INITIAL COMMENTS
|
This report is a result of an on-site licensure renewal inspection and methadone monitoring conducted on July 17, 2023 through July 19, 2023 by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, New Directions Treatment Services 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
|
709.28 (c) (2) LICENSURE Confidentiality
§ 709.28. Confidentiality.
(c) The project shall obtain an informed and voluntary consent from the client for the disclosure of information contained in the client record. The consent must be in writing and include, but not be limited to:
(2) Specific information disclosed.
|
Observations
Based on a review of client records, the facility failed to document the specific information to be disclosed on a consent to release information form in one of seven client records reviewed. Client #2 was admitted on June 23, 2023 and was active at the time of inspection. A release of information form to an emergency contact was signed and dated by the client on June 26, 2023; however, the form did not include the specific information to be disclosed. This finding was reviewed with facility staff during the licensing process.
|
Plan of Correction
On 8/10/23, during weekly team meeting, all clinicians were reminded of the requirement to document the specific information to be disclosed when completing a release of information for disclosure of client PHI. The Primary therapist met with Client #2 and documented the specific information to be disclosed on the Consent.The Clinical Supervisor will be responsible for monitoring compliance with the regulation through random record review and during clinical supervision on an ongoing basis. |
709.28 (c) (4) LICENSURE Confidentiality
§ 709.28. Confidentiality.
(c) The project shall obtain an informed and voluntary consent from the client for the disclosure of information contained in the client record. The consent must be in writing and include, but not be limited to:
(4) Dated signature of client or guardian as provided for under 42 CFR 2.14(a) and (b) and 2.15 (relating to minor patients; and incompetent and deceased patients).
|
Observations
Based on a review of client records, the facility failed to document the dated signature of the client on a release of information form in one of seven client records reviewed.Client #2 was admitted on June 23, 2023 and was active at the time of inspection. A release of information form to an emergency contact, signed by the witness on June 27, 2023, was included in the client record; however, the release form did not include the dated signature of the client. This finding was reviewed with facility staff during the licensing process.
|
Plan of Correction
During weekly treatment team meeting on 8/10/23, regulatory requirements for releases of confidential information were reviewed with clinicians. Clinicians were reminded to ensure that the consent provided by the client was documented on the release by a dated client signature. The Primary Therapist met with Client #2 and the client completed the dated signature required on the release. The Clinical Supervisor will be responsible for ensuring compliance with the regulation through random record review and during individual supervision meetings with clinicians. |
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
Based on a review of patient records, the facility failed to provide an average of 2.5 hours of psychotherapy per month during the patient's first 2 years in treatment in one of three applicable patient records reviewed. Patient #7 was admitted on March 1, 2021 and was discharged February 11, 2023. The record of service and progress notes documented that during the following months less than 2.5 hours of psychotherapy per month was provided to the patient: September 2022: 2 hours of psychotherapy; October 2022: 2 hours of psychotherapy; November 2022: 1 hour of psychotherapy; and December 2022: 2 hours of psychotherapy.This is a repeat citation from the July 21, 2022, October 28, 2021, and May 12, 2021 annual licensing renewal inspections.This finding was reviewed with facility staff during the licensing process.
|
Plan of Correction
By 8/17/23 the Facility Director will facilitate a training to clinicians on recommended interventions to ensure that clients receive the required number of hours of therapy stipulated by the regulations. The Clinical Supervisor will assist the clinicians with implementation of the interventions and will be responsible for ongoing compliance with the regulation by reviewing monthly audits of therapy provided to clients. |
715.23(b)(5) LICENSURE Patient records
(b) Each patient file shall include the following information:
(5) The results of all annual physical examinations given by the narcotic treatment program which includes an annual reevaluation by the narcotic treatment physician.
|
Observations
Based on a review of patient records, the facility failed to ensure that the results of an annual physical examination given by the narcotic treatment program which is to include an annual reevaluation by the narcotic treatment physician, was documented in one of five applicable patient records reviewed. Patient #5 was admitted on April 18, 2022 and was discharged on May 15, 2023. The patient's previous physical exam was completed on April 18, 2022 and the next exam was due to be completed by the physician on April 18, 2023; however, the exam and reevaluation was not completed prior to patient's discharge. This finding was reviewed with facility staff during the licensing process.
|
Plan of Correction
Beginning on 9/05/2023, an alert and tracking system will be implemented in the EMR that will provide notification to staff of the names of clients who are due to have an annual physical examination during the upcoming month. Nursing staff will be responsible for scheduling and reminding clients of upcoming appointments. The Nursing Director will be responsible for ongoing compliance with the regulation by monitoring the record of completed examinations and ensuring that clients who miss appointments are rescheduled and attend their appointments in a timely manner. |
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.
