INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection and methadone monitoring conducted on September 30, 2024 through October 1, 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 Family Health Care LLC, dba Lansdowne 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:
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Plan of Correction
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704.6(c) LICENSURE Core Curriculum - Supervisor Training
704.6. Qualifications for the position of clinical supervisor.
(c) Clinical supervisors and lead counselors who have not functioned for 2 years as supervisors in the provision of clinical services shall complete a core curriculum in clinical supervision. Training not provided by the Department shall receive prior approval from the Department.
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Observations
Based on a review of personnel files, the facility failed to ensure that one applicable clinical supervisor had completed a core curriculum in clinical supervision which is a requirement for the position.
Employee # 4 was promoted to the position of clinical supervisor on October 16, 2023 and is current in that position. Employee # 4 did not function for 2 years as a supervisor and has not completed a core curriculum 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
All newly hired or promoted clinical supervisors who do not have at least 2 years of clinical supervision experience will be enrolled by the Executive Director in one of the DDAP-approved clinical supervision curricula by their third business day in the supervisor position.
Clinical Supervisor has been enrolled in the Clinical Supervisor curriculum on Relias and will be complete by 11/30/2024 |
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.
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Observations
Based on a review of nine client records, the facility failed to obtain an informed and voluntary consent from the client for the disclosure of information in one record reviewed.
Client # 5 was admitted on July 2, 2024 and was active at the time of the inspection. Per a discussion with the Facility Director, information such as the client's diagnosis was disclosed to the funding source; however, the consent to release information form to the funding source signed by the client on July 2, 2024, did not allow for the release of that information.
This is a repeat citation from the September 1, 2023 and November 3, 2023 annual renewal licensing inspections.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Each admission chart will be reviewed for accuracy by the Clinical Director or Clinical Supervisor within seven days of admission and any incorrect releases will be deactivated and corrected.
The release reviewed during the inspection was corrected on 10/2/2024.
Teammates have been retrained on correct completion of releases of information |
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.
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Observations
Based on a review of nine client records, the facility failed to ensure that informed and voluntary consent to release information forms included the specific information to be disclosed in two records reviewed.
Client # 1 was admitted on August 6, 2024 and was active at the time of the inspection. The record contained a consent to release information form to the funding source signed by the client on August 6, 2024, that was missing the specific information to be disclosed.
Client # 9 was admitted on March 11, 2024 and was discharged on August 26, 2024. The record contained a consent to release information form to the funding source signed by the client on March 11, 2024, that was missing the specific information to be disclosed.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Each admission chart will be reviewed for accuracy by the Clinical Director or Clinical Supervisor within seven days of admission and any incorrect releases will be deactivated and corrected.
The release reviewed during the inspection was corrected on 10/2/2024.
Teammates have been retrained on correct completion of releases of information |
709.33 (a) LICENSURE Notification of termination.
§ 709.33. Notification of termination.
(a) Project staff shall notify the client, in writing, of a decision to involuntarily terminate the client ' s treatment at the project. The notice shall include the reason for termination.
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Observations
Based on a review of nine client records, the facility failed to document that the client was notified, in writing, of the facility's decision to involuntarily terminate the client's treatment at the project in one of one applicable record reviewed.
Client # 3 was admitted on April 26, 2022 and was involuntarily discharged on March 26, 2024. Documentation in the record indicated that the involuntary detoxication began on February 23, 2024; however, the client was not notified in writing until March 26, 2024.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Counselors were retrained on 4/29/2024 regarding proper documentation of notice for medically supervised withdrawal, both with patient signature and without. All involuntary discharges are to be reviewed with Executive Director prior to discharge being initiated and ED will confirm that all required documentation is completed on the day of the notice. |
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 receiving narcotic treatment program 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 in one of one applicable record reviewed.
Patient # 1 was transferred to the facility on August 6, 2024 and was active at the time of the inspection. There was no documentation that the transferring narcotic treatment program was notified of the patient ' s admission or date of the initial dose.
This is a repeat citation from the September 1, 2023 and November 3, 2023 annual renewal licensing inspections.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Clinical and Nursing team have been trained on sending acknowledgement of transfer to all programs patients are admitted from, including withdrawal management and residential programs, if dosing was provided at the transferring facility. Notification will be sent on the day of admission to the program. The Nurse Supervisor will ensure notice has been sent within 24 hours of admission. |
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.
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Observations
Based on a review of patient records, the facility failed to ensure an annual physical reevaluation in two of three applicable records reviewed.
Patient # 2 was admitted on May 26, 2022 and was discharged on August 6, 2024. The record did not contain a recent annual physical reevaluation.
