INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection and methadone monitoring conducted on September 19, 2024 and September 20, 2024, 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 Healthcare, 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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704.9(c) LICENSURE Supervised Period
704.9. Supervision of counselor assistant.
(c) Supervised period.
(1) A counselor assistant with a Master's Degree as set forth in 704.8 (a)(1) (relating to qualifications for the position of counselor assistant) may counsel clients only under the close supervision of a trained counselor or clinical supervisor for at least the first 3 months of employment.
(2) A counselor assistant with a Bachelor's Degree as set forth in 704.8 (a)(2) may counsel clients only under the close supervision of a trained counselor or clinical supervisor for at least the first 6 months of employment.
(3) A registered nurse as set forth in 704.8 (a)(3) may counsel clients only under the close supervision of a trained counselor or clinical supervisor for at least the first 6 months of employment.
(4) A counselor assistant with an Associate Degree as set forth in 704.8 (a)(4) may counsel clients only under the close supervision of a trained counselor or clinical supervisor for at least the first 9 months of employment.
(5) A counselor assistant with a high school diploma or GED equivalent as set forth in 704.8 (a)(5) may counsel clients only under the direct observation of a trained counselor or clinical supervisor for the first 3 months of employment. For the next 9 months, the counselor assistant may counsel clients only under the close supervision of a lead counselor or a clinical supervisor.
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Observations
Based on a review of seven personnel records, the facility failed to ensure that two counselor assistants were counseling clients under the supervision of a trained counselor or clinical supervisor based on their education. Employee # 5 was promoted to the position of counselor assistant on March 31, 2024. Employee # 5 had a Bachelor ' s degree at the time of promotion and may counsel clients only under the direct observation of a trained counselor or clinical supervisor for the first six months of employment. The supervision notes provided at the time of the inspection did not indicate that direct observation of the provision of counseling services was a part of the close supervision. Employee # 7 was promoted to the position of counselor assistant on May 8, 2024. Employee # 7 had a Bachelor ' s degree at the time of promotion and may counsel clients only under the direct observation of a trained counselor or clinical supervisor for the first six months of employment. The supervision notes provided at the time of the inspection did not indicate that direct observation of the provision of counseling services was a part of the close supervision. Close supervision is defined by regulation as follows: "Formal documented case review and an additional hour of direct observation by a supervising counselor or a clinical supervisor once a week."Direct observation is defined by regulation as follows: "In person observation of staff working in a clinical setting for the purpose of planning, oversight, monitoring and evaluating their activities." In accordance with 28 Pa. Code 704.9(a), a counselor assistant must be supervised by a fulltime clinical supervisor or a full-time counselor. The fully qualified clinical supervisor or counselor is then responsible for weekly supervision notes relating to the counselor assistant. Clear documentation in the weekly notes and in the pertinent client charts must also demonstrate that direct observation is occurring.This is a repeat citation from the November 6, 2023 annual licensing renewal inspection. These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Executive Director and Clinical Supervisor have been retrained on requirements for supervision on 10/10/2024. ED and CS will ensure that personnel categorized as Counselor Assistants are receiving direct observation which will be documented in the clinical supervision note. Staff status will be reviewed for appropriateness to change to counselor from counselor assistant. |
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 provide a written individual training plan for each employee, that documented it was developed annually in three out of seven personnel records reviewed.Employee # 4 has been in the position of counselor assistant since July 25, 2022. The record did not contain documentation of an individual training plan.Employee # 5 has been in the position of counselor assistant since March 31, 2024. The record did not contain documentation of an individual training plan.Employee # 6 has been in the position of counselor assistant since September 6, 2022. The record did not contain documentation of an individual training plan.This finding was reviewed with the facility staff during the licensing process.
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Plan of Correction
All employees will work with Executive Director and Clinical Supervisor to develop annual, individual training plans. Annual goals will be tracked via chart audits, staff retraining and a calendar reminder system will be developed to assess goals twice per year. |
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 seven personnel records and the facility's Staffing Requirement Facility Summary Report (SRFSR) form, the facility failed to ensure that one employee received the minimum of 6 hours of HIV/AIDS training within the regulatory timeframe.Employee # 3 was promoted to the position of counselor on May 1, 2023 and was due to have the communicable disease trainings no later than May 1, 2024. However, there was no documentation of the completion of the HIV/AIDS training as of the date of the inspection.This is a repeat citation from the November 6, 2023 annual licensing renewal inspection. The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
All employees will ensure that they are meeting training requirements. Employee #3 contacted DDAP to obtain record of her training completion certificate. Due to a change in the website it was not able to be obtained. The training will be repeated no later than 10/31/2024. All staff have been retrained on requirements. Staff are required to maintain their training records in addition to providing the completion certificates to the Executive Director to be maintained in employee records. Clinical Supervisor will assist counselors in ensuring they are meeting training requirements. |
705.26 (2) LICENSURE Heating and cooling.