|
Observations
Based on a review of patient records, the facility failed to ensure that an annual evaluation of the patient's status was completed by the patient's counselor and was reviewed, dated, and signed by the medical director in two of five applicable patient records reviewed. Patient #5 was admitted on April 18, 2022 and was discharged on May 15, 2023. The annual evaluation of the patient's status was completed by the counselor on April 26, 2023; however, the evaluation was not signed by the medical director. Patient #6 was admitted on June 16, 2021 and was discharged on May 22, 2023. The annual evaluation of the patient's status was last completed May 1, 2022 and was due to be completed by the counselor on May 1, 2023; however, the evaluation was not completed prior to patient's discharge. This is a repeat citation from the July 21, 2022 annual licensing renewal inspection.This finding was reviewed with facility staff during the licensing process.
|
Plan of Correction
By 9/30/2023, the IT Director will implement an alert and tracking system in the EMR to notify clinicians of the due dates and the signature requirements for client Annual Evaluations. Alerts will be included in the Task List and will remain active until the Evaluation has been completed and the physician's and other staff signature regulatory requirements have been met.
The Clinical Supervisor will be responsible for monitoring ongoing compliance with the regulation through random record review and during individual supervision |
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.
|
Observations
Based on a review of the facility's unusual incident logs, the facility failed to file a written unusual incident report with the Department within 48 hours following a death due to trauma, suicide, medication error or unusual circumstances. The facility was notified of the off-site deaths of several patients on August 29, 2022, September 27, 2022, October 6, 2022 and February 17, 2023; however, none of the incidents were reported to the Department within the regulatory timeframe. This finding was reviewed with facility staff during the licensing process.
|
Plan of Correction
By 8/24/23 the Facility Director will provide training to clinical and medical staff on the regulatory requirements for reporting of Unusual Incidents involving active clients enrolled in the program. Clinical Supervisors, Clinicians and Medical staff will be required notify the Facility Director and/or the Nursing Director immediately if an Unusual Incident occurs at the facility of if staff receives notification of an unusual incident that occurred outside the facility. The Facility Director and/or the Nursing Director will be responsible for submitting an Unusual Incident Report electronically to the Department within 48 hours of the incident or the receipt of an incident report from outside the facility. Nursing staff will be required to retain delivery confirmation in the event that the report has been submitted by fax. The Nursing Director will be responsible for ongoing compliance with the regulation by maintaining a log of Unusual Incidents as well as copies of the reports submitted to the department. |
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.
|
Observations
Based on a review of client records, the facility failed to ensure that treatment and rehabilitation plans were reviewed and updated at least every 60 days in three of six applicable client records reviewed.Client #1 was admitted on October 13, 2022 and was active at the time of inspection. The comprehensive treatment plan was completed on November 6, 2022 and the first update was due no later than January 6, 2023; however, the update was not completed until January 23, 2023. Additionally, a treatment plan update was completed on March 24, 2023 and the next update was due no later than May 24, 2023; however, the update was not completed until June 13, 2023.Client #4 was admitted on May 16, 2018 and was discharged on February 7, 2023. A treatment plan update was completed on May 24, 2022 and the next update was due no later than July 24, 2022; however, the update was not completed until September 20, 2022.Client #5 was admitted on April 18, 2022 and was discharged on May 15, 2023. A treatment plan update was completed on September 14, 2022 and the next update was due no later than November 14, 2022; however, the update was not completed until November 23, 2022.This finding was reviewed with facility staff during the licensing process.
|
Plan of Correction
By 9/30/2023, the IT Director will implement an alert and tracking system in the EMR to notify clinicians of the due dates for the review and update of treatment and rehabilitation plans. Alerts will be included in the Task List and will remain active until the Review and Update has been completed in accordance with the regulatory requirement.
The Clinical Supervisor will be responsible for ensuring ongoing compliance with the regulation through random record review and during individual supervision.
|
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.
|
Observations
Based on a review of patient records, the facility failed to comply with plans of correction that were approved by the Department. Plans of correction for failing to provide an average of 2.5 hours of psychotherapy per month during the patient's first 2 years in treatment were submitted and approved by the Department for the July 21, 2022, October 28, 2021, and May 12, 2021 annual licensing inspections. Failing to provide an average of 2.5 hours of psychotherapy per month during the patient's first 2 years in treatment was again found to be a deficiency in the July 17, 2023 through July 19, 2023 licensing inspection.This finding was reviewed with facility staff during the licensing process.
|
Plan of Correction
By 8/28/2023,the Facility Director will meet with the Treatment Team to review the Plans of Correction submitted to the department in May 2021, October 2021, July 2022 and AUGUST 2023 and to address the regulatory requirement to follow all plans of correction approved by the Department. The QA/UR Manager and the Clinical Supervisor will be responsible for ongoing compliance with meeting the requirements through monthly record of service audits and during group and individual Clinical Supervision. |