INITIAL COMMENTS
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Based on the concerns arising from COVID-19, The Department of Drug and Alcohol Programs, Bureau of Program Licensure, has implemented temporary procedures for conducting an annual renewal inspection. The inspection will be divided into two parts. 1, an abbreviated off-site inspection, will be conducted off site, and will require the submission of administrative information via email to a Licensing Specialist. 2, an abbreviated on-site inspection, will be conducted on-site at a later date and will include a review of client/patient records, and a physical plant inspection.This report is a result of Part 2, an abbreviated on-site inspection, conducted on May 11, 2021 through May 12, 2021 by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Not all regulations were reviewed, the remainder of the regulations were reviewed during Part 1.Based on the findings of Part 2, an abbreviated on-site inspection, New Direction 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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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 obtain an informed and voluntary consent from the client for the disclosure of information contained in the client record in one of ten client records reviewed.Client #3 was admitted on May 28, 2020 and was an active client at the time of the inspection. There was no release of information form for the funding source documented in the client ' s record. These findings were reviewed with project staff during the licensing process.
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Plan of Correction
As of June 1st, the Facility Director has reminded the Clinical Supervisors to review all Intake documentation to ensure that Consents to Disclose Confidential Information are completed for funding providers before the Intake records are transferred to the assigned Primary Therapist.
As of 6/16/2021, the Primary Therapist assisted Client #3 with completion of a Consent to Release Confidential Information for the client's funding source. Ongoing compliance will be monitored by the Clinical Supervisors during random record review and during Individual Supervision with Clinicians. |
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 the review of client records, the project failed obtain an informed and voluntary consent from the client for the disclosure of information contained in the client record that included the specific information to be disclosed in one of ten client records reviewed.Client #10 was admitted on July 15, 2020 and was an active client at the time of the inspection. A release of information form, to a correctional facility, signed and dated by the client on October 15, 2020, did not document the specific information to be disclosed.These findings were reviewed with project staff during the licensing process.
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Plan of Correction
As of 6/07/2021, the Nursing Director will remind Medical Staff that Releases of Information for a correctional facility must have the Purpose of Disclosure completed prior to releasing of confidential information whenever a client has been incarcerated.
As of 6/16/2021 Nursing staff met with Client #10 when she attended the clinic and had her complete the Release of Information to include the specific information disclosed and the purpose of the disclosure. The Nursing Director has notified the correctional facility staff of the requirement and will be responsible for monitoring ongoing compliance through a review of the record upon notification that an individual is receiving medication while incarcerated. |
709.28 (c) (3) 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:
(3) Purpose of disclosure.
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Observations
Based on the review of client records, the project failed obtain an informed and voluntary consent from the client for the disclosure of information contained in the client record that included the purpose of disclosure in one of ten client records reviewed.Client #10 was admitted on July 15, 2020 and was an active client at the time of the inspection. A release of information form to a correctional facility, signed and dated by the client on October 15, 2020, did not document the purpose of disclosure.These findings were reviewed with project staff during the licensing process.
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Plan of Correction
As of 6/07/2021, the Nursing Director will remind Medical Staff that Releases of Information for a correctional facility must have the Specific Information disclosed completed prior to releasing of confidential information whenever a client has been incarcerated.
As of 6/16/2021 Nursing staff met with Client #10 when she attended the clinic and had her complete the Release of Information to include the purpose of disclosure and the specific information disclosed. The Nursing Director has notified the correctional facility staff of the requirement and will be responsible for monitoring ongoing compliance through a review of the record upon notification that an individual is receiving medication while incarcerated. |
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 obtain an informed and voluntary consent from the client for the disclosure of information contained in the client record that included a dated client signature in three of ten client records reviewed.Client #1 was admitted on September 8, 1991 and was an active client at the time of the inspection. Three release of information forms to a laboratory, family member and funding source were signed and dated by a witness on December 3, 2020; however, there was no client signature documented on the forms.Client #2 was admitted on May 24, 2017 and was an active client at the time of the inspection. Five release of information forms to a laboratory, family member, funding source, governmental agency and hospital were signed and dated by a witness on May 18, 2020; however, there was no client signature documented on the forms.Client #6 was admitted on October 11, 2019 and was discharged on September 28, 2020. A release of information form to another treatment facility was signed and dated by a witness on June 24, 2020; however, there was no client signature documented on the form.These findings were reviewed with project staff during the licensing process.
