INITIAL COMMENTS
|
This report is a result of an on-site licensure renewal inspection conducted on January 23, 2018 through January 24, 2018 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:
|
Plan of Correction
|
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.
|
Observations
Based on a review of personnel records and the facility's Staffing Requirement Facility Summary Report (SRFSR) form, the facility failed to ensure that 2 employees received the minimum of 6 hours of HIV/AIDS training and/or at least 4 hours of TB/STD and other health related topics within the regulatory timeframe.Employee #19 was hired as a counselor on 07/13/2016 and was due to have the TB/STD and other health related topics no later than 07/13/17. There was no documentation in the personnel file of the completion of the TB/STD training as of the date of the inspection.Employee #23 was hired as a counselor assistant on 12/19/2016 and was due to have the HIV/AIDS training no later than 12/19/17. There was no documentation in the personnel file of the completion of the HIV/AIDS training as of the date of the inspection.The findings were discussed with facility staff during the licensing process.
|
Plan of Correction
The Vice President of Addiction Recovery Services ensured that both employee #19 and #23 received the required trainings on February 13 and February 20. The Vice President will work with the Director of Operations to ensure that all staff receive TB/STD and HIV/AIDS training within 1 year of hire. |
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.
|
Observations
Based on the review of 13 client records, the facility failed to ensure that every consent to release information form in 9 client records had the dates of both the client and witness signatures.Client #1 was admitted into the outpatient drug free level of care on 10/16/2017 and was still active at the time of the inspection.Client #2 was admitted into the outpatient drug free level of care on 10/12/2017 and was still active at the time of the inspection.Client #3 was admitted into the outpatient drug free level of care on 10/5/2017 and was still active at the time of the inspection.Client #4 was admitted into the outpatient drug free level of care on 9/08/2017 and was still active at the time of the inspection.Client #5 was admitted into the outpatient drug free level of care on 11/28/2017 and was still active at the time of the inspection.Client #6 was admitted into the outpatient drug free level of care on 12/21/2016 and was discharged on 12/04/2017.Client #7 was admitted into the outpatient drug free level of care on 4/07/2017 and was discharged on 12/25/2017.Client #8 was admitted into the outpatient drug free level of care on 8/28/2017 and was still active at the time of the inspection.Client #9 was admitted into the outpatient drug free level of care on 10/23/2017 and was still active at the time of the inspection.The findings were reviewed with facility staff during the licensing inspection.
|
Plan of Correction
On March 6, 2018 the Vice President of Addiction Recovery Services directed the information technology department to remedy the issue of releases being able to be individually printed to show signature dates for both client and witness. The IT team worked with the electronic health record (EHR) technical assistance department of the software company that supports the EHR to determine what the problem was with the consents to release information. The problem was a technical problem, and the EHR systems administrator successfully fixed the problem on March 26, 2018. The problem was caused by a technical glitch that did not display the signatures at the bottom of the release WITH the signature date. The EHR systems administrator and Director of Information Technology will be responsible for ensuring that the issue does not reoccur. The QA Supervisor and QA Specialist will routinely audit charts on a weekly basis, and the Program Director and Site Supervisor will do an another review of the charts again by May 6, 2018 to ensure that the consents to release information have both signatures from client/witness and both signatures have the date of signature next to them. |
715.1(a)(b) LICENSURE General Provisions
(a) An entity within this Commonwealth which uses agents for maintenance or detoxification of persons shall obtain the approval of the Department to operate a narcotic treatment program.
(b) The Department's approval of a narcotic treatment program shall be contingent upon the narcotic treatment program's compliance with the standards and conditions in this part. In addition, the program shall comply with applicable Federal laws and regulations.
