and at least 4 hours of tuberculosis, sexually transmitted diseases and other health related topics training using a Department approved curriculum. Counselors and counselor assistants shall complete the training within the first year of employment. All other staff shall complete the training within the first 2 years of employment.
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Observations
Based on a review of personnel records, the facility failed to ensure that all staff persons received a minimum of 6 hours of HIV/AIDS training and at least 4 hours of TB/STD and other health related topics within the regulatory timeframe in two of five applicable personnel records reviewed.
Employee # 5 was hired as a counselor on June 1, 2020 and was due to have HIV/AIDS training and TB/STD training no later than June 1, 2021. There was no documentation of the HIV/AIDS training and the TB/STD and other health related topics training being completed in the personnel record at the time of the inspection.
Employee # 6 was hired as a counselor on May 20, 2020 and was due to have TB/STD training no later than May 20, 2021. There was no documentation of the TB/STD and other health related topics training being completed in the personnel record at the time of the inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
NEFHC will use DDAP approved curriculum. This based on licensing alert 1-97 and 6-67 provided by surveyor. Director and clinical supervisor will ensure all new staff obtain required training within 7 days of hire. |
705.28 (c) (4) LICENSURE Fire safety.
705.28. Fire safety.
(c) Fire extinguishers. The nonresidential facility shall:
(4) Instruct staff in the use of the fire extinguisher upon staff employment. This instruction shall be documented by the facility.
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Observations
Based on a review of personnel records, the facility failed to instruct all staff in the use of the fire extinguisher upon employment in two of four applicable personnel records reviewed.
Employee # 4 was hired as a counselor on August 12, 2019. The personnel record documented that the fire extinguisher training was not completed until February 19, 2020.
Employee # 8 was hired as a counselor assistant on August 17, 2020. The personnel record documented that the fire extinguisher training was not completed until December 1, 2020.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
NEFHC will train all new hires on fire safety and fire extinguishers within 7 days of hire. This will be noted in personnel file signed by CS or ED and new hire. Personnel in reference will receive fire extinguisher training by 8/6/2021. All staff complete training in Relias as new hires as well. |
705.28 (d) (3) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(3) Ensure that all personnel on all shifts are trained to perform assigned tasks during emergencies.
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Observations
Based on a review of personnel records, the facility failed to ensure that all personnel on all shifts were trained to perform assigned tasks during emergencies in two of four applicable personnel records reviewed.
Employee # 4 was hired as a counselor on August 12, 2019. The personnel record documented that the training to perform assigned tasks during emergencies was not completed until February 19, 2020.
Employee # 8 was hired as a counselor assistant on August 17, 2020. The personnel record documented that the training to perform assigned tasks during emergencies was not completed until December 1, 2020.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
NEFHC will train all new hires on fire safety and fire extinguishers within 7 days of hire. This will be noted in personnel chart. Personnel in reference will sign off on training by 8/6/2021 signed off by CS/ED and personnel. All staff are required to attend training on Relias at hire and annually.
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705.28 (d) (4) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(4) Maintain a written fire drill record including the date, time, the amount of time it took for evacuation, the exit route used, the number of persons in the facility at the time of the drill, problems encountered and whether the fire alarm or smoke detector was operative.
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Observations
Based on a review of the facility's July 2019 through May 2021 fire drill log, the facility failed to ensure that their written fire drill log included the amount of time it took for evacuation and whether the fire alarm or smoke detector was operative. The April 2020 and September 2020 fire drill logs were missing whether the fire alarm or smoke detector was operative, while the July 2020 fire drill log was missing the whether the fire alarm or smoke detector was opeative and the amount of time it took for evacuation.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
NEFHC transitioned drills from paper to electronic versions. All boxes on the new version require a responses to complete. This new process will eliminating risk of missed documentation required. |
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 applicable client records reviewed.
Client # 1 was admitted on February 22, 2021 and was still active at the time of the inspection. There was evidence of a disclosure to a physician on February 24, 2021; however, the consent to release information form was signed by the client on March 17, 2021.
Client # 3 was admitted on April 30, 2020 and was still active at the time of the inspection. There was evidence of disclosures to the funding source during the client's treatment episode; however, there was no consent to release information form signed by the client documented in the record prior to any of the disclosures.
Client # 4 was admitted on May 16, 2019 and was discharged on September 10, 2020. There was evidence of disclosures to the funding source during the client's treatment episode; however, there was no current consent to release information form signed by the client documented in the record prior to any of the disclosures.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Client #1 best practice at Pinnacle is to obtain all related information at intake for coordinating care as applicable. There is no formal evidence of disclosure noted in this patient chart. There is a letter/form prepared in patient chart to physician, though no physical evidence of disclosure noted on 2/24/21 or after. Release was signed on 3/17/21 at that time and to date the letter has not been sent. Moving forward the facility will continue to gather information as needed at time of intake. If information is disclosed evidence of disclosure will be noted separately as PHI disclosure and or faxed documentation scanned to patient chart. The formal letter and consent will be sent to the physician after consent is signed and uploaded to the patient record.