705.26. Heating and cooling.
The nonresidential facility:
(2) May not permit in the facility heaters that are not permanently mounted or installed.
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Observations
Based on a physical plant inspection on September 20, 2024, the facility failed to ensure that heaters were permanently mounted as a space heater was found in the Facility Director ' s office. These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Heaters will be removed from the facility. If they are found to be required due to limitations of the building HVAC system, an exception will be requested. Executive Director will include checking for heaters in semi-annual physical plant checks to ensure they are not present or that an exception is requested if needed. |
705.28 (d) (1) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(1) Conduct unannounced fire drills at least once a month.
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Observations
Based on a review of fire drill logs from December 2023 through July 2024, the facility failed to conduct unannounced fire drills during December 2023 and January 2024.This is a repeat citation from the November 6, 2023 annual licensing renewal inspection. The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Executive Director and/or Health and Safety Officer will ensure that fire drills are conducted on a monthly basis and documented as required. All leadership staff have been retrained on conducting monthly fire drills. |
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 nine client records, the facility failed to obtain an informed and voluntary consent from the client for the disclosure of information in four records reviewed. Client # 2 was admitted on February 14, 2024 and was active at the time of the inspection. The record contained documentation of a disclosure of information to another treatment provider on February 15, 2024, however, the client did not sign a consent to release information form to the treatment provider until March 5, 2024.Client # 5 was admitted on March 29, 2019 and was discharged on June 20, 2024. Per a discussion with the Facility Director, information such as the client's diagnosis was disclosed to the funding source; however, the consent to release information form to the funding source signed by the client on March 14, 2024, did not allow for the release of that information.Client # 7 was admitted on June 10, 2024 and was active at the time of the inspection. The consent to release information form to the funding source was not signed until June 18, 2024; however, there was evidence of billing prior to the client signed consent to release information form.Client # 9 was admitted on May 1, 2024 and was active at the time of the inspection. The record did not contain a client signed consent to release information form to the funding source; however, there was evidence of billing.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Informed and voluntary consent forms will be obtained upon intake, by intake counselor, for all patients. Consents will include any and all information to be released. Retraining of all staff on informed and voluntary consent was provided on 10/2/2024. Executive Director and Clinical Supervisor will perform intake chart audit within 7 days of intake. Client #9 will sign completed ROI upon next counseling session, no later than 10/31/2024. |
709.28 (c) (2) LICENSURE Confidentiality
§ 709.28. Confidentiality.
(c) The project shall obtain an informed and voluntary consent from the client for the disclosure of information contained in the client record. The consent must be in writing and include, but not be limited to:
(2) Specific information disclosed.
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Observations
Based on a review of nine client records, the facility failed to ensure that informed and voluntary consent to release information forms included the specific information to be disclosed in one record reviewed.Client # 6 was admitted on April 10, 2024 and was active at the time of the inspection. The record contained a consent to release information form to the funding source signed by the client on April 10, 2024, that was missing the specific information to be disclosed.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Informed and voluntary consents will be obtained at intake, by intake counselor, and throughout treatment episode as needed. Release of information to funding source will include all information needed for proper billing. Executive Director and/or Clinical Supervisor will preform an intake chart audit within 7 days of intake to ensure proper completion of all forms. Staff has been retrained on items to be included in ROI's on 10/9/2024. Client #6 will have a revised ROI completed no later than 10/22/2024. |
709.32 (b) LICENSURE Medication control
§ 709.32. Medication control.
(b) Verbal orders for medication can be given only by a physician or other medical professional authorized by State and Federal law to prescribe medication and verbal orders may be received only by another physician or medical professional authorized by State and Federal law to receive verbal orders. When a verbal or telephone order is given, it has to be authenticated in writing by a physician or other medical professional authorized by State and Federal law to prescribe medication. In detoxification levels of care, written authentication shall occur no later than 24 hours from the time the order was given. Otherwise, written authentication shall occur within 3 business days from the time the order was given.
