INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on December 15, 2020 through December 16, 2020 by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, Northeast Treatment Centers, Inc 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(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
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 seven applicable personnel records reviewed.
Employee #7 was hired as a counselor on August 6, 2019 and was due to have HIV/AIDS training and TB/STD training no later than August 6, 2020; however, the HIV/AIDS training was completed on December 4, 2020 and the TB/STD training was not completed at the time of the inspection.
Employee #8 was hired as a counselor on October 7, 2019 and was due to have HIV/AIDS training and TB/STD training no later than October 7, 2020; however, the HIV/AIDS training and the TB/STD training were not completed at the time of the inspection.
Employee #12 was hired as a counselor on October 21, 2019 and was due to have HIV/AIDS training and TB/STD training no later than October 21, 2020; however, the HIV/AIDS training and the TB/STD training were not completed at the time of the inspection.
Employee #13 was hired as behavioral health staff on October 8, 2018 and was due to have HIV/AIDS training and TB/STD training no later than October 8, 2020; however, the HIV/AIDS training was completed on November 25, 2020 and the TB/STD training was not completed at the time of the inspection.
Employee #14 was hired as behavioral health staff on May 10, 2018 and was due to have HIV/AIDS training and TB/STD training no later than May 10, 2020; however, the HIV/AIDS training was completed on November 25, 2020 and the TB/STD training was not completed at the time of the inspection.
Employee #15 was hired as a facility technician on August 6, 2018 and was due to have HIV/AIDS training and TB/STD training no later than August 6, 2020; however, the HIV/AIDS training and the TB/STD training were not completed at the time of the inspection.
Employee #16 was hired as a BHA on April 9, 2018 and was due to have HIV/AIDS training and TB/STD training no later than April 9, 2020; however, the HIV/AIDS training and the TB/STD training were not completed at the time of the inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The VP of Integrated Care, the Site Director of Addictions at Spring Garden and the Senior Director of Access Point will ensure that all staff persons receive 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 time frame. Employee #7, #8, #12, #13, #14, #15 and #16 did not have the mandated training's as set forth by regulations. These staff will have these training's by 3/22 and all new staff hired will have the mandated training within one year of hire. |
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
The facility failed to ensure that the February 2020 and March 2020 fire drill logs included the time of the drill, 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. Additionally, the facility failed to ensure that the April 2020 through November 2020 fire drill logs included the exit route used. This was based on a review of the facility's February 2020 through November 2020 fire drill logs.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Vice President of Integrated Care, Director of Addictions at ICWC and Senior Director for Access Point will ensure that that fire drills will occur monthly and will include the time of the drill, the exit route used, the number of persons in the facility at the time of the drill, problems encountered and whether the smoke detector was operative. The Facility switched to an new system of collecting this information and during this time frame, errors occurred. This change occurred during the pandemic contributed to the error. The Addictions director and Senior Director of Acute services will review the fire drill log on a monthly basis to ensure compliance. They will then notify the VP of Integrated Care that the task has been completed. |
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
The facility failed to obtain an informed and voluntary consent to release information form prior to the disclosure of information in two of twenty-one patient records reviewed.
Patient #18 was admitted on June 5, 2020 and was discharged on November 8, 2020. 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 the disclosures.
Patient #19 was admitted on June 15, 2020 and was discharged on September 2, 2020. 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 the disclosures.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The VP of Integrated Care and Addictions Director at Spring garden are aware that the facility failed to obtain an informed and voluntary consent to release information prior to disclosure of information. This error due to the use of a release of Information form that had been in use and was difficult for staff to understand. Training's will be scheduled with the director, QM and staff that release information so that they have a better understanding of the regulations. A new ROI form was also created and added to our electronic health record system that is easier to understand for users. A training will be held on how to complete this form. |
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
The facility failed to document the name of the person to whom the disclosure was to be made to on a consent form in two of twenty-one patient records reviewed.
Patient #5 was admitted into the outpatient buprenorphine-waiver activity on January 21, 2020 and was discharged on January 22, 2020. There was a consent to release information form signed and dated by the client on January 21, 2020; however, the consent form did not include the specific name of the person or agency to whom the disclosure was to be made.