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Plan of Correction
By June 8th Clinical staff will be notified that Client Signatures on Consents to Release Confidential Information may not be accepted verbally or deferred due to implementation of telehealth services. If a client is receiving telehealth services, Clinicians will be required to notify their clients to contact the counselor to complete releases with signatures in person when the clients present to the clinic for medication. As of 6/16/2021, the Primary Therapists met with the active clients to review and obtain Clients' signed consents on the Releases of Confidential Information that had lacked Clients' signatures. The Clinical Supervisors will be responsible for monitoring ongoing compliance with the signature requirements during individual supervision and through regular record review. |
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.
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Observations
Based on the review of patient records, the program failed to ensure that each patient receive an average of 2.5 hours of psychotherapy per month during the patient 's first 2 years in two of ten patient records reviewed.Patient #3 was admitted on May 28, 2020 and was an active patient at the time of the inspection. There was no documentation in the patient record indicating that the patient received 1.5 of the 2.5 psychotherapy hours required for the month of December 2020 and .5 of the 2.5 psychotherapy hours required for the months of November 2020 and March 2021.Patient #7 was admitted on March 27, 2020 and was discharged on September 11, 2020. There was no documentation in the patient record indicating that the patient received 1 hour of the 2.5 psychotherapy hours required for the months of April 2020 and July 2020 and .5 of the 2.5 psychotherapy hours required for the month of May 2020.These findings were reviewed with program staff during the licensing process.
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Plan of Correction
By 6/08/2021, Clinicians will be reminded of the requirement to meet the minimum Counseling attendance requirements for all clients receiving MAT for less than two years. The Clinical Supervisors will assist the clinicians with implementing interventions to encourage clients to meet the counseling attendance requirements. Ongoing compliance will be monitored by the Clinical Supervisor through monitoring of counseling attendance records and clinical documentation to ensure that clinicians are utilizing interventions to help clients meet the regulatory requirement. |
715.19(2) LICENSURE Psychotherapy services
A narcotic treatment program shall provide individualized psychotherapy services and shall meet the following requirements:
(2) A narcotic treatment program shall provide each patient at least 1 hour per month of group or individual psychotherapy during the third and fourth year of treatment. Additional psychotherapy shall be provided as dictated by ongoing assessment of the patient.
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Observations
Based on the review of patient records, the program failed to ensure that a patient in their third and fourth year receive at least one hour of psychotherapy per month in two of ten patient records reviewed.Patient # 2 was admitted on May 24, 2017 and was an active patient at the time of the inspection. There was no documentation in the patient record indicating that the patient received psychotherapy for the months of November 2020 and March 2021.Patient #8 was admitted on April 1, 2016 and was discharged on August 21, 2020. There was no documentation in the patient record indicating that the patient received psychotherapy for the months of March 2020, April 2020 and June 2020.These findings were reviewed with program staff during the licensing process.
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Plan of Correction
By 6/08/2021, Clinical Supervisors will remind the clinicians of the minimum counseling attendance required for individuals receiving treatment for three, or four years or more of MAT services. The supervisors will assist with implementation of appropriate interventions to help clients meet the requirements. The Clinical Supervisor will be responsible for ensuring ongoing compliance through a review of the Counseling Attendance record based on time in treatment as well as ongoing review of interventions provided during Individual Supervision and random record review. |
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 the review of patient records, the program failed to document an annual physical examination in three of ten patient records reviewed.Patient #1 was admitted on September 8, 1991 and was an active patient at the time of the inspection. An annual physical exam was documented in the record on April 18, 2019 and the next annual physical exam was due not later than April 18, 2020; however, an annual physical exam was not documented in the record until May 10, 2021.Patient # 2 was admitted on May 24, 2017 and was an active patient at the time of the inspection. An annual physical exam was documented in the record on May 13, 2019 and the next annual physical exam was due not later than May 13, 2020; however, an annual physical exam was not documented in the record at the time of the inspection.Patient #8 was admitted on April 1, 2016 and was discharged on August 21, 2020. An annual physical exam was documented in the record on April 1, 2019 and the next annual physical exam was due not later than April 1, 2020; however, an annual physical exam was not documented in the record until June 10, 2020.These findings were reviewed with program staff during the licensing process.
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Plan of Correction
By 6/08/2021, IT staff will assist the Nursing Director with developing a monthly spreadsheet to track the due dates of the Annual Physical examination for all clients. Nursing staff will provide reminders of Annual physical examination due dates to clients and will track completion of the examination to ensure compliance with the regulation. Ongoing compliance will be monitored by the Nursing Director through a weekly review of the tracking log and will ensure missed appointments are re-scheduled and provided when clients present for medication to meet the requirements. |