INITIAL COMMENTS
|
This report is a result of an on-site licensure renewal inspection and buprenorphine monitoring conducted on December 13, 2021 through December 14, 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:
|
Plan of Correction
|
704.11(f)(2) LICENSURE Trng Hours Req-Coun
704.11. Staff development program.
(f) Training requirements for counselors.
(2) Each counselor shall complete at least 25 clock hours of training annually in areas such as:
(i) Client recordkeeping.
(ii) Confidentiality.
(iii) Pharmacology.
(iv) Treatment planning.
(v) Counseling techniques.
(vi) Drug and alcohol assessment.
(vii) Codependency.
(viii) Adult Children of Alcoholics (ACOA) issues.
(ix) Disease of addiction.
(x) Aftercare planning.
(xi) Principles of Alcoholics Anonymous and Narcotics Anonymous.
(xii) Ethics.
(xiii) Substance abuse trends.
(xiv) Interaction of addiction and mental illness.
(xv) Cultural awareness.
(xvi) Sexual harassment.
(xvii) Developmental psychology.
(xviii) Relapse prevention.
(3) If a counselor has been designated as lead counselor supervising other counselors, the training shall include courses appropriate to the functions of this position and a Department approved core curriculum or comparable training in supervision.
|
Observations
Based on a review of personnel records, the facility failed to ensure that each counselor completed at least 25 clock hours of training annually during the facility's July 1, 2020 through June 30, 2021 training year in one of two applicable personnel records reviewed.
Employee # 8 was hired as a counselor on December 19, 2016. The personnel record documented 18 hours of training received during the training year reviewed.
This finding was reviewed with facility staff during the licensing process.
|
Plan of Correction
The Senior Director of Acute Recovery Services and the Site Director of Addictions will ensure that all counselors complete at least 25 clock hours of training annually between July 1 and June 30th of each calendar year. All counselors will be re-trained and reminded of this expectation and regulation. Directors will work with their Relias Training Coordinators to ensure that they are receiving monthly reports of each counselor's training hours. If a counselor is falling behind on training hours, they will prompt the counselor to complete training hours in Relias or from an outside approved training entity. Oversight of compliance will be conducted by the assigned quality assurance staff, program director, and Vice President. The facility will be in compliance by 2/1/2022 |
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.
|
Observations
Based on a review of client records, the facility failed to obtain an informed and voluntary consent to release information form prior to the disclosure of information in ten of twenty-one client records reviewed.
Client # 1 was admitted to the outpatient detoxification activity on March 17, 2021 and was discharged on March 17, 2021. There was evidence of disclosures to the funding source during the client's treatment episode; however, there was no consent to release information form signed by the client documented in the record prior to any of the disclosures.
Client # 2 was admitted to the outpatient detoxification activity on August 11, 2021 and was discharged on August 12, 2021. There was evidence of disclosures to the funding source during the client's treatment episode; however, there was no consent to release information form signed by the client documented in the record prior to any of the disclosures.
Client # 3 was admitted to the outpatient detoxification activity on June 24, 2021 and was discharged on June 24, 2021. There was evidence of disclosures to the funding source during the client's treatment episode; however, there was no consent to release information form signed by the client documented in the record prior to any of the disclosures.
Client # 4 was admitted to the outpatient detoxification activity on October 15, 2021 and was discharged on October 15, 2021. There was evidence of disclosures to the funding source during the client's treatment episode; however, there was no consent to release information form signed by the client documented in the record prior to any of the disclosures.
Client # 5 was admitted to the outpatient detoxification activity on October 25, 2021 and was discharged on October 25, 2021. There was evidence of disclosures to the funding source during the client's treatment episode; however, there was no consent to release information form signed by the client documented in the record prior to any of the disclosures. Additionally, there was evidence of disclosures to other treatment providers on October 25, 2021; however, there were no consent to release information forms signed by the client documented in the record prior to the disclosures.
Client # 6 was admitted to the outpatient detoxification activity on November 10, 2021 and was discharged on November 11, 2021. There was evidence of disclosures to the funding source during the client's treatment episode; however, there was no consent to release information form signed by the client documented in the record prior to any of the disclosures.