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Observations
Based on a review of client records, the facility failed to ensure that verbal medication orders were authenticated in writing by a physician or other medical professional within three business days in seven of eight applicable records reviewed. Client # 2 was admitted on February 14, 2024 and was active at the time of the inspection. A verbal order given on March 29, 2024 was not authenticated in writing until August 20, 2024. Client # 3 was admitted on August 7, 2023 and was discharged on August 2, 2024. A verbal order given on January 25, 2024 was not authenticated in writing until February 9, 2024. Client # 4 was admitted on April 26, 2023 and was discharged on May 16, 2024. A verbal order given on April 10, 2024 was not authenticated in writing until August 20, 2024. A verbal order given on May 3, 2024 was not authenticated in writing until August 20, 2024. Client # 5 was admitted on March 29, 2019 and was discharged on June 20, 2024. A verbal order given on March 14, 2024 was not authenticated in writing until March 19, 2024. Client # 6 was admitted on April 10, 2024 and was active at the time of the inspection. Verbal orders given on April 10, 2024, April 15, 2024, April 19, 2024, May 6, 2024, and June 6, 2024 were not authenticated in writing until August 20, 2024. A verbal order given on May 1, 2024 was not authenticated in writing until May 9, 2024. Client # 7 was admitted on June 10, 2024 and was active at the time of the inspection. Verbal orders given on June 10, 2024, July 8, 2024, and July 12, 2024 were not authenticated in writing until August 20, 2024.Client # 8 was admitted on January 12, 2023 and was discharged on June 12, 2024. A verbal order was given on January 10, 2024, and was not authenticated in writing until February 9, 2024. This is a repeat citation from the November 6, 2023 annual licensing renewal inspection. These findings were reviewed with project staff during the licensing process.
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Plan of Correction
Medical Director will review all verbal orders and will authenticate in writing within 3 business days of order. Executive Director and/or Clinical Director will include a review of verbal order authentication during chart audits. |
709.34 (c) (1) 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:
(1) Physical or sexual assault by staff or a client.
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Observations
Based on the review of the unusual incident logbook and patient records, the project failed to file a written unusual incident report with the Department within three business days following an unusual incident involving the physical or sexual assault by staff or a client.There was documentation of a patient assault on April 29, 2024; however, there was no documentation that a written unusual incident report was ever filed with the Department.These findings were reviewed with project staff during the licensing process.
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Plan of Correction
All facility staff were retrained in incident reporting requirements. The facility Director will file a written unusual incident report to the Department within 3 days of the incident occurring. This incident was reported to the department on 10/16/2024. |
715.6(d) LICENSURE Physician Staffing
(d) A narcotic treatment program shall provide narcotic treatment physician services at least 1 hour per week onsite for every ten patients
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Observations
Based on the review of three months of physician and certified registered nurse practitioner timesheets, the facility failed to provide at least one hour of physician time a week on site for every ten patients in one week reviewed. During the week of July 1, 2024 through July 7, 2024, the patient census was 296. The facility was required to provide at least 29.6 physician hours. There were 5.25 hours documented.This is a repeat citation from the November 6, 2023 and May 23, 2023 annual renewal licensing inspections. These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Executive Director will develop a physician and certified registered nurse practitioner schedule that will ensure that facility is providing 1 hour per every 10 clients of physician time per week. During holiday or vacations adjustments to the schedule will occur to ensure medical professional availability remains in compliance with regulation. |
715.6(e) LICENSURE Physician Staffing
(e) A physician assistant or certified registered nurse practitioner may perform functions of a narcotic treatment physician in a narcotic treatment program if authorized by Federal, State and local laws and regulations, and if these functions are delegated to the physician assistant or certified registered nurse practitioner by the medical director, and records are properly countersigned by the medical director or a narcotic treatment physician. One-third of all required narcotic treatment physician time shall be provided by a narcotic treatment physician. Time provided by a physician assistant or certified registered nurse practitioner may not exceed two-thirds of the required narcotic treatment physician time.