|
Observations
The facility is approved for Narcotic Treatment Program maintenance activities; however, they are conducting maintenance activities via the administration of Suboxone prescribed to clients by their DATA 2000 waived doctor.Additionally, the facility is administering Suboxone via the patients ' individual prescriptions that the facility keeps on premises. The facility is prohibited to take possession of the controlled substances (Suboxone) that was prescribed by the client ' s DATA waived doctor and dispense it back to the clients (21 U.S.C. 825(c)).When a client has controlled substances that has been dispensed to him/her, the controlled substances should remain with him/her. Further, the client has no authority to distribute to others the controlled substances that he or she has legally obtained. Such activity constitutes unlawful distribution by the ultimate user and unlawful possession by the person who receives these controlled substances, which are violations of Title 21, United States Code, Sections 841(a)(1) and 844 (21 U.S.C. 841(a)(1) and 844).These findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
In consultation with the Drug Enforcement Agency (DEA), the Director of Operations and Nurse Manager of the Spring Garden MAT securely disposed of buprenorphine (Suboxone) that was prescribed to clients by a DATA 2000 waived doctor, but was being stored at the Spring Garden facility. The secure disposal was made on February 28, 2018 with the Philadelphia Police Department by the Director of Operations and Nurse Manager. The DEA gave instruction to do this and indicated that the program was to consider the buprenorphine "abandoned" for those individuals who had been discharged for not returning to treatment. Buprenorphine for individuals who were still enrolled in the facility was returned to them by February 28, 2018. The DATA 2000 waived doctor now provides prescriptions for buprenorphine to those for whom it is clinically appropriate, or the facility is using stock buprenorphine to dose clients for whom that is clinically and medically appropriate. NET's DATA 2000 waived doctor no longer prescribes buprenorphine to individuals and stores them on site after the prescription is filled. The only medication that is stored on site is stock medication (buprenorphine or other) that is not prescribed to an individual. The Vice President of Addiction Recovery Services and Director of Operations informed all narcotic treatment program staff, including DATA 2000 waived doctor, on February 28, 2018 that this practice is not to reoccur. The Director of Operations and Nurse Manager will be responsible for monitoring that this practice does not reoccur. |
715.2(a)(b) LICENSURE Relationship of Federal and State Regulations
(a) A narcotic treatment program shall comply with Federal regulations and requirements governing the administration, dispensing and storage of agents.
(b) This chapter is intended to supplement the Federal regulations governing narcotic treatment programs in 21 CFR Chapter II, 1300-1399 (relating to Drug Enforcement Administration, Department of Justice).
|
Observations
The facility services clients on an out-patient basis and prohibited taking possession of the clients controlled substances (suboxone) that was prescribed by the client ' s DATA waived doctor and dispensing it back to the clients (21 U.S.C. 825(c)).These findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
In consultation with the Drug Enforcement Agency (DEA), the Director of Operations and Nurse Manager of the Spring Garden MAT securely disposed of buprenorphine (Suboxone) that was prescribed to clients by a DATA 2000 waived doctor, but was being stored at the Spring Garden facility. The secure disposal was made on February 28, 2018 with the Philadelphia Police Department by the Director of Operations and Nurse Manager. The DEA gave instruction to do this and indicated that the program was to consider the buprenorphine "abandoned" for those individuals who had been discharged for not returning to treatment. Buprenorphine for individuals who were still enrolled in the facility was returned to them by February 28, 2018. The DATA 2000 waived doctor now provides prescriptions for buprenorphine to those for whom it is clinically appropriate, or the facility is using stock buprenorphine to dose clients for whom that is clinically and medically appropriate. NET's DATA 2000 waived doctor no longer prescribes buprenorphine to individuals and stores them on site after the prescription is filled. The only medication that is stored on site is stock medication (buprenorphine or other) that is not prescribed to an individual. The Vice President of Addiction Recovery Services and Director of Operations informed all narcotic treatment program staff, including DATA 2000 waived doctor, on February 28, 2018 that this practice is not to reoccur. The Director of Operations and Nurse Manager will be responsible for monitoring that this practice does not reoccur. |
715.3(a)-(h) LICENSURE Approval of narcotic treatment programs
(a) An entity shall apply for and receive approval as required from the Department, DEA and CSAT or an organization designated by the Substance Abuse and Mental Health Services Administration (SAMHSA), under the authority of section 303 of the Controlled Substances Act (21 U.S.C.A. § 823) and sections 501(d), 509(a), 543, 1923, 1927(a) and 1976 of the Public Health Service Act (42 U.S.C.A. §§ 290aa(d), 290bb-2(a), 290dd-2, 300x-23, 300x-27(a) and 300y-11), prior to offering services within this Commonwealth as a narcotic treatment program. Application for approval shall be made simultaneously to the Department, DEA and CSAT or SAMHSA designee.