Patient # 14 was admitted into the outpatient maintenance activity on November 4, 2019 and was discharged May 29, 2020. There was a consent to release information form signed and dated by the client on November 4, 2019; however, the consent form did not include the specific name of the person or agency to whom the disclosure was to be made.
These findings were reviewed with facility staff during the licensing inspection
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Plan of Correction
The VP of Integrated Care, the director of Addictions at spring Garden and the Senior director of Access Point are responsible for ensuring that the facility will document the specific name and of the person and agency to whom a disclosure is made to on the ROI form. They will ensure that this information is documented in the outpatient buprenorphine-waiver activity program and the outpatient maintenance activity program. This error was due to the use of a release of Information form that had been in use and was difficult for staff to understand. Training's will be scheduled with the director, QM and staff that release information so that they have a better understanding of the regulations. A new ROI form was also created and added to our electronic health record system that is easier to understand for users. A training will be held on how to complete this form. |
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
The facility failed to keep disclosures of client identifying information within the limits established by 4 Pa. Code 255.5 (b) for releases of information in seventeen of twenty-one patient records reviewed.
Patient #1 was admitted into the outpatient buprenorphine-waiver activity on December 14, 2020 and was active at the time of inspection. There was a release of information form to a funding source, signed and dated by the client, that included the "entire health record", which exceeds the limits established by 4 Pa. Code 255.5.
Patient # 2 was admitted into the outpatient buprenorphine-waiver activity on December 15, 2020 and was active at the time of inspection. There was a release of information form to a funding source, signed and dated by the client, that included the "entire health record", which exceeds the limits established by 4 Pa. Code 255.5.
Patient #3 was admitted into the outpatient buprenorphine-waiver activity on December 15, 2020 and was active at the time of inspection. There was a release of information form to a funding source, signed and dated by the client, that included the "entire health record", which exceeds the limits established by 4 Pa. Code 255.5.
Patient #4 was admitted into the outpatient buprenorphine-waiver activity on September 17, 2020 and was discharged September 18, 2020. There was a release of information form to a funding source, signed and dated by the client, that included the "entire health record", which exceeds the limits established by 4 Pa. Code 255.5.
Patient #5 was admitted into the outpatient buprenorphine-waiver activity on January 21, 2020 and was active discharged on January 22, 2020. There was a release of information form to a funding source, signed and dated by the client, that included the "entire health record", which exceeds the limits established by 4 Pa. Code 255.5.
Patient #6 was admitted into the outpatient buprenorphine-waiver activity on July 21, 2020 and was discharged July 22, 2020. There was a release of information form to a funding source, signed and dated by the client, that included the "entire health record", which exceeds the limits established by 4 Pa. Code 255.5.
Patient #7 was admitted into the outpatient buprenorphine-waiver activity on December 4 ,2020 and was discharged December 6, 2020. There was a release of information form to a funding source, signed and dated by the client, that included the "entire health record", which exceeds the limits established by 4 Pa. Code 255.5.
Patient #8 was admitted into the outpatient maintenance activity on October 9, 2018 and was active at the time of inspection. There was a release of information form to a funding source, signed and dated by the client, that included the "entire health record", which exceeds the limits established by 4 Pa. Code 255.5.
Patient #9 was admitted into the outpatient maintenance activity on September 25, 2019 and was active at the time of inspection. There was a release of information form to a funding source, signed and dated by the client, that included the "entire health record", which exceeds the limits established by 4 Pa. Code 255.5.
Patient #10 was admitted into the outpatient maintenance activity on August 22, 2017 and was active at the time of inspection. There was a release of information form to a funding source, signed and dated by the client, that included the "entire health record", which exceeds the limits established by 4 Pa. Code 255.5.
Patient #11 was admitted into the outpatient maintenance activity on December 9, 2019 and was discharged May 17, 2020. There was a release of information form to a funding source, signed and dated by the client, that included the "entire health record", which exceeds the limits established by 4 Pa. Code 255.5.
Patient #12 was admitted into the outpatient maintenance activity on July 17, 2019 and was discharged September 25, 2020. There was a release of information form to a funding source, signed and dated by the client, that included the "entire health record", which exceeds the limits established by 4 Pa. Code 255.5.