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Observations
Based on the review three months of physician time sheets, the facility failed to provide the required number of hours onsite for the physician based on the census for two weeks reviewed. A physician must provide one-third of the required hours, with a certified registered nurse practitioner or physician's assistant providing the remaining two-thirds of the required hours. During the week of May 13, 2024 through May 19, 2024, the patient census was 297. The physician was required to provide one-third of the 29.7 hours, which equals to 9.9 hours. The physician provided 9.39 hours. During the week of July 1, 2024 through July 7, 2024, the patient census was 296. The physician was required to provide one-third of the 29.6 hours, which equals to 9.8 hours. The physician provided 5.25 hours. This is a repeat citation from the November 6, 2023 annual licensing renewal inspection. These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Executive Director and Physician will ensure that Physician is providing a minimum of one third of the required hours, based on patient census. A schedule will be developed to ensure that Physician is providing the a minimum of one third of the required hours. |
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 was administered in one of four applicable records reviewed.Patient # 6 was admitted on April 10, 2024 and was active at the time of the inspection. The patient was initially administered an agent on April 10, 2024; however, the informed, voluntary, written consent was not signed until April 17, 2024.This is a repeat citation from the November 6, 2023 annual licensing renewal inspection. These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Clinical Supervisor, counselor, and nursing will ensure that informed, voluntary, written consent is obtained before an agent is administered. Staff retraining occurred on 10/7/2024 to ensure that all documentation is signed prior to an agent being administered. Nursing provided a checklist that must be complete before agent administration. Clinical supervisor will conduct intake chart audits within 7 days of intake. |
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 eight patient records, the narcotic treatment physician failed to document in the patient record the rationale for permitting take-home medication in two of six applicable records reviewed. Patient # 5 was admitted on March 29, 2019 and was discharged on June 20, 2024. The patient received take-home medication on February 15, 2024 and the rationale for take-home medication was not signed by the physician until February 27, 2024.Patient # 7 was admitted on June 10, 2024 and was active at the time of the inspection. The patient received take-home medication on August 9, 2024 and the rationale for take-home medication was not signed by the physician as of the date of the inspection. These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Executive Director, physician and dispensing nurses retrained on take home bottle approval documentation. All nursing staff will ensure that all signatures for rationale of take home medications are obtained before any take home medication is permitted. Development of system to review, sign, and alert of approval before any take home medication is dispensed has been in place since 10/2/2024. |
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 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 in two of five applicable records.Patient # 7 was admitted on June 10, 2024 and was active at the time of the inspection. The patient only received 1.25 hours of psychotherapy for the month of July 2024. Patient # 8 was admitted on January 12, 2023 and was discharged on June 12, 2024. The patient only received 2 hours of psychotherapy for the months of May and April 2024. This is a repeat citation from the November 6, 2023 annual licensing renewal inspection. These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Executive Director and Clinical Supervisor will ensure that patients are provided a minimum of 2.5 hours of psychotherapy, one hour shall be individual psychotherapy per month, during the patients first two years of treatment. ED and CS will review patient services weekly and use EMR to hold counselors and patients accountable to psychotherapy requirements. |
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 an annual evaluation of each patient's status was completed by the patient's counselor in one of three applicable records reviewed. Patient # 8 was admitted on January 12, 2023 and was discharged on June 12, 2024. An annual evaluation was due to be completed by January 12, 2024, however, the annual evaluation was not completed until March 19, 2024.This is a repeat citation from the November 6, 2023 and May 23, 2023 annual renewal licensing inspections. These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Executive Director, Clinical Supervisor and counselors will ensure that all patients have an annual status evaluation no later than their annual due date. Staff have been retrained on requirements of patients attending annual evaluations. A calendar reminder event is created for each patient upon intake. Patients will be altered to schedule an annual evaluation appointment with medical and counselor one month prior to due date to ensure this deficiency does not recur. |
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 a review of client records, the facility failed to document treatment plan updates within the regulatory timeframe in seven of nine records reviewed.Client # 1 was admitted on November 23, 2021 and was active at the time of the inspection. A treatment plan update was completed on January 23, 2024, and the next update was due no later than March 23, 2024; however, the next treatment plan update was not completed until July 16, 2024. Client # 2 was admitted on February 14, 2024 and was active at the time of the inspection. A treatment plan update was completed on May 9, 2024, and the next update was due no later than July 9, 2024; however, the next treatment plan update was not completed until August 20, 2024. Client # 3 was admitted on August 7, 2023 and was discharged on August 2, 2024. A treatment plan update was completed on December 14, 2023, and the next update was due no later than February 14, 2024; however, the next treatment plan update was not completed until February 23, 2024. Client # 4 was admitted on April 26, 2023 and was discharged on May 16, 2024. A treatment plan update was completed on February 2, 2024, and the next update was due no later than April 2, 2024; however, the next treatment plan update was not completed until April 18, 2024.Client # 7 was admitted on June 10, 2024 and was active at the time of the inspection. The individual treatment and rehabilitation plan was completed on June 10, 2024, and the update was due no later than August 10, 2024; however, the treatment plan update was not completed until August 20, 2024.Client # 8 was admitted on January 12, 2023 and was discharged on June 12, 2024. A treatment plan update was completed on September 25, 2023, and the next update was due no later than November 25, 2023; however, the next treatment plan update was not completed until January 23, 2024.Client # 9 was admitted on May 1, 2024 and was active at the time of the inspection. A treatment plan update was completed on June 17, 2024, and the next update was due no later than August 17, 2024; however, no additional treatment plan updates were completed prior to discharge. This is a repeat citation from the November 6, 2023, May 23, 2023, and June 9, 2022 annual renewal licensing inspections. These findings were discussed with facility staff during the inspection process.
