INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on January 6, 2021 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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704.11(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 the review of personnel records, the project failed to document an annual written individual training plan that included input from both the employee and the supervisor in two of six personnel records reviewed.Employee # 4 was employed on November 25, 2019 and was a current employee at the time of the inspection. An annual training plan, completed on May 11, 2020 was documented in the employee's personnel records; however, the training plan was not signed and dated until January 5, 2021.Employee #6 was employed on March 11, 2019 and was a current employee at the time of the inspection. An annual training plan, completed on May 18, 2020 was documented in the employee's personnel record; however, the training plan was not signed by the employee.These findings were reviewed with project staff during the licensing process.
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Plan of Correction
Individual training plans will be written and signed by the Employee and the employee's Direct Supervisor. The plans will be signed in-person. If circumstances prevent both parties from meeting in-person, the Supervisor will email a PDF version to the employee. The PDF version will be signed and emailed back to the Supervisor who will in turn sign and file the training plan. The Program Director will provide training to staff on the electronic signing procedure during group supervision. The Program Director will provide oversight and ensure compliance with the regulation. The program will be in compliance on 2/15/2021. |
704.11(d)(2) LICENSURE Annual Training Requirements
704.11. Staff development program.
(d) Training requirements for project directors and facility directors.
(2) A project director and facility director shall complete at least 12 clock hours of training annually in areas such as:
(i) Fiscal policy.
(ii) Administration.
(iii) Program planning.
(iv) Quality assurance.
(v) Grantsmanship.
(vi) Program licensure.
(vii) Personnel management.
(viii) Confidentiality.
(ix) Ethics.
(x) Substance abuse trends.
(xi) Developmental psychology.
(xii) Interaction of addiction and mental illness.
(xiii) Cultural awareness.
(xiv) Sexual harassment.
(xv) Relapse prevention.
(xvi) Disease of addiction.
(xvii) Principles of Alcoholics Anonymous and Narcotics Anonymous.
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Observations
Based on the reviewed of personnel records, the project failed to ensure that the facility director completed at least twelve clock hours of training annually.Employee # 2 was employed as the facility director on October 25, 2019 and was still in the position at the time of the inspection. There were only 7.25 training hours documented in the employee's personnel record for the 2019/2020 training year.These findings were reviewed with project staff during the licensing process.
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Plan of Correction
The Program has implemented the use of monthly reports in Relias to assign training and track the completion of training hours. Training hours for the Facility Director will be monitored by the Director of Learning & Clinical Development for compliance. The program will be in compliance as of 6/30/2021. |
705.28 (d) (1) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(1) Conduct unannounced fire drills at least once a month.
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Observations
Based on the review of the December 2019 through December 2020 fire drills, the facility failed to conduct unannounced monthly fire drills for the months of April 2020, May 2020, and June 2020.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Fire drills are conducted by the site Emergency Manager and Emergency Coordinator. The Emergency Manager will schedule monthly fire drills. Fire Drill logs are recorded in the Electronic Health Record. The Program Director will monitor for compliance. The program will be in compliance on 2/15/2021. |
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 the review of personnel records, the project failed to document an annual written individual staff performance evaluation that was reviewed and signed by the employee in two of six personnel records reviewed.Employee #4 was employed on November 25, 2019 and was a current employee at the time of the inspection. An annual staff performance evaluation was documented in the personnel record on May 11, 2020; however, it was not signed until January 5, 2021. Employee #6 was employed on March 11, 2019 and was a current employee at the time of the inspection. An annual staff performance evaluation was due no later than March 11, 2020; however, there was no annual staff performance evaluation documented in this employee's record at the time of this inspection.These findings were reviewed with project staff during the licensing process.