Client # 7 was admitted to the outpatient detoxification activity on June 11, 2021 and was discharged on June 11, 2021. There was evidence of disclosures to the funding source during the client's treatment episode; however, there was no consent to release information form signed by the client documented in the record prior to any of the disclosures.
Client #8 was admitted to the outpatient maintenance activity on October 27, 2020 and was still active at the time of inspection. The release of information form to the funding source was signed and dated by the client on October 27, 2020 and it expired on October 27, 2021. There was evidence of disclosures to the funding source after the release of information form expired; however, there was no updated consent to release information form signed by the client documented in the record prior to any of the disclosures after October 27, 2020.
Client #15 was admitted into the outpatient drug free activity on August 13, 2021 and was still active at the time of inspection. The release of information form to the funding source was signed and dated by the client on August 11, 2020 and it expired on August 11, 2021. There was evidence of disclosures to the funding source after the release of information form expired; however, there was no updated consent to release information form signed by the client documented in the record prior to any of the disclosures after August 11, 2020.
Client #17 was admitted into the outpatient drug free activity on October 7, 2020 and was still active at the time of inspection. The release of information form to the funding source was signed and dated by the client on October 20, 2020 and it expired on October 20, 2021; There was evidence of disclosures to the funding source after the release of information form expired; however, there was no updated consent to release information form signed by the client documented in the record prior to any of the disclosures after October 20, 2021.
This is a repeat citation from the December 16, 2020 annual licensing renewal inspection.
These findings were discussed with facility staff during the licensing process.
|
Plan of Correction
The Senior Director of Acute Recovery and Site Director of Addictions Services will provide training for all staff regarding compliance with confidentiality standards. The training will ensure that staff understand that they need to obtain voluntary consent to release information prior to the disclosure of information. This pertains to the funding source, providers and anyone else that information is released to. Consents will be signed by staff and the client. This will be reviewed in supervision and staff meetings. As noted in the observations, any client that is still active in treatment will have an updated ROI completed by 2/1/22. This will not be able to occur for clients that have been discharged. Chart reviews will be conducted by directors to ensure that this does not continue to occur. Oversight will be conducted by the facilities' quality assurance department, program director and Vice President. The facility will be in compliance by 2/1/2022 |
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.
|
Observations
Based on a review of client records, the facility failed to document the name of the person, agency or organization to whom the disclosure is made on consent to release information forms in seven of twenty-one client records reviewed.
Client # 1 was admitted to the outpatient detoxification activity on March 17, 2021 and was discharged on March 17, 2021. The client record contained a release of information form to the emergency contact and a general release of information form that were signed and dated by the client and witness on March 17, 2021; however, the forms failed to document the name of the person, agency or organization to whom the disclosures would be made.
Client # 2 was admitted to the outpatient detoxification activity on August 11, 2021 and was discharged on August 12, 2021. The client record contained a release of information form to the emergency contact and a general release of information form that were signed and dated by the client and witness on August 11, 2021; however, the forms failed to document the name of the person, agency or organization to whom the disclosures would be made.
Client # 3 was admitted to the outpatient detoxification activity on June 24, 2021 and was discharged on June 24, 2021. The client record contained a release of information form to the emergency contact and a general release of information form that were signed and dated by the client and witness on June 24, 2021; however, the forms failed to document the name of the person, agency or organization to whom the disclosures would be made.
Client # 4 was admitted to the outpatient detoxification activity on October 15, 2021 and was discharged on October 15, 2021. The client record contained a release of information form that was signed and dated by the client and witness on October 15, 2021; however, the form failed to document the name of the person, agency or organization to whom the disclosure would be made.
Client # 5 was admitted to the outpatient detoxification activity on October 25, 2021 and was discharged on October 25, 2021. The client record contained a release of information form to the emergency contact and a general release of information form that were signed and dated by the client and witness on October 25, 2021; however, the forms failed to document the name of the person, agency or organization to whom the disclosures would be made.
Client # 6 was admitted to the outpatient detoxification activity on November 10, 2021 and was discharged on November 11, 2021. The client record contained a release of information form that was signed and dated by the client and witness on March 17, 2021 however, the form failed to document the name of the person, agency or organization to whom the disclosure would be made.
