INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection and monitoring inspection conducted for the approval to use a narcotic agent, specifically Methadone and Buprenorphine, in the treatment of narcotic addiction. This inspection was conducted on October 3, 2016 - October 5, 2016 by staff from the Division of Drug and Alcohol 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 4 PA Code and 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
Based on a review personnel records, the facility failed to ensure that all staff members received the required communicable disease training within the required timeframes.
Staff member #36 was hired on 1/12/14 as a recovery specialist. This staff member was required to obtain 4 hours of TB/STD training by 1/12/16. Employee #36 failed to obtain the training as of the date of the inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Director of Operations will identify all employees who need this training, and will enroll them in this training within 1 year of their hire date. Employee # 36 will be trained on the required STD/TB by the above date. |
705.4 (3) LICENSURE Counseling areas.
705.4. Counseling areas.
The residential facility shall:
(3) Ensure privacy so that counseling sessions cannot be seen or heard outside the counseling room. Counseling room walls shall extend from the floor to the ceiling.
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Observations
A physical plant inspection was conducted on October 5, 2016 at approximately 11:10 AM.
There were multiple clients participating in group counseling sessions in Group Rooms 4 and 214. The doors for both Group Room 4 and Room 214 were wide open while the group counseling was in session.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Clinical Supervisors will conduct a training with all staff on clients' confidentiality and privacy, and the importance of keeping all counselors' doors closed while sessions are in progress. Facilities Techs will be designated by the clinical supervisor to make rounds hourly to ensure all doors are closed. |
705.8 (2) LICENSURE Heating and cooling.
705.8. Heating and cooling.
The residential facility:
(2) May not permit in the facility heaters that are not permanently mounted or installed.
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Observations
A physical plant inspection was conducted on October 5, 2016 at approximately 11:10 AM.
Portable space heaters that were not permanently mounted or installed were observed under a reception desk next to Room 219 and on the floor in Room 204.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Director of Operations will inform all staff in a staff meeting that space heaters are not permitted in any workspace. |
705.9 (3) LICENSURE General safety and emergency procedures.
705.9. General safety and emergency procedures.
The residential facility shall:
(3) Limit smoking to designated smoking areas.
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Observations
A physical plant inspection was conducted on October 5, 2016 at approximately 11:10 AM. Neither of these following locations were designated smoking areas.
There were many cigarette butts scattered on the ground at the bottom of the stairs that lead to the enterance of the facility from the parking lot.
There were 3 cigarette butts in the toilet in first stall in the bathroom located in Dorm #2.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Residential Program Director reviewed the Wharton Center's existing policies regarding smoking with all residents at the Wharton Center, reminding them that the only area where smoking is permitted is outside of the facility and that there is signage clearly indicating that smoking is not permitted in the bathroom or the facility.
In addition, the Residential Program Director reviewed the program's enforcement plan with all program staff to ensure that all staff meet the expected requirements of the program's ongoing procedures for monitoring and enforcement of the program's smoking policies.
To ensure ongoing compliance the Residential Program Director will continue to implement and ensure regular enforcement of the smoking policies of the facility, which will include the ongoing and frequent daily monitoring of the communal bathrooms to prevent residents from smoking in these areas.
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705.10 (c) (4) LICENSURE Fire safety.
705.10. Fire safety.
(c) Fire extinguisher. The residential facility shall:
(4) Instruct all staff in the use of the fire extinguishers upon staff employment. This instruction shall be documented by the facility.
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Observations
Based on a review of personnel records, employee # 17 failed to have documentation upon hire for the fire extinguisher training.
Employee #17 was hired on 9/25/15 as a clinical supervisor. The fire extinguisher training was completed on 10/15/15.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Director of Operations will meet with all new hires within 7 days of hire and conduct the fire extinguisher training and document it on a signed form. |
709.26 (b) (3) LICENSURE Personnel management.
§ 709.26. Personnel management.