Director will ensure confidentiality and release of information training is conducted as review for all staff on 7/26/21 in all staff team meetings.
Findings were reviewed, however director was not informed prior to exit interview and could have demonstrated compliance in this area.
Facility will continue to offer support navigating the EHR as applicable.
Client #3 During time in question, the facility as well as others experienced a global pandemic. Pinnacle had decided for the safety of staff and patients to reduce the risk of exposure and transmission of COVID-19 to remove signature pad options and obtain verbal consents from patients. Releases in this patient chart were conducted using verbal consent noted in patient signature. Facility has resumed obtaining consents with patient formal signatures upon determination of safety for the patients and staff. Patients record will be updated by counselor to have current releases with physical signature by August 6th
Client #4 Upon review of record, at the time patient was in treatment the releases were in place and active. Previous EHR upon patient discharge will relocate the releases to an "expired" section. Patient releases will be scanned in new EHR and new releases obtained by August 6th.
Findings were reviewed, however director was not informed prior to exit interview and could have demonstrated compliance in this area.
Facility will continue to offer support navigating the EHR as applicable.
Facility will continue to ensure confidentiality of patients and comply with regulations. All staff complete annual trainings on documentation and confidentiality and will continue this process as well as receive an overview training in team meeting on 7/26/21. |
709.28 (c) (4) 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:
(4) Dated signature of client or guardian as provided for under 42 CFR 2.14(a) and (b) and 2.15 (relating to minor patients; and incompetent and deceased patients).
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Observations
Based on a review of client records, the facility failed to document the dated signature of the client on release of information forms in two of seven client records reviewed.
Client # 3 was admitted on April 30, 2020 and was still active at the time of the inspection. The release of information forms to the funding source, a physician, several government agencies, and an emergency contact were signed and dated by the witness on April 30, 2020, but none of the forms documented the dated signature of the client. Additionally, the release of information form to a social service provider was signed and dated by the witness on May 15, 2020, but it did not document the dated signature of the client.
Client # 4 was admitted on May 16, 2019 and was discharged on September 10, 2020. The release of information forms to the funding source, several government agencies, and an emergency contact were signed and dated by the witness on May 12, 2020, but none of the forms documented the dated signature of the client.
These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
Due to the global pandemic, for the safety of staff and patients, and to reduce the risk of transmissions of COVID-19, Pinnacle was obtaining verbal consents. At the time in question, NEFHC was obtaining verbal consents from patients in treatment and chart documents "verbal consent" on patient signature line.
NEFHC has resumed obtaining patient signatures formally, following period of reduced risk determination. All patient charts with verbal consent ROIs will be updated by 9/1/21. For patients audited this will occur by 8/6/21
Director and clinical supervisor will ensure confidentiality and release of information training is conducted as review for all staff on 7/26/21 in all staff team meetings.
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709.28 (c) (5) LICENSURE Confidentiality
§ 709.28. Confidentiality.
(c) The project shall obtain an informed and voluntary consent from the client for the disclosure of information contained in the client record. The consent must be in writing and include, but not be limited to:
(5) Dated signature of witness.
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Observations
Based on a review of client records, the facility failed to document the dated signature of the witness at the same time as the client on release of information forms in one of seven client records reviewed.
Client # 1 was admitted on February 22, 2021 and was still active at the time of the inspection. The release of information forms to the emergency contact, the billing company, several government agencies, and another treatment provider were signed by the client on February 22, 2021; however, they were not signed by the witness until February 23, 2021.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
NEFHC will ensure proper and completed releases are noted to patients chart. Witness will complete a signature following patients permission on the same day of the release. This release will be updated with counselor by 8/6/21
Director and clinical supervisor will ensure confidentiality and release of information training is conducted as review for all staff on 7/26/21 in all staff team meetings.
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709.28 (c) (6) LICENSURE Confidentiality
§ 709.28. Confidentiality.
(c) The project shall obtain an informed and voluntary consent from the client for the disclosure of information contained in the client record. The consent must be in writing and include, but not be limited to:
(6) Date, event or condition upon which the consent will expire.
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Observations
Based on a review of client records, the facility failed to document the date, event or condition upon which the consent will expire on a consent to release information form in two of seven client records reviewed.
Client # 1 was admitted on February 22, 2021 and was still active at the time of the inspection. The release of information form to the billing company was signed and dated by the client on February 22, 2021; however, the form failed to document the date, event or condition upon which the consent will expire.
