INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on January 27, 2017 by staff from the Department of Drug and Alcohol Programs, Bureau of Quality Assurance for Prevention and Treatment, Program Licensure Division. 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(f)(2) LICENSURE Trng Hours Req-Coun
704.11. Staff development program.
(f) Training requirements for counselors.
(2) Each counselor shall complete at least 25 clock hours of training annually in areas such as:
(i) Client recordkeeping.
(ii) Confidentiality.
(iii) Pharmacology.
(iv) Treatment planning.
(v) Counseling techniques.
(vi) Drug and alcohol assessment.
(vii) Codependency.
(viii) Adult Children of Alcoholics (ACOA) issues.
(ix) Disease of addiction.
(x) Aftercare planning.
(xi) Principles of Alcoholics Anonymous and Narcotics Anonymous.
(xii) Ethics.
(xiii) Substance abuse trends.
(xiv) Interaction of addiction and mental illness.
(xv) Cultural awareness.
(xvi) Sexual harassment.
(xvii) Developmental psychology.
(xviii) Relapse prevention.
(3) If a counselor has been designated as lead counselor supervising other counselors, the training shall include courses appropriate to the functions of this position and a Department approved core curriculum or comparable training in supervision.
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Observations
Based on a review of the Staffing Requirements Facility Summary Report (SRFSR) and personnel records, the facility failed to document the completion of 25 clock hours of annual training required for counselors in employee #5's personnel record.
Employee #5 was hired as a counselor on April 23, 2015 and was promoted to a clinical supervisor on August 26, 2016. The facility's training year that was reviewed was from July 1, 2015 through June 30, 2016. Employee #5's personnel record only documented 17.5 hours of annual training for the training year reviewed.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Program Director will review employee training hours on a quarterly basis to ensure staff are meeting their quarterly target of 6.5 hours, or 10 hours for all new staff within their first year. Staff who do not meet this quarterly target will be assigned trainings to complete in the Relias Training System. As of January 31, 2017, Employee #5 has completed 54.5 training hours for this fiscal year, putting the employee well above target to meet the required 12.5 clock hours of annual training for clinical supervisors. |
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 client records, the facility failed to provide patient #'s 2 and 3 with an average of 2.5 hours of psychotherapy per month, including at least one hour of individual psychotherapy, during the patients' first 2 years of treatment.
Patient # 2 was admitted on 07/06/2016 and was an active patient at the time of inspection. In November 2016, the patient had 15 hours of group therapy and 0 hours of individual therapy. In October 2016, patient had 18 hours of group therapy and 30 minutes of individual therapy. There was no documentation of patient no shows or cancellations during those time periods.
Patient # 3 was admitted on 05/03/2016 and was discharged on 08/15/2016. In July 2016, the patient had 15 hours of group therapy and 0 hours of individual therapy. There was no documentation of patient no shows or cancellations during those time periods.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Clinical Supervisor will ensure that each patient enrolled in NET's Buprenorphine program are properly scheduled, at minimum, one hour of individual sessions per month. The Clinical Supervisor will review the average psychotherapy hours for each Buprenorphine client on a bi-weekly basis, to ensure that each patient receives one hour of psychotherapy a month. No later than March 1st, 2017, clinical schedule will be adjusted to accommodate additional clinical hours needed to ensure all Buprenorphine clients receive the required psychotherapy hours each month. |