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Plan of Correction
Executive Director, and Clinical Supervisor retrained all staff on treatment plan requirements on 10/2/2024. ED and CS will conduct chart audits with counselors in supervision. Counselors implemented calendar event reminders to ensure that treatment plan updates are created, completed and signed prior to the expiration date of current treatment plan. |
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 nine client records and the facility's policy and procedure manual, the facility failed to ensure a complete client record included information relative to the client's involvement with the project to include case consultation notes every three months for the first year of treatment and annually thereafter, per the facility's policy, in six records reviewed. Client # 1 was admitted on November 23, 2021 and was active at the time of the inspection. The last documented case consultation in the record was December 21, 2022.Client # 2 was admitted on February 14, 2024 and was active at the time of the inspection. The first case consultation was due to be completed by May 14, 2024; however, it was not completed until June 4, 2024. No subsequent case consultations were documented in the record. Client # 3 was admitted on August 7, 2023 and was discharged on August 2, 2024. A case consultation was documented on November 7, 2023 and another quarterly consultation was due to be completed by February 7, 2023; however, it was not completed until February 26, 2024. No subsequent case consultations were documented in the record. Client # 6 was admitted on April 10, 2024 and was active at the time of the inspection. The client record did not contain documentation of case consultation notes.Client # 7 was admitted on June 10, 2024 and was active at the time of the inspection. The client record did not contain documentation of case consultation notes.Client # 9 was admitted on May 1, 2024 and was active at the time of the inspection. The client record did not contain documentation of case consultation notes.This is a repeat citation from the November 6, 2023 annual licensing renewal inspection. These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Executive Director, Clinical Supervisor provided retraining to clinical staff on 10/7/2024. Counselors implemented calendar reminders and will review each patient and document case consultations every 90 days within the patients first year, and annually or as needed for every year the patient participates in treatment. |
709.93(a)(11) 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:
(11) Follow-up information.
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Observations
Based on a review of client records, the facility failed to provide a complete client record, which is to include follow-up information in four of four applicable records. Facility policy and procedure states that follow-up information will be obtained seven days, 30 days, and 60 days following discharge. Client # 3 was admitted on August 7, 2023 and was discharged on August 2, 2024. The client record did not contain documentation of follow-up information.Client # 4 was admitted on April 26, 2023 and was discharged on May 16, 2024. The client record did not contain documentation of follow-up information.Client # 5 was admitted on March 29, 2019 and was discharged on June 20, 2024. The client record did not contain documentation of follow-up information.Client # 8 was admitted on January 12, 2023 and was discharged on June 12, 2024. The client record did not contain documentation of follow-up information.This is a repeat citation from the November 6, 2023 annual licensing renewal inspection. This finding was reviewed with the facility staff during the licensing process.
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Plan of Correction
Executive Director provided training to clinical staff on 10/7/2024. Clinical Supervisor will conduct discharge chart audits. Counselors will ensure that patients discharged from the program are contacted for follow up every 7, 30 and 90 days per agency policy, and that documentation of follow up is completed. Counselors will implement EMR calendar events to track when discharge follow up is required per policy. |
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 client records and administrative documents, the facility failed to comply with plans of correction that were approved by the Department. A plan of correction for completing treatment plan updates within the regulatory timeframe was submitted and approved by the Department for the November 6, 2023, May 23, 2023, and June 9, 2022 annual licensing inspections. Completing treatment plan updates was again found to be a deficiency in the September 20, 2024 licensing inspection. A plan of correction for ensuring narcotic treatment physician services at least 1 hour per week onsite for every ten patients was submitted and approved by the Department for the November 6, 2023 and May 23, 2023 annual licensing inspections. Physician services was again found to be a deficiency in the September 20, 2024 licensing inspection. A plan of correction for completing an annual clinical evaluation was submitted and approved by the Department for the November 6, 2023 and May 23, 2023 annual licensing inspections. Completing annual clinical evaluations was again found to be a deficiency in the September 20, 2024 licensing inspection. These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Executive Director will ensure that plan of correction is followed by all facility staff to ensure that all regulations and agency policies are being met and that plan of correction was enacted. This will be completed through consistent training reviews, intake and discharge chart audits, work schedule reviews, calendar reminders and consistent follow up during staff supervision. |