(1) The Department will forward a recommendation for approval to the Federal officials after a review of policies and procedures and an onsite inspection by an authorized representative of the Department and after a determination has been made that the requirements for approval under this chapter have been met.
(2) The decision of the Federal officials set forth in 21 CFR Chapter II (relating to Drug Enforcement Administration, Department of Justice) or other Federal statutes shall constitute the final determination on the application for approval by DEA and CSAT or SAMHSA designee.
(b) A narcotic treatment program shall be licensed under the Department's regulations for drug and alcohol facilities in Chapter 157, 704, 705, 709 or 711. When a licensee applies to operate a narcotic treatment program, the history component of the application of the licensee shall include the licensee's record of operation of any facility regulated by any State or Federal entity. A narcotic treatment program may not be recommended for approval unless licensure has been obtained under Chapters 157, 704, 705, 709 or 711.
(c) The Department will grant approval as a narcotic treatment program after an onsite inspection and review of narcotic treatment program policies, procedures and other material, when the Department determines that the requirements for approval have been met.
(d) The Department will inspect a narcotic treatment program at least annually to determine compliance with State narcotic treatment program regulations. This inspection shall consist of an onsite visit and shall include an examination of patient records, reports, files, policies and procedures, and other similar items to enable the Department to make an evaluation of the status of the narcotic treatment program. The Department may inspect the narcotic treatment program without notice during any regular business hours of the narcotic treatment program.
(e) During the inspection process, a narcotic treatment program shall make available to the authorized staff of the Department full and free access to its premises, facilities, records, reports, files and other similar items necessary for a full and complete evaluation. The Department may make copies of materials it deems necessary under 42 CFR 2.53 (relating to audit and evaluation activities) and §§ 709.15 and 711.15 (relating to right to enter and inspect; and right to enter and inspect).
(f) The authorized Department representative may interview patients and staff as part of the inspection process.
(g) The Department may grant approval as a narcotic treatment program after an onsite inspection when the Department determines that a narcotic treatment program satisfies the following:
(1) It has substantially complied with applicable requirements for approval.
(2) It is complying with a plan of correction approved by the Department with regard to any outstanding deficiencies.
(3) Its existing deficiencies will not adversely alter the health, welfare or safety of the facility 's patients.
(h) Notification of deficiencies involves the following:
(1) The authorized Department representative will provide the program director with a record of deficiencies with instructions to submit a plan of correction.
(2) The narcotic treatment program shall complete the plan of correction and submit it to the Department within 21 days after the last day of the onsite inspection.
(3) The Department will not grant approval as narcotic treatment program until the Department receives and approves a plan of correction.
|
Observations
This regulation requires that maintenance be a part of the chapter 709 licensed activity which in this case is outpatient. The program was regularly servicing 17 individuals as maintenance patients who were not enrolled in the licensed outpatient services at this location.These findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
The Director of Operations was responsible for working with site supervisors at NET sites that were providing outpatient treatment to clients who were receiving medicated-assisted treatment (buprenorphine) from a DATA 2000 waived doctor who worked at the Spring Garden facility (807292). The Director of Operations worked quickly after the site inspection from DDAP to transfer clients to the Spring Garden facility for full treatment (outpatient treatment plus medicated-assisted treatment with buprenorphine) or to refer clients out for outpatient plus buprenorphine treatment at another provider. As of February 28, 2018 the practice of dosing clients at the Spring Garden facility with buprenorphine treatment but serving them at another NET narcotic treatment facility had ceased. The Vice President of Addiction Recovery Services will be responsible for ensuring that this practice does not again reoccur in the future and that clients receive all buprenorphine medication-assisted treatment and outpatient treatment in the same licensed narcotic treatment program. |
715.17(a) LICENSURE Medication control
(a) A narcotic treatment program shall comply with applicable Federal and State statutes and regulations regarding the storing, compounding, administering and dispensing of medication.
