INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection and methadone buprenorphine monitoring inspection conducted on December 17, 2024 through December 18, 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 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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704.7(b) LICENSURE Counselor Qualifications
704.7. Qualifications for the position of counselor.
(a) Drug and alcohol treatment projects shall be staffed by counselors proportionate to the staff/client and counselor/client ratios listed in 704.12 (relating to full-time equivalent (FTE) maximum client/staff and client/counselor ratios).
(b) Each counselor shall meet at least one of the following groups of qualifications:
(1) Current licensure in this Commonwealth as a physician.
(2) A Master's Degree or above from an accredited college with a major in chemical dependency, psychology, social work, counseling, nursing (with a clinical specialty in the human services) or other related field which includes a practicum in a health or human service agency, preferably in a drug and alcohol setting. If the practicum did not take place in a drug and alcohol setting, the individual's written training plan shall specifically address a plan to achieve counseling competency in chemical dependency issues.
(3) A Bachelor's Degree from an accredited college with a major in chemical dependency, psychology, social work, counseling, nursing (with a clinical specialty in the human services) or other related field and 1 year of clinical experience (a minimum of 1,820 hours) in a health or human service agency, preferably in a drug and alcohol setting. If a person's experience did not take place in a drug and alcohol setting, the individual's written training plan shall specifically address a plan to achieve counseling competency in chemical dependency issues.
(4) An Associate Degree from an accredited college with a major in chemical dependency, psychology, social work, counseling, nursing (with a clinical specialty in the human services) or other related field and 2 years of clinical experience (a minimum of 3,640 hours) in a health or human service agency, preferably in a drug and alcohol setting. If a person's experience was not in a drug and alcohol setting, the individual's written training plan shall specifically address a plan to achieve counseling competency in chemical dependency issues.
(5) Current licensure in this Commonwealth as a registered nurse and a degree from an accredited school of nursing and 1 year of counseling experience (a minimum of 1,820 hours) in a health or human service agency, preferably in a drug and alcohol setting. If a person's experience was not in a drug and alcohol setting, the individual's written training plan shall specifically address a plan to achieve counseling competency in chemical dependency issues.
(6) Full certification as an addictions counselor by a statewide certification body which is a member of a National certification body or certification by another state government's substance abuse counseling certification board.
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Observations
Based on a review of personnel records, the facility failed to ensure all counselors met the educational qualifications in one of six applicable personnel records reviewed.
Employee #12 was hired as a counselor on October 10, 2022. The employee has a bachelor's degree with a major in English; however, English is not a qualifying major and there was no documentation indicating the employee had full certification from a certification board or an approved exception from the Department.
This is a repeat citation from the January 11, 2023 and January 9, 2024 annual licensing renewal inspections.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
The program failed to request the waiver for exemption for employee #12 since the last DDAP audit in 2024 and did not adhere to the plan of correction. The program will submit a waiver from DDAP by 3/1/2025 regarding Employee #12 bachelor's degree in English.
If the waiver is not granted by DDAP, the program manager will terminate employment of Employee #12 upon receiving the denial letter.
Effective immediately, the senior program director will hold a meeting that will review the DDAP clinical staffing requirements with the program's recruiting department to ensure all staff being onboarded meet the educational requirements. In addition, prior to all onboarding, the senior program director will review the candidate's transcript and degree for final approval. |
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 ensure a written individual training plan was developed annually with input from both the employee and the supervisor in one of sixteen personnel records reviewed.
Employee #15 was hired as a counselor on August 30, 2023. The individual training plan was signed and dated on December 12, 2024 by the employee, but there was no additional documentation indicating the training plan had input from the supervisor.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
Effective immediately, clinical supervisors will ensure all documentation will be signed and reviewed prior to submission to ensure accuracy. Additional training will be conducted with the management team to emphasize the importance of ensuring all documentation is completed in full prior to submission of training plans.