Client # 6 was admitted on November 24, 2020 and was discharged on June 15, 2021. The release of information form to the billing company was signed and dated by the client on May 12, 2021; however, the form failed to document the date, event or condition upon which the consent will expire.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Pinnacle updated the EHR system to reflect increased prompting for the completion of releases of information. All staff completing releases will ensure that each release has documented the date, event, or condition upon which the consent will expire. This patient in question will have an updated release with counselor by 8/6/2021
Director and clinical supervisor will ensure confidentiality and release of information training is conducted as review for all staff on 7/26/21 in all staff team meetings.
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709.33 (b) LICENSURE Notification of termination.
§ 709.33. Notification of termination.
(b) The client shall have an opportunity to request reconsideration of a decision terminating treatment.
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Observations
Based on a review of client records, the facility failed to provide an involuntarily terminated client with an opportunity to request reconsideration of the facility's decision to terminate treatment in one of one applicable client records reviewed.
Client # 4 was admitted on May 16, 2019 and was administratively discharged on September 10, 2020. There was no documentation in the client record indicating that the client was given the opportunity to request reconsideration of the decision to terminate treatment.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
NEFHC patient handbook is provided to all patients at admission which notes patient rights. Patient rights are posted in the lobby for all patients access. Patient in question was able to be successfully transferred without disruption to her treatment. The New EHR administrative discharge letter includes a sentence about patients right to appeal. NEFHC staff will present at administrative discharge and note to chart patients right to appeal and when applicable/available patient will sign letter in patient chart. If patient is unavailable to sign and at all administrative discharges, a letter will be sent to patients home and uploaded to the patient chart. |
715.9(a)(4) 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:
(4) Have a narcotic treatment physician make a face-to-face determination of whether an individual is currently physiologically dependent upon a narcotic drug and has been physiologically dependent for at least 1 year prior to admission for maintenance treatment. The narcotic treatment physician shall document in the patient 's record the basis for the determination of current dependency and evidence of a 1 year history of addiction.
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Observations
Based on a review of patient records, the facility failed to have a narcotic treatment physician make a face-to-face determination of whether an individual is currently physiologically dependent upon a narcotic drug and has been physiologically dependent for at least 1 year prior to admission for maintenance treatment in two of four applicable patient records reviewed.
Patient # 3 was admitted on April 30, 2020 and was still active at the time of the inspection. The patient record documented that the initial face-to-face determination of whether an individual is currently physiologically dependent upon a narcotic drug and has been physiologically dependent for at least 1 year was conducted via telehealth services, not in person.
Patient # 6 was admitted on November 24, 2020 and was still discharged on June 15, 2021. The patient record documented that the initial face-to-face determination of whether an individual is currently physiologically dependent upon a narcotic drug and has been physiologically dependent for at least 1 year was conducted via telehealth services, not in person.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Considering the global pandemic, NEFHC implemented social distancing protocols per CDC guidelines, for the safety of patients and staff. At time in question, providers conducted hybrid physical exams. The provider used video technology to conduct a portion of the exam and a portion was conducted face to face. The patient is located in a kiosk room with video and computer while the provider is in a separate office space using the same equipment. The provider conducts a face to face determination of dependency as well as vital assessment as part of the hybrid exam. Physicals will continue to be hybrid, however the provider will clearly document to reflect process of the face to face determination in patient chart. |
715.12(1-5) LICENSURE Informed patient consent
A narcotic treatment program shall obtain an informed, voluntary, written consent before an agent may be administered to the patient for either maintenance or detoxification treatment. The following shall appear on the patient consent form:
(1) That methadone and LAAM are narcotic drugs which can be harmful if taken without medical supervision.
(2) That methadone and LAAM are addictive medications and may, like other drugs used in medical practices, produce adverse results.
(3) That alternative methods of treatment exist.
(4) That the possible risks and complications of treatment have been explained to the patient.
(5) That methadone is transmitted to the unborn child and will cause physical dependence.
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Observations
Based on a review of patient records, the facility failed to obtain an informed, voluntary, written consent before an agent may be administered to the patient for either maintenance or detoxification treatment in one of four applicable patient records reviewed.
Patient # 3 was admitted on April 30, 2020 and was still active at the time of the inspection. The patient record documented that the informed, voluntary consent was obtained verbally and not in writing.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
As a result of global pandemic, NEFHC, for the safety of patients and staff obtained verbal consents. This was in place to reduce the risk of exposure and transmission of COVID 19. NEFHC has since resumed obtaining formal patient signatures and will continue this process. All verbal consents will be re done by 9/1/21 to collect the physical signature of patients. The charts references in audit will be completed by 8/6/21. Clinical Supervisor will monitor via monthly chart audits the successful completion of ROIs. New EHR has started an intake checklist to ensure all documents are completed at intake completed by the clinical supervisor. This patient record will update the informed consent to obtain physical signature by 8/6/2021. |