|
Observations
When a client has controlled substances that has been dispensed to the him/her, the controlled substances should remain with him/her. Further, the client has no authority to distribute to others the controlled substances that he or she has legally obtained. Such activity constitutes unlawful distribution by the ultimate user and unlawful possession by the person who receives these controlled substances, which are violations of Title 21, United States Code, Sections 841(a)(1) and 844 (21 U.S.C. 841(a)(1) and 844).These findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
In consultation with the Drug Enforcement Agency (DEA), the Director of Operations and Nurse Manager of the Spring Garden MAT securely disposed of buprenorphine (Suboxone) that was prescribed to clients by a DATA 2000 waived doctor, but was being stored at the Spring Garden facility. The secure disposal was made on February 28, 2018 with the Philadelphia Police Department by the Director of Operations and Nurse Manager. The DEA gave instruction to do this and indicated that the program was to consider the buprenorphine "abandoned" for those individuals who had been discharged for not returning to treatment. Buprenorphine for individuals who were still enrolled in the facility was returned to them by February 28, 2018. The DATA 2000 waived doctor now provides prescriptions for buprenorphine to those for whom it is clinically appropriate, or the facility is using stock buprenorphine to dose clients for whom that is clinically and medically appropriate. NET's DATA 2000 waived doctor no longer prescribes buprenorphine to individuals and stores them on site after the prescription is filled. The only medication that is stored on site is stock medication (buprenorphine or other) that is not prescribed to an individual. The Vice President of Addiction Recovery Services and Director of Operations informed all narcotic treatment program staff, including DATA 2000 waived doctor, on February 28, 2018 that this practice is not to reoccur. The Director of Operations and Nurse Manager will be responsible for monitoring that this practice does not reoccur. |
715.18(a) LICENSURE Rehabilitative services
(a) A narcotic treatment program shall provide, either onsite or through referral agreements, a full range of rehabilitative services. Rehabilitative services shall include:
|
Observations
The program was regularly servicing 17 individuals as maintenance patients who were not enrolled in the licensed outpatient services at this location and therefore patients did not receive a full range of rehabilitative services at this location. 28 Pa. Code 715.3 (b) requires that maintenance be a part of the chapter 709 licensed activity which in this case is outpatient.These findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
The Director of Operations was responsible for working with site supervisors at NET sites that were providing outpatient treatment to clients who were receiving medicated-assisted treatment (buprenorphine) from a DATA 2000 waived doctor who worked at the Spring Garden facility (807292). The Director of Operations worked quickly after the site inspection from DDAP to transfer clients to the Spring Garden facility for full treatment (outpatient treatment plus medicated-assisted treatment with buprenorphine) or to refer clients out for outpatient plus buprenorphine treatment at another provider. As of February 28, 2018 the practice of dosing clients at the Spring Garden facility with buprenorphine treatment but serving them at another NET narcotic treatment facility had ceased. The Vice President of Addiction Recovery Services will be responsible for ensuring that this practice does not again reoccur in the future and that clients receive all buprenorphine medication-assisted treatment and outpatient treatment in the same licensed narcotic treatment program. |
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.
|
Observations
The program was regularly servicing 17 individuals as maintenance patients who were not enrolled in the licensed outpatient services at this location and therefore patients did not receive individualized psychotherapy services at this location. 28 Pa. Code 715.3 (b) requires that maintenance be a part of the chapter 709 licensed activity which in this case is outpatient.These findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
The Director of Operations was responsible for working with site supervisors at NET sites that were providing outpatient treatment to clients who were receiving medicated-assisted treatment (buprenorphine) from a DATA 2000 waived doctor who worked at the Spring Garden facility (807292). The Director of Operations worked quickly after the site inspection from DDAP to transfer clients to the Spring Garden facility for full treatment (outpatient treatment plus medicated-assisted treatment with buprenorphine) or to refer clients out for outpatient plus buprenorphine treatment at another provider. As of February 28, 2018 the practice of dosing clients at the Spring Garden facility with buprenorphine treatment but serving them at another NET narcotic treatment facility had ceased. The Vice President of Addiction Recovery Services will be responsible for ensuring that this practice does not again reoccur in the future and that clients receive all buprenorphine medication-assisted treatment and outpatient treatment in the same licensed narcotic treatment program. |
715.23(b) LICENSURE Patient records
(b) Each patient file shall include the following information:
|
Observations
The program was regularly servicing 17 individuals as maintenance patients who were not enrolled in the licensed outpatient services at this location and therefore, there was no complete patient records for outpatient activities at this location. 28 Pa. Code 715.3 (b) requires that maintenance be a part of the chapter 709 licensed activity which in this case is outpatient.These findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
The Director of Operations was responsible for working with site supervisors at NET sites that were providing outpatient treatment to clients who were receiving medicated-assisted treatment (buprenorphine) from a DATA 2000 waived doctor who worked at the Spring Garden facility (807292). The Director of Operations worked quickly after the site inspection from DDAP to transfer clients to the Spring Garden facility for full treatment (outpatient treatment plus medicated-assisted treatment with buprenorphine) or to refer clients out for outpatient plus buprenorphine treatment at another provider. As of February 28, 2018 the practice of dosing clients at the Spring Garden facility with buprenorphine treatment but serving them at another NET narcotic treatment facility had ceased. The Vice President of Addiction Recovery Services will be responsible for ensuring that this practice does not again reoccur in the future and that clients receive all buprenorphine medication-assisted treatment and outpatient treatment in the same licensed narcotic treatment program. |
715.23(d) LICENSURE Patient records
(d) A narcotic treatment program shall prepare a treatment plan that outlines realistic short and long-term treatment goals which are mutually acceptable to the patient and the narcotic treatment program.