Employee #15's training plan was signed and dated 12/18/24. |
705.28 (d) (6) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(6) Conduct fire drills on different days of the week, at different times of the day and on different staffing shifts.
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Observations
Based on a review of the facility's January 2024 through November 2024 fire drill logs, the facility failed to conduct fire drills on different days of the week, at different times of the day and on different staffing shifts.
The facility's posted hours of operation are Monday through Thursday 5:15AM - 3:00PM, Friday - Sunday 5:15AM - 11:45AM, and Evening Groups 5:00PM - 6:30PM. There were no fire drills conducted in the weekend hours of operations during the entire reviewed period.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Effective immediately, the senior program director will ensure the program facilities technician will begin to include weekends on the rotation of monthly fire drills.
At the conclusion of each month, the senior program director will review with the facilities technician when the fire drills have been conducted, to ensure they are occurring at different times of the day and on different staffing shifts. |
709.23 LICENSURE Project Director
§ 709.23. Project director.
Project directors shall prepare, annually update and sign a written manual delineating project policies and procedures.
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Observations
Based on an administrative review, the project director failed to prepare, annually update, and sign the written manual delineating the project policies and procedures. The policy and procedure manual was last reviewed, updated, and signed on January 20, 2023.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
Moving forward, the program will ensure the project director will review and complete the annual policy and procedures manual and approve it annually at the start of each fiscal year. This will include holding a quarterly meeting to discuss new updates or additions to the policy. This meeting with include the quality assurance director, senior program director and project director. Any changes will be updated within the manual by the quality assurance director, with final approval from the project director. This will be effective immediately starting with the third fiscal quarter. |
709.25 LICENSURE Fiscal Management
§ 709.25. Fiscal management.
The project shall obtain the services of an independent certified public accountant for an annual financial audit of activities associated with the project ' s drug/alcohol abuse services, in accordance with generally accepted accounting principles which include reference to the drug and alcohol treatment activities.
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Observations
Based on an administrative review, the project failed to obtain the services of an independent certified public accountant for the completion of an annual financial audit of activities associated with the project's drug/alcohol abuse services, in accordance with generally accepted accounting principles which include reference to the drug and alcohol treatment activities, for the project's fiscal year ending June 2023.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
NET obtained the services of an independent certified public accounting firm for the Fiscal period ending June 2023. The audit has not yet been completed due to NET being without a CFO for over a year. NET has had a new CFO for the past year and has been able to manage and put safeguards in place to prevent this from occurring in the future. The NET CFO and the fiscal department have been working closely with the independent certified public accounting firm to complete this audit. The audit will be completed by March 31st, 2025. NET will send the results of the audit to DDAP by 3/31/25. |
709.28 (c) (3) 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:
(3) Purpose of disclosure.
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Observations
Based on a review of client records, the facility failed to document the purpose of the disclosure on consent to release information forms in three of eight client records reviewed.
Client #1 was admitted on November 22, 2024 and was active at the time of the inspection. There were release of information forms to a funding source, a transportation agency, and two government agencies signed and dated by the client on November 22, 2024; however, there was no purpose of the disclosure included on any of the release forms.
Client #3 was admitted on May 8, 2024 and was transferred to another narcotic treatment program on September 12, 2024. There were release of information forms to a funding source, a transportation agency, a probation and parole office, a physician, and two government agencies signed and dated by the client on May 8, 2024; however, there was no purpose of the disclosure included on any of the release forms.
Client #8 was admitted on June 9, 2022 and was discharged on November 28, 2024. There was a release of information form to another treatment provider signed and dated by the client on November 12, 2024; however, there was no purpose of the disclosure included on the release form.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The intake department, clinical staff and the quality assurance (QA) department will be re-trained in confidentiality and the process of completing a release of information. This training will include the importance of obtaining written and informed consent for disclosure of information that is in the patient record. Effective immediately, all releases of information will be reviewed by the QA department weekly to ensure that the purpose of the disclosure is included. |
709.28 (d) LICENSURE Confidentiality
§ 709.28. Confidentiality.