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Plan of Correction
Annual Performance Evaluations will be written, reviewed and signed by the Employee and the employee's Direct Supervisor at the end of the fiscal year. The Annual Performance Evaluations will be signed in-person. If circumstances prevent both parties from meeting in-person, the Supervisor will email a PDF version to the employee. The PDF version will be reviewed, signed and emailed back to the Supervisor who will in turn sign and file the Annual Performance Evaluations. The Program Director will provide training to staff on the electronic signing procedure during group supervision. The Program Director will provide oversight and ensure compliance with the regulation. The program will be in compliance on 7/1/2021. |
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 the review of client records, the project failed to document an informed and voluntary consent to release information form from the client for the disclosure of information contained in the client record in two of seven client records reviewed.Client #1 was admitted on August 21, 2020 and was a current client at the time of the inspection. There was no consent to release information documented in the client record for the funding source and there was evidence that the facility billed the funding source during the treatment episode.Client #2 was admitted on June 5, 2020 and was a current client at the time of the inspection. There was no consent to release information documented in the client record for the funding source and there was evidence that the facility billed the funding source during the treatment episode.These findings were reviewed with project staff during the licensing process.
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Plan of Correction
Consents to Release of Information are completed with the client by the Care Coordinator at the time of intake and as needed following intake. The Care Coordinator received training from the Program Director regarding the regulation and the form on 1/6/2021. The Clinical Supervisor will monitor for compliance. The Clinical Supervisor will spot check ROI's for compliance when signing off on the client's Initial Treatment Plan. The program will be in compliance as of 1/28/2021.
Client #1 will meet with the Care Coordinator by 1/28/2021 and sign the Consent to Release of Information.
Client #2 was discharged as of 1/6/2021
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709.28 (c) (1) 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:
(1) Name of the person, agency or organization to whom disclosure is made.
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Observations
Based on the review of client records, the project failed to ensure that all consent to release information forms documented in the client record included the name of the person, agency or organization to whom the disclosure is made to in one of seven client records reviewed. Client #1 was admitted on August 21, 2020 and was a current client at the time of the inspection. A release of information form, signed and dated by the client on September 23, 2020, did not document the name of the person, agency or organization to whom the disclosure would be made.These findings were reviewed with project staff during the licensing process.
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Plan of Correction
Consents to Release of Information are completed with the client by the Care Coordinator at the time of intake. On 1/22/2021, the Care Coordinator received training from the Program Director regarding the need to include the name of the person, agency, or organization to whom the disclosure is made. If the Consent form is not needed, it should not be signed by the client. The Clinical Supervisor will monitor for compliance. The Clinical Supervisor will spot check ROI's for compliance when signing off on the client's Initial Treatment Plan. The Program will be in compliance as of 1/25/2021.
Client #1 the deleted from the record on 1/22/2021
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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 client records, the project failed to keep disclosures of client identifying information within the limits established by 4 Pa. Code 255.5 (b) for releases of information in two of seven client records reviewed.Client #4 was admitted on January 22, 2020 and was discharged on May 15, 2020. Two release of information forms to court officials, signed and dated by the client on January 22, 2020, allowed for the release of drug screen results, which exceeds the limits established by 4 Pa. Code 255.5. Additionally, a release of information form to a primary care physician, signed and dated on January 22, 2020, did not document the specific information that was to be disclosed.Client #6 was admitted on January 22, 2020 and was discharged on April 26, 2020. A release of information form to a primary care physician, signed and dated on January 22, 2020, did not document the specific information that was to be disclosed.These findings were reviewed with project staff during the licensing process.
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Plan of Correction
Consents to Release of Information are completed with the client by the Care Coordinator at the time of intake. On 1/22/2021, the Care Coordinator received training from the Program Director regarding the need to list the specific information to be released and the limitations set by PA 255.5. The Clinical Supervisor will monitor for compliance. The Clinical Supervisor will spot check ROI's for compliance when signing off on the client's Initial Treatment Plan. The Program will be in compliance as of 1/25/2021.
Client # 4 was discharged on 5/15/2020
Client #6 was discharged on 4/26/2020
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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).
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Observations
Based on the review of client records, the project failed to ensure that all consent to release information forms documented in the client record included the dated signature of the client in one of seven client records reviewed. Client #3 was admitted on July 20, 2020 and was a current client at the time of the inspection. Three release of information forms documented in the client record, were not signed by the client; however, all three forms were signed and dated by a witness on October 14, 2020.These findings were reviewed with project staff during the licensing process.Based on the review of client records, the project failed to ensure that all consent to release information forms documented in the client record included the dated signature of the client in one of seven client records reviewed.