|
Observations
The program was regularly servicing 17 individuals as maintenance patients who were not enrolled in the licensed outpatient services at this location and therefore, there were no treatment plans for outpatient activities at this location. 28 Pa. Code 715.3 (b) requires that maintenance be a part of the chapter 709 licensed activity which in this case is outpatient.These findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
The Director of Operations was responsible for working with site supervisors at NET sites that were providing outpatient treatment to clients who were receiving medicated-assisted treatment (buprenorphine) from a DATA 2000 waived doctor who worked at the Spring Garden facility (807292). The Director of Operations worked quickly after the site inspection from DDAP to transfer clients to the Spring Garden facility for full treatment (outpatient treatment plus medicated-assisted treatment with buprenorphine) or to refer clients out for outpatient plus buprenorphine treatment at another provider. As of February 28, 2018 the practice of dosing clients at the Spring Garden facility with buprenorphine treatment but serving them at another NET narcotic treatment facility had ceased. The Vice President of Addiction Recovery Services will be responsible for ensuring that this practice does not again reoccur in the future and that clients receive all buprenorphine medication-assisted treatment and outpatient treatment in the same licensed narcotic treatment program. |
709.91(a)(1) LICENSURE Intake and admission
709.91. Intake and admission.
(a) The project director shall develop a written plan providing for intake and admission which includes, but not be limited to:
(1) Criteria for admission.
|
Observations
The program failed to develop a written plan providing for intake and admission. The program was regularly servicing 17 individuals as maintenance patients who were not enrolled in the licensed outpatient services at this location. 28 Pa. Code 715.3 (b)requires that maintenance be a part of the chapter 709 licensed activity which in this case is outpatient.These findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
The Director of Operations was responsible for working with site supervisors at NET sites that were providing outpatient treatment to clients who were receiving medicated-assisted treatment (buprenorphine) from a DATA 2000 waived doctor who worked at the Spring Garden facility (807292). The Director of Operations worked quickly after the site inspection from DDAP to transfer clients to the Spring Garden facility for full treatment (outpatient treatment plus medicated-assisted treatment with buprenorphine) or to refer clients out for outpatient plus buprenorphine treatment at another provider. As of February 28, 2018 the practice of dosing clients at the Spring Garden facility with buprenorphine treatment but serving them at another NET narcotic treatment facility had ceased. The Vice President of Addiction Recovery Services will be responsible for ensuring that this practice does not again reoccur in the future and that clients receive all buprenorphine medication-assisted treatment and outpatient treatment in the same licensed narcotic treatment program. |
709.91(b)(1) LICENSURE Intake and admission
709.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(1) Disclosure to the client of criteria for admission, treatment, completion and discharge.