(d) A copy of a client consent shall be offered to the client and a copy maintained in the client record.
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Observations
Based on a review of client records, the facility failed to ensure a copy of a client consent to release information form was offered to the client in one of eight client records reviewed.
Client #2 was admitted on July 25, 2024 and was active at the time of the inspection. There was a release of information form to another treatment provider signed and dated by the client on July 25, 2024; however, there was no documentation indicating that a copy of the release form was offered to the client.
This is a repeat citation from the January 9, 2024 annual licensing renewal inspection.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
Effective immediately, the quality assurance department updated the release of information (ROI) form to adhere to the DDAP guidelines. The updated form now includes a section that indicates a copy of the ROI was offered to the patient, which prompts the patient to accept or deny a copy.
Effective Immediately, releases of information will be monitored upon completion by the QA department and clinical management team to ensure all patients are offered a copy of their ROI. |
715.9(a)(4) LICENSURE Intake
(a) Prior to administration of an agent, a narcotic treatment program shall screen each individual to determine eligibility for admission. The narcotic treatment program shall:
(4) Have a narcotic treatment physician make a face-to-face determination of whether an individual is currently physiologically dependent upon a narcotic drug and has been physiologically dependent for at least 1 year prior to admission for maintenance treatment. The narcotic treatment physician shall document in the patient 's record the basis for the determination of current dependency and evidence of a 1 year history of addiction.
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Observations
Based on a review of patient records, the facility failed to have a narcotic treatment physician make a face-to-face determination of whether an individual is currently physiologically dependent upon a narcotic drug prior to the administration of a maintenance agent in three of five applicable patient records reviewed.
Patient #1 was admitted on November 22, 2024 and was active at the time of the inspection. The physician prescribed the patient's first dose of medication on November 22, 2024; however, there was no documentation in the record of an initial face-to-face meeting with the physician prior to the first dose at the time of inspection.
Patient #2 was admitted on June 14, 2024 and was active at the time of the inspection. The physician prescribed the patient's first dose of medication on June 14, 2024; however, there was no documentation in the record of an initial face-to-face meeting with the physician prior to the first dose at the time of inspection.
Patient #5 was admitted on July 25, 2024 and was active at the time of the inspection. The physician prescribed the patient's first dose of medication on July 25, 2024; however, there was no documentation in the record of an initial face-to-face meeting with the physician prior to the first dose at the time of inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Effective immediately, the program's physician will ensure that all documentation completed during the intake process is signed prior to the patient's first dose of medication. This will include a re-training by the Senior Program Director with the program physician and intake staff on the intake process documentation and DDAP expectations.
The Senior Program Director will request a daily report from the QA department to to confirm all intake documents were signed and completed by the program's physician.
On 12/17/2024, the program's physician signed the initial physical exam documentation for Patient #1.
On 12/17/2024, the program's physician signed the initial physical exam documentation for Patient #2.
On 12/17/2024, the program's physician signed the initial physical exam documentation for Patient #5. |
715.9(e) LICENSURE Intake
(e) A narcotic treatment program shall secure a personal history from the patient within the first week of admission. The personal history shall be made a part of the patient record.
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Observations
Based on a review of patient records, the narcotic treatment program failed to complete a personal history from the patient within the first week of admission in three of five applicable patient records reviewed.
Patient #1 was admitted on November 22, 2024 and was active at the time of the inspection. There was no documentation of a personal history in the patient record at the time of inspection.
Patient #2 was admitted on June 14, 2024 and was active at the time of the inspection. There was no documentation of a personal history in the patient record at the time of inspection.