Client # 7 was admitted to the outpatient detoxification activity on June 11, 2021 and was discharged on June 11, 2021. The client record contained a release of information form to the emergency contact and a general release of information form that were signed and dated by the client and witness on June 10, 2021; however, the forms failed to document the name of the person, agency or organization to whom the disclosures would be made.
This is a repeat citation from the January 16, 2020 and December 16, 2020 annual licensing renewal inspections.
These findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
The Senior Director of Acute Recovery Services will provide training for all staff regarding the need to document the person, agency or organization to all outside entities to whom a disclosure is being made on a consent to release information. This training will occur in supervision and in staff meetings. The program director will also complete chart reviews to ensure that this is being completed. Oversight will be conducted by the the facilities quality assurance department, program director and Vice President. The facility will be in compliance by 2/1/22. |
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.
|
Observations
Based on a review of client records, the facility failed to document that a copy of a client consent to release information form was offered to the client in thirteen of twenty-one client records reviewed.
Client # 1 was admitted to the outpatient detoxification activity on March 17, 2021 and was discharged on March 17, 2021. A release of information form to another treatment provider was signed and dated by the client on March 17, 2021; however, there was no documentation that a copy of the consent was offered to the client.
Client # 2 was admitted to the outpatient detoxification activity on August 11, 2021 and was discharged on August 12, 2021. A release of information form to another treatment provider was signed and dated by the client on August 11, 2021; however, there was no documentation that a copy of the consent was offered to the client.
Client # 3 was admitted to the outpatient detoxification activity on June 24, 2021 and was discharged on June 24, 2021. A release of information form to another treatment provider was signed and dated by the client on June 24, 2021; however, there was no documentation that a copy of the consent was offered to the client.
Client # 4 was admitted to the outpatient detoxification activity on October 15, 2021 and was discharged on October 15, 2021. A release of information form to another treatment provider was signed and dated by the client on October 15, 2021; however, there was no documentation that a copy of the consent was offered to the client.
Client # 5 was admitted to the outpatient detoxification activity on October 25, 2021 and was discharged on October 25, 2021. A release of information form to another treatment provider was signed and dated by the client on October 25, 2021; however, there was no documentation that a copy of the consent was offered to the client.
Client # 6 was admitted to the outpatient detoxification activity on November 10, 2021 and was discharged on November 11, 2021. A release of information form to another treatment provider was signed and dated by the client on November 10, 2021; however, there was no documentation that a copy of the consent was offered to the client.
Client # 7 was admitted to the outpatient detoxification activity on June 11, 2021 and was discharged on June 11, 2021. A release of information form to another treatment provider was signed and dated by the client on June 11, 2021; however, there was no documentation that a copy of the consent was offered to the client.
Client #9 was admitted to the outpatient maintenance activity on July 29, 2021 and was still active at the time of inspection. A release of information form to another treatment provider was signed and dated by the client on July 28, 2021; however, there was no documentation that a copy of the consent was offered to the client.
Client #10 was admitted to the outpatient maintenance activity on June 14, 2021 and was still active at the time of inspection. A release of information form to another treatment provider was signed and dated by the client on June 15, 2021; however, there was no documentation that a copy of the consent was offered to the client.
Client #11 was admitted to the outpatient maintenance activity on June 7, 2021 and was discharged on October 18, 2021. A release of information form to another treatment provider was signed and dated by the client on June 4, 2021; however, there was no documentation that a copy of the consent was offered to the client.
Client #12 was admitted to the outpatient maintenance activity on March 25, 2021 and was discharged on April 1, 2021. A release of information form to another treatment provider was signed and dated by the client on March 24, 2021; however, there was no documentation that a copy of the consent was offered to the client.
Client #13 was admitted to the outpatient maintenance activity on September 3, 2021 and was discharged on October 20, 2021. A release of information form to another treatment provider was signed and dated by the client on September 1, 2021; however, there was no documentation that a copy of the consent was offered to the client.
Client #14 was admitted to the outpatient maintenance activity on May 12, 2021 and was discharged on July 16, 2021. A release of information form to another treatment provider was signed and dated by the client on April 16, 2021; however, there was no documentation that a copy of the consent was offered to the client.
These findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
The Senior Director of Acute Recovery Services will amend the Release of Information Form to comply with confidentiality standards. This Release of Information form will be added to our electronic health record. The release of information form will indicate the following: a copy of the consent was offered to the client, client accepted a copy of consent, client declined a copy of consent, and a copy of consent will remain within the clients' record. The program director will review with staff in supervision and in staff meetings. Chart reviews will be conducted by the director to ensure that this is corrected. The program director will provide training to the staff regarding the change in practice. Oversight of compliance will be conducted by the assigned quality assurance staff, program director and Vice President. The facility will be in compliance by 2/1/2022. |
709.34 (c) (4) LICENSURE Reporting of unusual incidents
§ 709.34. Reporting of unusual incidents.
(c) To the extent permitted by State and Federal confidentiality laws, the project shall file a written unusual incident report with the Department within 3 business days following an unusual incident involving:
(4) Event at the facility requiring the presence of police, fire or ambulance personnel.
|
Observations
Based on a review of the facility's January 2021 through December 2021 unusual incident logs, the facility failed to file a written unusual incident report with the Department within 3 business days following an event that required the presence of police and/or ambulance personnel at the facility on the following dates: January 3, 2021; January 21, 2021; January 22, 2021; February 5, 2021; March 11, 2021, April 4, 2021; April 14, 2021; April 18, 2021; April 21, 2021; June 28, 2021 and September 11, 2021.
These findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
The Senior Director of Acute Recovery Services will provide training for program director and staff regarding the reporting of unusual incidents. All incident reports will be submitted to the Department within 3 business days following an event that requires the presence of police and/or ambulance personnel. The unusual incident reports documented in the observations that were not reported, will be reported and sent to DDAP by 2/1/22. Oversight of compliance will be conducted by The Director of Quality and Compliance once per quarter, Program Director and Vice President. The facility will be in compliance by 2/1/2022. |
715.12(1-5) LICENSURE Informed patient consent
A narcotic treatment program shall obtain an informed, voluntary, written consent before an agent may be administered to the patient for either maintenance or detoxification treatment. The following shall appear on the patient consent form:
(1) That methadone and LAAM are narcotic drugs which can be harmful if taken without medical supervision.
(2) That methadone and LAAM are addictive medications and may, like other drugs used in medical practices, produce adverse results.
(3) That alternative methods of treatment exist.
(4) That the possible risks and complications of treatment have been explained to the patient.
(5) That methadone is transmitted to the unborn child and will cause physical dependence.
|
Observations
Based on a review of patient records, the narcotic treatment program failed to obtain an informed, voluntary, written consent that included all of the required components, before an agent was administered to the patient for either maintenance or detoxification treatment in ten of ten applicable patient records reviewed.
Patient # 1 was admitted to the outpatient detoxification activity on March 17, 2021 and was discharged on March 17, 2021. The informed, voluntary, written consent failed to include that the agent is an addictive medication, that alternative methods of treatment exist, and that the agent is transmitted to an unborn child and will cause physical dependence.
Patient # 2 was admitted to the outpatient detoxification activity on August 12, 2021 and was discharged on August 12, 2021. The informed, voluntary, written consent failed to include that the agent is an addictive medication, that alternative methods of treatment exist, and that the agent is transmitted to an unborn child and will cause physical dependence.
Patient # 3 was admitted to the outpatient detoxification activity on June 24, 2021 and was discharged on June 24, 2021. The informed, voluntary, written consent failed to include that the agent is an addictive medication, that alternative methods of treatment exist, and that the agent is transmitted to an unborn child and will cause physical dependence.
Patient # 4 was admitted to the outpatient detoxification activity on October 15, 2021 and was discharged on October 15, 2021. The informed, voluntary, written consent failed to include that the agent is an addictive medication, that alternative methods of treatment exist, and that the agent is transmitted to an unborn child and will cause physical dependence.
Patient # 9 was admitted to the outpatient maintenance activity on July 29, 2021 and was still
active at the time of the inspection. The informed, voluntary, written consent failed to include that that alternative methods of treatment exist and the agent is transmitted to the unborn child and will cause physical dependence.
Patient # 10 was admitted to the outpatient maintenance activity on June 14, 2021 and was still active at the time of the inspection. The informed, voluntary, written consent failed to include that that alternative methods of treatment exist and the agent is transmitted to the unborn child and will cause physical dependence.