|
Observations
The program was regularly servicing 17 individuals as maintenance patients who were not enrolled in the licensed outpatient services at this location and therefore there was no documentation of the disclosure to the individual of the criteria for admission, treatment, completion and discharge for outpatient activities at this location. 28 Pa. Code 715.3 (b)requires that maintenance be a part of the chapter 709 licensed activity which in this case is outpatient.These findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
The Director of Operations was responsible for working with site supervisors at NET sites that were providing outpatient treatment to clients who were receiving medicated-assisted treatment (buprenorphine) from a DATA 2000 waived doctor who worked at the Spring Garden facility (807292). The Director of Operations worked quickly after the site inspection from DDAP to transfer clients to the Spring Garden facility for full treatment (outpatient treatment plus medicated-assisted treatment with buprenorphine) or to refer clients out for outpatient plus buprenorphine treatment at another provider. As of February 28, 2018 the practice of dosing clients at the Spring Garden facility with buprenorphine treatment but serving them at another NET narcotic treatment facility had ceased. The Vice President of Addiction Recovery Services will be responsible for ensuring that this practice does not again reoccur in the future and that clients receive all buprenorphine medication-assisted treatment and outpatient treatment in the same licensed narcotic treatment program. |
709.91(b)(2)(i) LICENSURE Intake and admission
709.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(2) Client orientation to the project which shall include, but is not limited to, a familiarization with the following:
(i) Project policies.
|
Observations
The program was regularly servicing 17 individuals as maintenance patients who were not enrolled in the licensed outpatient services at this location and therefore there was no client orientation documentation for outpatient activities at this location. 28 Pa. Code 715.3 (b)requires that maintenance be a part of the chapter 709 licensed activity which in this case is outpatient. These findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
The Director of Operations was responsible for working with site supervisors at NET sites that were providing outpatient treatment to clients who were receiving medicated-assisted treatment (buprenorphine) from a DATA 2000 waived doctor who worked at the Spring Garden facility (807292). The Director of Operations worked quickly after the site inspection from DDAP to transfer clients to the Spring Garden facility for full treatment (outpatient treatment plus medicated-assisted treatment with buprenorphine) or to refer clients out for outpatient plus buprenorphine treatment at another provider. As of February 28, 2018 the practice of dosing clients at the Spring Garden facility with buprenorphine treatment but serving them at another NET narcotic treatment facility had ceased. The Vice President of Addiction Recovery Services will be responsible for ensuring that this practice does not again reoccur in the future and that clients receive all buprenorphine medication-assisted treatment and outpatient treatment in the same licensed narcotic treatment program. |
709.92(a) LICENSURE Treatment and rehabilitation services
709.92. Treatment and rehabilitation services.
(a) An individual treatment and rehabilitation plan shall be developed with a client. This plan shall include, but not be limited to, written documentation of:
|
Observations
The program was regularly servicing 17 individuals as maintenance patients who were not enrolled in the licensed outpatient services at this location and therefore there was no individual treatment and rehabilitation plan developed with the individual regarding the required outpatient activities at this location. 28 Pa. Code 715.3 (b)requires that maintenance be a part of the chapter 709 licensed activity which in this case is outpatient.Additionally, based on the review of 13 client records, the facility failed to provide documentation that the comprehensive treatment plans were developed with the client's input in 4 client records.Client #1 was admitted on 10/16/2017 and was still active at the time of the inspection. The comprehensive treatment plan was signed and dated by staff on 10/31/17; however, the client signed the plan on 11/6/17.Client #2 was admitted on 10/12/2017 and was still active at the time of the inspection. The comprehensive treatment plan was signed and dated by staff on 10/31/17; however, the client signed the plan on 11/1/17.Client #3 was admitted on 10/5/2017 and was still active at the time of the inspection. The comprehensive treatment plan was signed and dated by staff on 10/17/17; however, the client signed the plan on 10/19/17.Client #4 was admitted on 9/08/2017 and was still active at the time of the inspection. The comprehensive treatment plan was signed and dated by staff on 9/19/17; however, the client signed the plan on 9/22/17.These findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
The Program Director provided education to all counseling staff on April 2, 2018 on the completion of treatment plans with training on collaborative treatment planning with client input. Counselors received clinical training and support from quality assurance specialists and clinical supervisors as well. The treatment plans will be signed and dated by both client and counselor on the same date showing collaboration on the process of treatment planning. The Program Director and Quality Assurance Supervisor are responsible for ensuring that this does not recur and will audit treatment plans on a weekly basis to ensure that this issue is remediated. Clinical supervisors will follow-up with counselors in bi-weekly clinical supervision. The Vice President of Addiction Recovery Services will also re-audit the treatment plans on May 4, 2018 to ensure that the treatment plans continue to be done in a collaborative manner with client input and with signature dates that are on the same date. |
709.92(c) LICENSURE Treatment and rehabilitation services
709.92. Treatment and rehabilitation services.
(c) The project shall assure that counseling services are provided according to the individual treatment and rehabilitation plan.