Patient # 6 was admitted on May 2, 2023 and was active at the time of the inspection. The most recent annual physical evaluation was due no later than May 2, 2024; however, it was not documented in the patient record until May 6, 2024.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Executive Director will send list of physicals due to the medical and front desk teams at the beginning of each month to ensure that all physical appointments are scheduled and completed with the patient by the date the service is due. |
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 the review of patient records, the facility failed to document a completed annual evaluation signed by the medical director in two of four applicable records.
Patient # 2 was admitted on May 26, 2022 and was discharged on August 6, 2024. The annual evaluation was due to be completed by May 26, 2024; however, an annual evaluation was not completed as of the date of the inspection.
Patient # 6 was admitted on May 2, 2023 and was active at the time of the inspection. The annual evaluation was due to be completed by May 2, 2024; however, it was not completed until May 6, 2024. Additionally, the annual evaluation was not signed by the medical director.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Clinical Director (CD) and Clinical Supervisor (CS) will run reports at the beginning of each week for upcoming annual evaluations needed and send them to counselors to complete. If a teammate is out of the office, CD and CS will ensure that either an available counselor or member of leadership completes the documentation so that it is completed by the due date. All required signatures (counselor, clinical supervisor, and medical director) will be obtained within 48 hours of the document being completed. |
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:
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Observations
Based on a review of client records, the facility failed to ensure that an individual treatment and rehabilitation plan was developed with the client within 30 days of admission, per the facility policy, in three of four applicable records reviewed.
Client # 1 was admitted on August 6, 2024 and was active at the time of the inspection. The individual treatment and rehabilitation plan was due to be completed by September 6, 2024; however, it was not completed until September 19, 2024.
Client # 5 was admitted on July 2, 2024 and was active at the time of the inspection. The individual treatment and rehabilitation plan was due to be completed by August 2, 2024; however, it was not completed as of the date of the inspection.
Client # 7 was admitted on January 12, 2024 and was discharged on April 5, 2024. The individual treatment and rehabilitation plan was due to be completed by February 12, 2024; however, it was not completed prior to the date of discharge.
This is a repeat citation from the September 1, 2023 and November 3, 2023 annual renewal licensing inspections.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Clinical Director (CD) and Clinical Supervisor (CS) will run reports at the beginning of each week for upcoming treatment plans needed and send them to counselors to complete. If a teammate is out of the office, CD and CS will ensure that either an available counselor or member of leadership completes the documentation so that it is completed and signed by all relevant parties by the date the plan is due. |
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 document treatment plan updates within the regulatory timeframe in four of five applicable records reviewed.
Client # 2 was admitted on May 26, 2022 and was discharged on August 6, 2024. A treatment plan update was completed on August 24, 2023, and the next treatment plan update was due no later than October 24, 2023; however, the next treatment plan update was not completed until February 23, 2024. The next treatment plan update was due to be completed by April 23, 2024; however, it was not completed until May 4, 2024.
Client # 4 was admitted on August 3, 2021 and was discharged on June 21, 2024. A treatment plan update was completed on December 13, 2023, and the next treatment plan update was due no later than February 13, 2024; however, the treatment plan update was not completed until April 28, 2024.
Client # 6 was admitted on May 2, 2023 and was active at the time of the inspection. A treatment plan update was completed on November 10, 2023, and the next treatment plan update was due no later than January 10, 2024; however, the treatment plan update was not completed until February 20, 2024. The next treatment plan update was due to be completed by April 20, 2024; however, it was not completed until April 30, 2024.
Client # 8 was admitted on October 2, 2020 and was active at the time of the inspection. A treatment plan update was completed on January 12, 2024, and the next treatment plan update was due no later than March 12, 2024; however, the treatment plan update was not completed until May 1, 2024. The next treatment plan update was due to be completed by July 1, 2024; however, it was not completed until August 23, 2024.
This is a repeat citation from the September 1, 2023 and November 3, 2023 annual renewal licensing inspections.
These findings were discussed with facility staff during the inspection process.
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Plan of Correction
Clinical Director (CD) and Clinical Supervisor (CS) will run reports at the beginning of each week for upcoming treatment plans needed and send them to counselors to complete. If a teammate is out of the office, CD and CS will ensure that either an available counselor or member of leadership completes the documentation so that it is completed and signed by all relevant parties by the date the plan is due. |
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 ensure that counseling services were provided according to the individual treatment and rehabilitation plans in four of eight applicable records reviewed.
Client # 1 was admitted on August 6, 2024 and was active at the time of the inspection. The treatment plans completed on August 6, 2024 and September 19, 2024, indicated that the client was to receive weekly individual sessions; however, the record only contained documentation of two individual sessions between the date of admission and the date of the inspection.
Client # 4 was admitted on August 3, 2021 and was discharged on June 21, 2024. The treatment plan completed on December 13, 2023, indicated that the client was to receive 15 - 60 minutes of individual counseling per month; however, the record did not contain documentation of any individual sessions for the 2024 months of January, February, March, and April.