Patient #5 was admitted on July 25, 2024 and was active at the time of the inspection. There was no documentation of a personal history in the patient record at the time of inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Senior Program Director will hold a meeting to work with the QA department to develop a new assessment form that will be utilized during the intake process that will capture the personal and treatment history of the patient to gain an understanding of the patient's history and current needs in treatment. Once implemented, the Senior Program Director will continue to monitor correct implementation and use of the updated form. This will be completed by February 1st, 2025. |
715.20(1) LICENSURE Patient transfers
A narcotic treatment program shall develop written transfer policies and procedures which shall require that the narcotic treatment program transfer a patient to another narcotic treatment program for continued maintenance, detoxification or another treatment activity within 7 days of the request of the patient.
(1) The transferring narcotic treatment program shall transfer patient files which include admission date, medical and psychosocial summaries, dosage level, urinalysis reports or summary, exception requests, and current status of the patient, and shall contain the written consent of the patient.
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Observations
Based on a review of patient records, the narcotic treatment program failed to ensure patient files, including admission date, medical and psychosocial summaries, dosage level, urinalysis reports or summary, exception requests, and current status of the patient, were transferred to the receiving narcotic treatment program in two of two applicable patient records reviewed.
Patient #3 was admitted on May 8, 2024 and was transferred to another narcotic treatment program on September 12, 2024. There was no documentation in the record indicating the receiving narcotic treatment program was notified of the date of admission of the patient, medical and psychosocial summaries, dosage level, urinalysis reports or summary, exception requests, and current status of the patient.
Patient #8 was admitted on June 9, 2022 and was transferred to another narcotic treatment program on November 28, 2024. There was no documentation in the record indicating the receiving narcotic treatment program was notified of the date of admission of the patient, medical and psychosocial summaries, dosage level, urinalysis reports or summary, exception requests, and current status of the patient.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Senior Program Director will hold a meeting with the upper management team to create a new policy and procedure on how to transfer individuals to another treatment provider. The senior program director will then re-train clinical staff on the new transfer process, the required documentation needed while transferring individuals to another facility and what will be needed to obtain from the outside provider. This will be completed effective March 1, 2025.
The director of operations will request a weekly report listing all transfers occurring within the program, to ensure all necessary documentation is included in the transfer paperwork and patient's chart. |
715.20(4) LICENSURE Patient transfers
A narcotic treatment program shall develop written transfer policies and procedures which shall require that the narcotic treatment program transfer a patient to another narcotic treatment program for continued maintenance, detoxification or another treatment activity within 7 days of the request of the patient.
(4) The receiving narcotic treatment program shall document in writing that it notified the transferring narcotic treatment program of the admission of the patient and the date of the initial dose given to the patient by the receiving narcotic treatment program.
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Observations
Based on a review of patient records, the narcotic treatment program failed to document, in writing, that it notified the transferring narcotic treatment program of the date of the admission of the patient and the date of the initial dose given to the patient in one of two applicable patient records reviewed.
Patient #4 was admitted on October 17, 2024 and was still active at the time of inspection. There was no documentation in the record indicating the program notified the transferring narcotic treatment program of the patient ' s date of admission and the date the initial dose was given.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
The Senior Program Director will ensure all documentation pertaining to patient transfers will be uploaded and documented on non-billable notes within the electronic medical records system. The Senior Program Director will ensure all clinical and QA staff will be re-trained by their supervisors on the transfer process to ensure accuracy. This will be completed effective February 1st, 2025. |
715.23(b)(4) LICENSURE Patient records
(b) Each patient file shall include the following information:
(4) The results of an initial intake physical examination.
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Observations
Based on a review of patient records, the narcotic treatment program failed to include documentation of the results of an initial intake physical examination in two of five applicable patient records reviewed.
Patient #2 was admitted on June 14, 2024 and was active at the time of the inspection. There was no documentation of the results of the initial intake physical examination in the record at the time of the inspection.
Patient #5 was admitted on July 25, 2024 and was active at the time of the inspection. There was no documentation of the results of the initial intake physical examination in the record at the time of the inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Effective immediately, the Senior Program Director will ensure the program's physician is re-trained on the intake process and DDAP regulations, to ensure that all documentation completed during the initial physical exam is completed and signed the same day the exam is conducted.