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Plan of Correction
Consents to Release of Information are completed with the client by the Care Coordinator at the time of intake. On 2/5/2021, the Program Director will provide training regarding the need to obtain client signatures on releases of information and procedures to carry that out safely during COVID-19 pandemic. The Clinical Supervisor will monitor for compliance. The Clinical Supervisor will spot check ROI's for compliance when signing off on the client's Initial Treatment Plan. The Program will be in compliance as of 2/15/2021.
Client #3 will meet with the Care Coordinator by 1/28/2021 and sign the Consent to Release of Information.
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709.91(b)(4) LICENSURE Intake and admission
709.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(4) Consent to treatment.
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Observations
Based on the review of client records, the project failed to include documentation of a consent to treatment during the intake process in two of seven client records reviewed.Client #1 was admitted on August 21, 2020 and was an active client at the time of the inspection.Client #2 was admitted on June 5, 2020 and was an active client at the time of the inspection. These findings were reviewed with project staff during the licensing process.
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Plan of Correction
Consents to Treatment are completed with the client by the Care Coordinator at the time of intake. On 2/5/2021, the Program Director will provide training regarding the need to obtain client signatures on the Consent to Treatment form and procedures to carry that out safely during COVID-19 pandemic. The Clinical Supervisor will monitor for compliance. The Clinical Supervisor will check the Consent to Treatment form for compliance when signing off on the client's Initial Treatment Plan. The Program will be in compliance as of 2/15/2021.
Client #1 will meet with the Care Coordinator by 1/28/2021 and sign the Consent to Treatment.
Client #2 was discharged as of 1/6/2021.
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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 the review of client records, the project failed to ensure that all treatment and rehabilitation plans were updated at least every 60 days in three of seven client records reviewed.Client #2 was admitted on June 5, 2020 and was an active client at the time of the inspection. A treatment plan update was completed on July 1, 2020 and the next treatment plan update was due no later than September 1, 2020; however, a treatment plan update was not completed until November 6, 2020. Client #3 was admitted on July 20, 2020 and was an active client at the time of the inspection. A treatment plan update was completed on July 1, 2020 and the next treatment plan update was due no later than September 1, 2020; however, a treatment plan update was not completed until November 6, 2020. Client #6 was admitted on January 22, 2020 and was discharged on April 26, 2020. A comprehensive treatment plan was completed on January 22, 2020 and the next treatment plan update was due no later than March 22, 2020; however, a treatment plan update was not documented in the record. These findings were reviewed with project staff during the licensing process.
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Plan of Correction
The Program uses a spreadsheet to monitor the timing of Treatment Plan Updates. The spreadsheet is monitored, updated and emailed to Counselors by the Quality Assurance Staff. The Program Director will provide training to counselors on 2/5/2020 regarding the timing on Treatment Plan Updates and the use of internal monitoring systems. The Clinical Supervisor will monitor for compliance. The facility will be in compliance on 2/15/2020.
Client #2 is discharged as of 1/6/2021
Client #3 was in compliance as of 1/6/2021
Client #6 was discharged as of 4/26/2020
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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 the review of client records, the project failed to document a complete client record on an individual with information relative to the client's involvement with the project, which is to include follow-up information, in four of seven client records reviewed.Client #4 was admitted on January 22, 2020 and was discharged on May 15, 2020. Follow-up information was not documented in the client record.Client #5 was admitted on September 23, 2019 and was discharged on May 14, 2020. Follow-up information was not documented in the client record.Client #6 was admitted on January 22, 2020 and was discharged on April 26, 2020. Follow-up information was not documented in the client record.Client #7 was admitted on July 19, 2019 and was discharged on November 20, 2019. Follow-up information was not documented in the client record.These findings were reviewed with project staff during the licensing process.
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Plan of Correction
Program staff are to conduct follow up with discharged clients post discharge. Staff are to document the follow up in an Outreach note in the EHR. The Program Director will provide training regarding post-discharge follow up on 2/5/2021. The Clinical Supervisor will monitor for compliance. Clinical Supervisors close the client's episode in the Credible EHR. Clinical Supervisors will ensure that the post-discharge follow up is documented prior to closing the episode.
Client #4 will be in compliance on 2/15/2021
Client #5 will be in compliance on 2/15/2021
Client #6 will be in compliance on 2/15/2021
Client #7 will be in compliance on 2/15/2021
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