Client # 6 was admitted on May 2, 2023 and was active at the time of the inspection. The treatment plans completed on June 22, 2024 and August 23, 2024, indicated that the client was to receive 60 minutes of individual counseling and 90 minutes of group counseling per month; however, no group sessions were documented for July or August 2024.
Client # 7 was admitted on January 12, 2024 and was discharged on April 5, 2024. The treatment plan completed on January 12, 2024, indicated that the client was to receive 2.5 hours of counseling per month; however, the record did not contain documentation of any counseling hours during February 2024.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Counselors have been trained in how to document attempts at engagement in clinical services and additional strategies to increase overall engagement in the clinical process. Requirements will be reviewed in weekly supervision and coaching will continue to be provided for documentation and engagement. |
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 client records and the facility's policy and procedure manual, the facility failed to ensure a complete client record included information relative to the client's involvement with the project to include case consultation notes every three months for the first year of treatment and annually thereafter, per the facility's policy, in three of six applicable records reviewed.
Client # 2 was admitted on May 26, 2022 and was discharged on August 6, 2024. The client record did not contain documentation of case consultation notes.
Client # 6 was admitted on May 2, 2023 and was active at the time of the inspection. A case consultation note was completed on November 10, 2023, and the next note was due to be completed by February 2, 2024; however, the next case consultation was not documented until May 6, 2024.
Client # 9 was admitted on March 24, 2024 and was discharged on August 26, 2024. The client record did not contain documentation of case consultation notes.
This is a repeat citation from the September 1, 2023 and November 3, 2023 annual renewal licensing inspections.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Clinical Director (CD) and Clinical Supervisor (CS) will run reports at the beginning of each week for upcoming case consultations needed and send them to counselors to complete. If a teammate is out of the office, CD and CS will ensure that either an available counselor or member of leadership completes the documentation so that it is completed and signed by all relevant parties by the date the document is due. |
709.93(a)(11) 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:
(11) Follow-up information.
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Observations
Based on a review of client records, the facility failed to ensure a complete client record included information relative to the client's involvement with the project to include follow-up information at 30- and 60-days post discharge, per facility policy, in two of four applicable records reviewed.
Client # 2 was admitted on May 26, 2022 and was discharged on August 6, 2024. The client record did not contain documentation of follow-up information.
Client # 9 was admitted on March 11, 2024 and was discharged on August 26, 2024. The client record did not contain documentation of follow-up information.
This is a repeat citation from the September 1, 2023 and November 3, 2023 annual renewal licensing inspections.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Clinical Director (CD) and Clinical Supervisor (CS) will run reports at the beginning of each week for upcoming discharge follow up calls needed and send them to counselors to complete. If a teammate is out of the office, CD and CS will ensure that either an available counselor or member of leadership completes the documentation so that it is completed by the due date. |
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 nine patient records, the facility failed to comply with plans of correction that were approved by the Department.
A plan of correction to ensure that individual treatment plans were completed according to facility policy was submitted and approved by the Department for the September 1, 2023 and November 3, 2023 licensing inspections. Individual treatment plans were again found to be a deficiency in the September 30, 2024 through October 1, 2024 annual licensing inspection.
A plan of correction to ensure that treatment plans were completed according to the regulatory timeframe was submitted and approved by the Department for the September 1, 2023 and November 3, 2023 licensing inspections. Treatment plan updates were again found to be a deficiency in the September 30, 2024 through October 1, 2024 annual licensing inspection.
A plan of correction to ensure that case consultations were completed according to facility policy was submitted and approved by the Department for the September 1, 2023 and November 3, 2023 licensing inspections. Case consultations were again found to be a deficiency in the September 30, 2024 through October 1, 2024 annual licensing inspection.
A plan of correction to ensure that follow-up information was completed according to facility policy was submitted and approved by the Department for the September 1, 2023 and November 3, 2023 licensing inspections. Follow-up information was again found to be a deficiency in the September 30, 2024 through October 1, 2024 annual licensing inspection.
A plan of correction for obtaining client signed consent to release information forms prior to disclosures of information was submitted and approved by the Department for the September 1, 2023 and November 3, 2023 licensing inspections. Obtaining client signed consent to release information forms prior to disclosing information was again found to be a deficiency in the September 30, 2024 through October 1, 2024 annual licensing inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Clinical Director (CD) and Clinical Supervisor (CS) will run reports at the beginning of each week for upcoming documentation needed (treatment plans, case consultations, etc.) and send them to counselors to complete. If a teammate is out of the office, CD and CS will ensure that either an available counselor or member of leadership completes the documentation so that it is timely. CD and CS will send status reports to the Executive Director every Friday. Teammates who are unable to follow the plan of correction will receive coaching, supervision, and/or disciplinary action as needed. |