In addition, the QA department will review all completed intake appointments by the end of business each day to ensure the program's physician has completed all documentation.
Patient #2 had the initial physical exam signed on 12/17/2024 by the program's physician.
Patient #5 had the initial physical exam signed on 12/17/2024 by the program's physician. |
715.28(c)(1-5) LICENSURE Unusual incidents
(c) A narcotic treatment program shall file a written Unusual Incident Report with the Department within 48 hours following an unusual incident including the following:
(1) Complaints of patient abuse (physical, verbal, sexual and emotional).
(2) Death or serious injury due to trauma, suicide, medication error or unusual circumstances.
(3) Significant disruption of services due to a disaster such as a fire, storm, flood or other occurrence.
(4) Incidents with potential for negative community reaction or which the facility director believes may lead to community concern.
(5) Drug related hospitalization of a patient.
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Observations
Based on a review of the unusual incident report logs, the narcotic treatment program failed to notify the Department within 48 hours of a death or serious injury due to trauma, suicide, medication error or unusual circumstances.
On November 19, 2024, the narcotic treatment program was notified of the off-site death of a patient. The treatment program did not report the unusual incident to the Department until December 5, 2024.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
The Program will continue to complete unusual incident reports within 48 hours. Staff will be retrained and educated in the process of submitting unusual incident reports via the electronic reporting system (ERS).
The Program manager will ensure the report has been completed and submitted to DDAP within the 48-hour requirement. |
709.91(b)(3)(i) LICENSURE Intake and admission
709.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(3) Histories, which include the following:
(i) Medical history.
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Observations
Based on a review of client records, the facility failed to document a medical history of the client, as part of their intake and admission process, in two of five applicable client records reviewed.
Client #2 was admitted on June 14, 2024 and was active at the time of the inspection. There was no documentation in the record indicating a medical history was completed at the time of the inspection.
Client #5 was admitted on July 25, 2024 and was active at the time of the inspection. There was no documentation in the record indicating a medical history was 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
Effective immediately, once a patient has been admitted to treatment and assigned their primary counselor, the counselor will be required to complete the biopsychosocial within their first 30 days of treatment, which includes the comprehensive medical history of the patient.
The QA department will monitor and submit weekly reports to each counselor and supervisors, which will include the due dates for the biopsychosocial of each patient.
Patient #2 had their biopsychosocial completed on 12/19/2024, documenting medical history of the patient.
Patient #5 will have their biopsychosocial complete on 1/20/2025, documenting medical history of the patient. |
709.91(b)(3)(ii) LICENSURE Intake and admission
709.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(3) Histories, which include the following:
(ii) Drug or alcohol history, or both.
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Observations
Based on a review of client records, the facility failed to document a drug and alcohol history of the client, as part of their intake and admission process, in two of five applicable client records reviewed.
Client #2 was admitted on June 14, 2024 and was active at the time of the inspection. There was no documentation in the record indicating a drug and alcohol history was completed at the time of the inspection.
Client #5 was admitted on July 25, 2024 and was active at the time of the inspection. There was no documentation in the record indicating a drug and alcohol history was 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
Effective immediately, once a patient has been admitted to treatment and assigned to their primary counselor, the counselor will be required to complete the biopsychosocial within their first 30 days of treatment, which includes the comprehensive drug and/or alcohol history of the patient.
The QA department will monitor and submit weekly reports to each counselor and supervisor, which will include the due dates for the biopsychosocial of each patient.
Patient #2 had their biopsychosocial completed on 12/19/2024, documenting the drug and alcohol history of the patient.
Patient #5 had their biopsychosocial complete on 1/20/2025, documenting the drug and alcohol history of the patient. |
709.91(b)(6) LICENSURE Intake and admission
709.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(6) Psychosocial evaluation.
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Observations
Based on a review of client records, the facility failed to document a psychosocial evaluation, as part of their intake and admission process, in four of four applicable client records reviewed.