(b) The personnel records must include, but are not limited to:
(3) Annual written individual staff performance evaluations, copies of which shall be reviewed and signed by the employee.
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Observations
Based on a review of personnel records, the facility failed to provide annual written individual staff performance evaluations in two personnel records.
Employee #1 was hired as Project Director/President/CEO on 7/1/2013. Employee #1's annual evaluation was not completed as of the date of the licensing inspection.
Employee #30 was hired as Facility Director/Vice President on 5/24/2000. Employee #30's annual evaluation was not completed as of the date of the licensing inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The CEO will provide the site with her annual evaluation. The CEO will conduct a performance evaluation on the VP. Human Resources Department will conduct quarterly reviews of personnel files to ensure performance evaluations are completed. |
715.19(3) LICENSURE Psychotherapy services
A narcotic treatment program shall provide individualized psychotherapy services and shall meet the following requirements:
(3) After 4 years of treatment, a narcotic treatment program shall provide each patient with at least 1 hour of group or individual psychotherapy every 2 months. Additional psychotherapy shall be provided as dictated by ongoing assessment of the patient.
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Observations
Based on a review of patient records, the facility failed to provided at least 1 hour of group or individual psychotherapy every 2 months for patient #2.
Patient #2 was admitted to methadone treatment on 10/23/2006. Patient #2 was being provided 6 take-homes. Patient #2 received .50 hrs of treatment on 9/14/2016 and 0.0 hrs of treatment for the month of August 2016.
These findings were reviewed with facility staff during the licensing process
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Plan of Correction
The clinical supervisor will review all counselors' caseloads weekly to ensure that patients are meeting their counseling requirements each month. Patient number two will be reassigned a permanent counselor and begin regular attendance in group and individual therapy. |
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 ten patient records, the facility failed to 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 in one patient record.
Patient #4 was transferred to the facility on 12/2/2015. There was no documentation in the patient record confirming the transferring facility was notified by the receiving facility.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Director of Operations will conduct a weekly audit of all transfers in and ensure that the Intake Department submits an admission verification to the sending clinic within 7 days of admission. |
715.23(c)(1-7) LICENSURE Patient records
(c) An annual evaluation of each patient 's status shall be completed by the patient 's counselor and shall be reviewed, dated and signed by the medical director. The annual evaluation period shall start on the date of the patient 's admission to a narcotic treatment program and shall address the following areas:
(1) Employment, education and training.
(2) Legal standing.
(3) Substance abuse.
(4) Financial management abilities.
(5) Physical and emotional health.
(6) Fulfillment of treatment objectives.
(7) Family and community supports.
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Observations
Based on a review of patient records, the facility failed to provide a completed annual evaluation of the patient's status in one of ten patient records, as required.
Patient #2 was admitted to the methadone treatment program on 10/23/2006. There was no documentation of an annual evaluation in the patient's record for 10/2015.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Clinical supervisor will run a monthly report to ensure all patients receive a clinical evaluation on their yearly admission anniversary. |
709.93(a)(8) LICENSURE Client records
709.93. Client records.
(a) There shall be a complete client record on an individual which includes information relative to the client's involvement with the project. This shall include, but not be limited to, the following:
(8) Case consultation notes.
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Observations
Based on a review of patient records during the licensing inspection of October 3-5, 2016, four out of ten patient records did not include case consultation notes, as required.
Patient #1 was admitted on 6/13/2006 and is still an active patient. There was no case consultation documented for patient #1 since 6/2015.
Patient #2 was admitted on 10/23/2006 and is still an active patient. The last case consultation for patient #2 was 9/30/2015.
Patient #4 was admitted on 12/2/2015 and was discharged 7/12/2016. The facility failed to document a case consultation as of the date of patient #4's discharge date.
Patient #10 was admitted on 11/11/2015 and was discharged 4/1/2016. The facility failed to document a case consultation as of the date of patient #10's discharge date.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Clinical Supervisor will run a monthly report to ensure all counseling staff complete a case consult within the regulatory timeframe. |