Patient # 11 was admitted to the outpatient maintenance activity on June 7, 2021 and was discharged on October 21, 2021. The informed, voluntary, written consent failed to include that that alternative methods of treatment exist and the agent is transmitted to the unborn child and will cause physical dependence.
Patient # 12 was admitted to the outpatient maintenance activity on March 25, 2021 and was discharged on April 1, 2021. The informed, voluntary, written consent failed to include that that alternative methods of treatment exist and the agent is transmitted to the unborn child and will cause physical dependence.
Patient # 13 was admitted to the outpatient maintenance activity on September 3, 2021 and was discharged on October 20, 2021. The informed, voluntary, written consent failed to include that that alternative methods of treatment exist and the agent is transmitted to the unborn child and will cause physical dependence.
Patient # 14 was admitted to the outpatient maintenance activity on May 12, 2021 and was discharged on July 16, 2021. The informed, voluntary, written consent failed to include that that alternative methods of treatment exist and the agent is transmitted to the unborn child and will cause physical dependence.
These findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
The Senior Director of Acute Recovery Services will amend the form (s) for informed, voluntary, written consent that include all of the required components, before an agent is administered to the patient for either maintenance or detoxification in our electronic health record. The informed, voluntary, written consent will include that the agent is an addictive medication, that alternative methods of treatment exist, and that the agent is transmitted to an unborn child and will cause physical dependence. The program director will provide training to the staff regarding the change in practice. Oversight of compliance will be conducted by the assigned quality assurance staff, program director and Vice President. The facility will be in compliance by 2/1/2022. |
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 narcotic treatment program 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 seven applicable patient records reviewed.
Patient #8 was admitted to the outpatient maintenance activity on October 27, 2020 and was still active at the time of inspection. The patient record documented 2 hours of psychotherapy during the month of June 2021 and 2 hours of psychotherapy during the month of October 2021.
This finding was reviewed with facility staff during the licensing process.
|
Plan of Correction
The Site Director of Addictions will work with the QM department to add a column to the Addictions tracker that indicates how many hours of psychotherapy is being provided for all individuals enrolled in the NTP program and receiving MAT. This will pertain for the first 2 years of treatment. This will help with tracking to ensure that the correct amount of psychotherapy is being provided. The Site Director will re-train staff in supervision and staff meetings that individuals receiving MAT and enrolled in NTP must have a minimum of 2.5 hours of psychotherapy per month. Oversight will be conducted by the the quality assurance department, program director and Vice President. The facility will be in compliance by 2/1/2022. |
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 narcotic treatment program failed to document the results of all annual physical examinations given by the narcotic treatment program which includes an annual reevaluation by the narcotic treatment physician in one of one applicable patient records reviewed.
Patient #8 was admitted to the outpatient maintenance activity on October 27, 2020 and was still active at the time of inspection. An annual physical examination was due by October 27, 2021; however, there was no annual physical examination given by the narcotic treatment program documented in the patient record at the time of inspection.
These findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
The Site Director of Addictions will monitor the Addictions tracker weekly to ensure that individuals enrolled in the NTP and on MAT have the results of the annual physical evaluation by the Narcotic Treatment Physician documented in the electronic health record. The Narcotics Treatment Physician will document the psychiatric evaluation and re-evaluations directly in the electronic health record to minimize errors. The director and/or her designee will ensure that individuals who are in NTP will be scheduled for a re-evaluation with the NTP physician 30 days prior to the annual re-evaluation is due. Therefore if there is a cancellation, there will be time to re-schedule. Oversight will be completed by the quality assurance department, program director and Vice President. The facility will be in compliance by 2/1/2022. |
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 narcotic treatment program failed to ensure an annual evaluation of the patient's status was completed by the patient's counselor and then reviewed, dated, and signed by the medical director in one of one applicable patient records reviewed.
Patient #8 was admitted to the outpatient maintenance activity on October 27, 2020 and was still active at the time of inspection. The annual evaluation of the patient's status was due by October 27, 2021. However, the annual evaluation wasn't completed by the counselor until December 10, 2021, and was not reviewed, dated, and signed by the medical director.
These findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
The Site Director of Addictions is working with the QM Department to ensure that a column is added to the Addictions tracker to ensure that after an annual evaluation is completed by the patient's counselor, it will be signed and dated, by the medical director. Utilizing the new information in the tracker will assist the director in the tracking. The signature will be documented in the electronic health record. The VP. Director of Addictions will inform the medical director that all annual evaluations must be signed and approved by him/her. Oversight will be conducted by the the quality assurance department, program director, medical director and Vice President. The facility will be in compliance by 2/1/2022. |
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 review and update treatment and rehabilitation plans at least every sixty days in eleven of fourteen applicable client records reviewed.
Client #8 was admitted to the outpatient maintenance activity on October 27, 2020 and was still active at the time of inspection. The individual treatment plan was completed on October 28, 2020, and a treatment plan update was due no later than December 28, 2020; however, the update was not completed until January 28, 2021. The next treatment plan update was due no later than March 28, 2021; however, the update was not completed until April 9, 2021. Additionally, a treatment plan update was completed on August 5, 2021 and another update was due no later than October 5, 2021; however, the update was not completed until October 15, 2021.
Client #9 was admitted to the outpatient maintenance activity July 29, 2021 and was still active at the time of inspection. The individual treatment plan was completed on August 8, 2021, and a treatment plan update was due no later than October 8, 2021; however, the update was not completed until October 28, 2021.
Client #10 was admitted to the outpatient maintenance activity on June 14, 2021 and was still active at the time of inspection. A treatment plan update was completed on August 25, 2021, and the next treatment plan update was due no later than October 25, 2021; however, the update was not completed until November 3, 2021.
Client #11 was admitted to the outpatient maintenance activity on June 7, 2021 and was discharged on October 18, 2021. A treatment plan update was completed on August 9, 2021, and the next treatment plan update was due no later than October 8, 2021; however, the update was not completed prior to discharge.
Client #15 was admitted into the outpatient drug free activity on August 13, 2021 and was still active at the time of inspection. A treatment plan update was completed on March 25, 2021 and the next update was due no later than May 25, 2021; however, the update was not completed until June 25, 2021.
Client #16 was admitted into the outpatient drug free activity on July 30, 2020 and was still active at the time of inspection. A treatment plan update was completed on March 18, 2021 and the next update was due no later than May 18, 2021; however, the update was not completed until October 27, 2021.
Client #17 was admitted into the outpatient drug free activity on October 7, 2020 and was still active at the time of inspection. A treatment plan update was completed on June 1, 2021 and the next update was due no later than August 1, 2021; however, the update was not completed until August 11, 2021.
Client #18 was admitted into the outpatient drug free activity on February 11, 2020 and was discharged on October 29, 2021. A treatment plan update was completed on July 22, 2021 and the next update was due no later than September 22, 2021; however, the update was not completed until October 6, 2021.
Client #19 was admitted into the outpatient drug free activity on March 14, 2019 and was discharged on November 1, 2021. A treatment plan update was completed on June 4, 2021 and the next update was due no later than August 4, 2021; however, the update was not completed until August 24, 2021.
Client #20 was admitted into the outpatient drug free activity on November 2, 2020 and was discharged on December 8, 2021. A treatment plan update was completed on August 30, 2021 and the next update was due no later than October 30, 2021; however, the update was not completed until November 10, 2021.
Client #21 was admitted into the outpatient drug free activity on March 30, 2018 and was discharged on October 12, 2021. A treatment plan update was completed on May 28, 2021 and the next update was due no later than July 28, 2021; however, the update was not completed until August 20, 2021.
These findings were reviewed with facility staff during the licensing inspection.
|
Plan of Correction
The Site Director of addictions will provide re-training for all counselors and the clinical supervisor that all drug free and maintenance patients must have treatment plan updated and signed every 60 days. The Site Director and clinical supervisor will use the Addictions tracker to ensure that treatment plans are completed. If the program director/clinical supervisor see that on day 50, a treatment plan has not been completed and/or scheduled, they will prompt the counselor to schedule and complete the treatment plan update. This will be addressed in clinical supervision and staff meetings. Oversight will be conducted by the quality management department, program director, clinical supervisor, and Vice President. This will be completed by 2/1/22. |