Client #2 was admitted on June 14, 2024 and was active at the time of the inspection. There was no documentation in the record indicating a psychosocial evaluation was completed at the time of the inspection.
Client #3 was admitted on May 8, 2024 and was transferred to another narcotic treatment program on September 12, 2024. There was no documentation in the record indicating a psychosocial evaluation was completed at the time of the inspection.
Client #4 was readmitted on October 17, 2024 and was active at the time of the inspection. There was no documentation in the record indicating a psychosocial evaluation was completed at the time of the inspection.
Client #5 was admitted on July 25, 2024 and was active at the time of the inspection. There was no documentation in the record indicating a psychosocial evaluation was 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
Effective immediately, once a patient has been admitted to treatment and assigned their primary counselor, based on the policy and procedures regarding the biopsychosocial, all will be required to complete the biopsychosocial within the first 30 days of treatment.
The QA department will monitor and submit weekly reports to each counselor and supervisors, which will include the due dates for the biopsychosocial of each patient.
Patient #2 had their biopsychosocial completed on 12/19/2024.
Patient #3 will have their biopsychosocial complete on 1/20/2025.
Patient #4 will have their biopsychosocial complete on 1/20/2025.
Patient #5 will have their biopsychosocial complete on 1/20/2025. |
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 ensure treatment and rehabilitation plans were reviewed and updated at least every sixty days in three of six applicable client records reviewed.
Client #2 was admitted on June 14, 2024 and was active at the time of the inspection. The individual treatment and rehabilitation plan was completed on June 27, 2024 and the first update was due no later than August 27, 2024; however, the update was completed on October 2, 2024. Additionally, the next treatment plan update was due no later than December 2, 2024; however, the update was completed on December 10, 2024.
Client #7 was admitted on July 11, 2007 and was discharged on August 19, 2024. A treatment plan update was completed on May 23, 2024 and the next update was due no later than July 23, 2024; however, the update was not completed prior to discharge.
Client #8 was admitted on June 9, 2022 and was discharged on November 28, 2024. A treatment plan update was completed on July 31, 2024 and the next update was due no later than September 30, 2024; however, the update was not completed prior to discharge.
This is a repeat citation from the January 11, 2023 and January 9, 2024 annual licensing renewal inspections.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The QA department will continue to send weekly reports to all clinical staff and supervisors, which includes each patient, and their treatment plan update due dates.
The leadership team will continue to monitor and retrain the clinical staff on completing treatment plan updates correctly and within the required times.
This will begin 2/1/2025 and will occur during bi-weekly supervisions and weekly clinical staff meetings.
Patient #2 treatment plan was completed on 12/10/2024. Moving forward, all treatment plan updates for patient #2 will be completed every sixty days.
Patient #7 was discharged on 8/19/2024, therefore a treatment plan update cannot be completed at this time.
Patient #8 was discharged on 11/28/2024, therefore a treatment plan update cannot be completed at this time. |
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.
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Observations
Based on a review of client records, the facility failed to assure that counseling services were being provided according to the individual treatment and rehabilitation plan in five of eight client records reviewed.
Client #2 was admitted on June 14, 2024 and was active at the time of the inspection. The June 27, 2024 individual treatment and rehabilitation plan and the October2, 2024 and December 10, 2024 treatment plan updates indicated the client was to receive group sessions three times per week. There was no documentation in the record of group sessions being conducted throughout the entire treatment episode.
Client #4 was readmitted on October 17, 2024 and was active at the time of the inspection. The November 1, 2024 treatment plan update indicated the client was to receive one individual session per week. There was no documentation in the record of individual sessions being conducted during the weeks of November 10, 2024 through November 23, 2024 and December 8, 2024 through December 14, 2024.