Patient #15 was admitted into the outpatient drug free activity on August 6, 2020 and was still active at the time of the inspection. There were release of information forms to the funding source and a treatment court, signed and dated by the client on August 6, 2020, that included "urine drug screen results" , which exceeds the limits established by 4 Pa. Code 255.5. Additionally, there was a release of information form to the public defender, signed and dated by the client on August 6, 2020, that included the "entire health record", which exceeds the limits established by 4 Pa. Code 255.5.
Patient #16 was admitted into the outpatient drug free activity on August 10, 2020 and was still active at the time of the inspection. There was a release of information form to funding source, signed and dated by the client on August 10, 2020, that included "urine drug screen results" , which exceeds the limits established by 4 Pa. Code 255.5. Additionally, there was a release of information form to the public defender, signed and dated by the client on August 10, 2020, that included the "entire health record", which exceeds the limits established by 4 Pa. Code 255.5.
Patient #17 was admitted into the outpatient maintenance activity on July 30, 2020 and was still active at the time of the inspection. There was a release of information form to a funding source, signed and dated by the client on July 30, 2020, that included the "entire health record", which exceeds the limits established by 4 Pa. Code 255.5.
Patient #20 was admitted into the outpatient maintenance activity on February 14, 2020 and was still discharged on April 1, 2020. There was a release of information form to a funding source, signed and dated by the client on February 14, 2020, that included the "D&A Admission Forms, PCPC Form and ASAM Form", which exceeds the limits established by 4 Pa. Code 255.5.
Patient #21 was admitted into the outpatient maintenance activity on February 18, 2020 and was still discharged on May 16, 2020. There was a release of information form to a funding source, signed and dated by the client on February 18, 2020, that included the "D&A Admission Forms, PCPC Form and ASAM Form", which exceeds the limits established by 4 Pa. Code 255.5.
These findings were discussed with facility staff during the licensing process.
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Plan of Correction
The VP of Integrated care, Director of Addictions at Spring Garden and Senior Director have created a plan to ensure that the facility will keep disclosures of client identifying information within the limits established by 4 Pa. code 255.5 (b) fore releases of information. A new ROI form has been created and added to our electronic health record that is more user friendly to utilize. Staff will be trained by the directors and QM on the regulations and how to complete the form. This training and new form will be in use for the outpatient buprenorphine-waiver activity program and the outpatient maintenance program. Staff will be re-trained that they cannot release information such as "entire health record", "all urine drug results" and "D/A Admission forms, PCPC form and ASAM forms" |
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
The facility failed to ensure that all consent to release information forms included the dated signature of the patient in one of twenty-one patient records reviewed.
Patient #17 was admitted into the outpatient drug free activity on July 30, 2020 and was still active at the time of the inspection. The release of information form to the psychologist was signed and dated by the witness on August 19, 2020, but was missing the dated client signature.
This finding was reviewed with facility staff during the licensing inspection.
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Plan of Correction
The VP of Integrated care, Director of Addictions at Spring Garden and Senior Director have created a plan to ensure that all consents to release information forms include the dated signature of the patient. A new ROI form has been created and added to our electronic health record that is more user friendly.The new consent to release information has already been added to our electronic health record. Patient #17's ROI will be updated the next time he presents at the clinic for treatment. Staff will be re-trained by the directors and QM on the regulations and how to complete the form. Staff will be re-trained that they must have the patient sign and date the consent. This training and new form will be in use for the outpatient buprenorphine-waiver activity program and the outpatient maintenance program. |
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
The facility failed to ensure that all consent to release information forms included the date, event or condition upon which the consent will expire in one of twenty-one patient records reviewed.
Patient #17 was admitted into the outpatient drug free activity on July 30, 2020 and was still active at the time of the inspection. The release of information form to the psychologist was signed and dated by the witness on August 19, 2020, but was missing an expiration date.
These finding were reviewed with facility staff during the licensing inspection.
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Plan of Correction
The VP of Integrated care, Addictions director at Spring Garden and Senior Director for Access Point have created a plan of correction to ensure that all consents to release information include the date, event or condition upon which the consent will expire. A new ROI form has been created and added to our electronic health record that is more user friendly. Staff will be re-trained by the directors on the regulations and how to complete the form correctly. Staff will be re-trained that they must include an expiration date on all consents and ROI's. This training and new form is in use now for the outpatient buprenorphine-waiver activity program and the outpatient maintenance program. On patient #17's next visit for treatment, a new ROI will be completed with all necessary information including the expiration date. |