|
Observations
The program was regularly servicing 17 individuals as maintenance patients who were not enrolled in the licensed outpatient services at this location and therefore the individual did not receive the required outpatient counseling at this location. 28 Pa. Code 715.3 (b) requires that maintenance be a part of the chapter 709 licensed activity which in this case is outpatient.These findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
The Director of Operations was responsible for working with site supervisors at NET sites that were providing outpatient treatment to clients who were receiving medicated-assisted treatment (buprenorphine) from a DATA 2000 waived doctor who worked at the Spring Garden facility (807292). The Director of Operations worked quickly after the site inspection from DDAP to transfer clients to the Spring Garden facility for full treatment (outpatient treatment plus medicated-assisted treatment with buprenorphine) or to refer clients out for outpatient plus buprenorphine treatment at another provider. As of February 28, 2018 the practice of dosing clients at the Spring Garden facility with buprenorphine treatment but serving them at another NET narcotic treatment facility had ceased. The Vice President of Addiction Recovery Services will be responsible for ensuring that this practice does not again reoccur in the future and that clients receive all buprenorphine medication-assisted treatment and outpatient treatment in the same licensed narcotic treatment program. |
709.92(d) LICENSURE Treatment and rehabilitation services
709.92. Treatment and rehabilitation services.
(d) Counseling shall be provided to a client on a regular and scheduled basis.
|
Observations
The program was regularly servicing 17 individuals as maintenance patients who were not enrolled in the licensed outpatient services at this location and therefore the individuals did not receive the required outpatient counseling on a regularly, scheduled basis at this location. 28 Pa. Code 715.3 (b) requires that maintenance be a part of the chapter 709 licensed activity which in this case is outpatient.These findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
The Director of Operations was responsible for working with site supervisors at NET sites that were providing outpatient treatment to clients who were receiving medicated-assisted treatment (buprenorphine) from a DATA 2000 waived doctor who worked at the Spring Garden facility (807292). The Director of Operations worked quickly after the site inspection from DDAP to transfer clients to the Spring Garden facility for full treatment (outpatient treatment plus medicated-assisted treatment with buprenorphine) or to refer clients out for outpatient plus buprenorphine treatment at another provider. As of February 28, 2018 the practice of dosing clients at the Spring Garden facility with buprenorphine treatment but serving them at another NET narcotic treatment facility had ceased. The Vice President of Addiction Recovery Services will be responsible for ensuring that this practice does not again reoccur in the future and that clients receive all buprenorphine medication-assisted treatment and outpatient treatment in the same licensed narcotic treatment program. |
709.93(a) 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:
|
Observations
The program was regularly servicing 17 individuals as maintenance patients who were not enrolled in the licensed outpatient services at this location and therefore the individuals did not have a complete client record for the required outpatient activities at this location. 28 Pa. Code 715.3 (b) requires that maintenance be a part of the chapter 709 licensed activity which in this case is outpatient.These findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
The Director of Operations was responsible for working with site supervisors at NET sites that were providing outpatient treatment to clients who were receiving medicated-assisted treatment (buprenorphine) from a DATA 2000 waived doctor who worked at the Spring Garden facility (807292). The Director of Operations worked quickly after the site inspection from DDAP to transfer clients to the Spring Garden facility for full treatment (outpatient treatment plus medicated-assisted treatment with buprenorphine) or to refer clients out for outpatient plus buprenorphine treatment at another provider. As of February 28, 2018 the practice of dosing clients at the Spring Garden facility with buprenorphine treatment but serving them at another NET narcotic treatment facility had ceased. The Vice President of Addiction Recovery Services will be responsible for ensuring that this practice does not again reoccur in the future and that clients receive all buprenorphine medication-assisted treatment and outpatient treatment in the same licensed narcotic treatment program. |