Client #6 was admitted on August 4, 2021 and discharged on October 23, 2024. The April 24, 2024, June 14, 2024, and August 6, 2024 treatment plan updates indicated the client was to receive one individual session per week. There was no documentation in the record of individual sessions being conducted during the weeks of April 28, 2024 through May 4, 2024, May 26, 2024 through June 1, 2024, June 16, 2024 through June 29, 2024, July 21, 2024 through August 3, 2024, August 11, 2024 through August 24, 2024, September 1, 2024 through September 7, 2024, and September 15, 2024 through September 21, 2024.
Client #7 was admitted on July 11, 2007 and discharged on August 19, 2024. The May 23, 2024 treatment plan update indicated the client was to receive one individual session per month. There was no documentation in the record of individual sessions being conducted during the months of June 2024 and July 2024.
Client #8 was admitted on June 9, 2022 and discharged on November 28, 2024. The July 31, 2024 treatment plan update indicated the client was to receive one individual session per week. There was no documentation in the record of individual sessions being conducted during the weeks of June 9, 2024 through June 29, 2024.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
All clinical staff will be reminded by the program manager and clinical supervisors to document any missed services expected to be completed within the treatment plan. This will begin 2/1/2025 and will occur during bi-weekly supervisions and weekly clinical staff meetings. The program manager will review and ensure that all treatment plan goals are being followed by counselors.
Effective immediately, Patient #2 will attend group sessions three times per week in accordance with what is stated in the current treatment plan. Moving forward, Patient #2 will receive services to align with their treatment plan. If services are not complete, missed services will be documented in Patient #2 chart.
Effective immediately, Patient #4 will receive one individual session per week in accordance with what is stated in the current treatment plan. Moving forward, Patient #4 will receive services to align with their treatment plan. If the services are not complete, missed services will be documented in Patient #4 chart.
Effective immediately, Patient #6 will receive one individual session per week in accordance with what is stated in the current treatment plan. Moving forward, Patient #6 will receive services to align with their treatment plan. If the services are not complete, missed services will be documented in Patient #6 chart.
Patient #7 was discharged on 8/19/2024, therefore an individual session cannot be completed at this time.
Patient #8 was discharged on 11/28/2024, therefore an individual session cannot be completed at this time. |
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, the facility failed to comply with plans of correction that were approved by the Department.
A plan of correction for ensuring all counselors met the educational qualifications of the position were submitted and approved by the Department for the January 11, 2023 and January 9, 2024 annual licensing inspections. Failing to ensure all counselors met the educational qualifications was again found to be a deficiency in the December 17, 2024 through December 18, 2024 licensing inspection.
A plan of correction for ensuring the completion of treatment plan updates within the regulatory timeframe was submitted and approved by the Department for the January 11, 2023 and January 9, 2024 annual licensing inspections. Failing to complete treatment plan updates within the regulatory timeframe was again found to be a deficiency in the December 17, 2024 through December 18, 2024 licensing inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The leadership team will continue to monitor and retrain the clinical staff on completing treatment plan updates correctly and within the required timeframe. The Clinical supervisors will meet with each counselor during bi-weekly supervisions to review caseload reports, and to provide direction and deadlines on upcoming treatment plan due dates. The clinical team will continue completing treatment plan updates every 45 days to prevent late treatment plan updates. This will begin 2/1/2025 and will occur during bi-weekly supervisions and weekly clinical staff meetings.
We will be requesting a waiver from DDAP explaining the desire to retain the Employee #12 due to developing a positive rapport and an established therapeutic relationship with his caseload by 3/1/2025. If the waiver is not granted by DDAP, the program will terminate employment Employee #12 upon receiving the denial letter.
Effective immediately, the senior program director will hold a meeting that will review the DDAP clinical staffing requirements with the program's recruiting department to ensure all staff being onboarded meet the educational requirements. In addition, prior to all onboarding, the senior program director will review the candidate's transcript and degree for final approval.
Effective immediately, the senior management team will meet quarterly to review the plan of corrections to monitor the implementation and progress in maintaining compliance with the plan of corrections. |