INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on January 4, 2023 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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705.28 (d) (7) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(7) Set off a fire alarm or smoke detector during each fire drill.
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Observations
Based on a review of the January 2022 through December 2022 fire drill logs, the facility failed to set off a fire alarm or a smoke detector during every fire drill conducted during the reviewed period.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Due to not owning the building, we were not able to set off the alarm during every fire drill.
The facility will have monthly fire drills and all staff and clients will evacuate the building. This will be facilitated by the program director.
Program Director will document which exit routes are used during fire drills. A fire drill training will be updated to address this need when training existing and future staff. Current staff will receive training before 2/28/23 regarding the regulation. The Program Director will monitor for compliance. The program will be in compliance by 2/28/2023.
The program diretor will maintain a written fire drill record including the date, time, the amount of time it took for evacuation, the exit route used, the number of persons in the facility at the time of the drill, problems encountered and whether the fire alarm or smoke detector was operative.
A waiver request was submitted on 1/19/23. |
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 a review of client records, the facility failed to document the purpose of disclosure on a consent to release information form in one of eight client records reviewed. Client #3 was admitted on August 1, 2022 and was active at time of inspection. A release of information form to a transportation service was signed and dated by the client on August 2, 2022; however, the form did not include the purpose of the disclosure. These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Consents to release information are completed with the client at the time of the intake. On 1/20/23 all staff were re-trained who how to complete a consent to release information. Specifically, they will be re-trained on how to document the purpose of the disclosure on the Release of Information form. A guide on how to complete a ROI was also distributed to staff.
The program director will monitor for compliance when reviewing all initial intake documentation. |
709.28 (c) (6) 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:
(6) Date, event or condition upon which the consent will expire.
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Observations
Based on a review of client records, the facility failed to document the date, event, or condition upon which a consent to release information form will expire in two of eight client records reviewed.Client #3 was admitted on August 1, 2022 and was active at time of inspection. There were release of information forms to a urinalysis laboratory, a transportation service, a funding source, and an emergency contact that were all signed and dated by the client on August 2, 2022; however, there was no date, event, or condition upon which the consent would expire on any of the forms. Additionally, a release of information form to a court officer was signed and dated by the client on August 16, 2022; however, there was no date, event, or condition which the consent would expire on the form.Client #4 was admitted on May 31, 2022 and was discharged on October 17, 2022. There were release of information forms to a urinalysis laboratory, a transportation service, a funding source, an emergency contact, and a pharmacy that were all signed and dated by the client on May 31, 2022; however, there was no date, event, or condition upon which the consent would expire on any of the forms.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
All staff will be re-trained on how to appropriately complete the consent to release of information form. Specifically, they will be trained on documenting the date, event, or condition upon which a consent to release information form will expire. They will be trained on how to complete this for all entities that we release information to. This training will be held by 2/10/23 by the program director. The program director will monitor this for compliance on a regular basis when she approves all intake documentation.
Client #2's ROI's will be updated by 2/10/23. The ROI for a urinalysis laboratory. transportation service, funding source, emergency contact and pharmacy will be re-done to include a date, event and/or condition in which the consent will expire. This will be completed by staff and monitored for compliance by the program director by 2/10/23. |
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 ensure that treatment and rehabilitation plans are reviewed and updated at least every sixty days in six of seven applicable client records reviewed.Client #1 was admitted on March 24, 2022 and was active at the time of inspection. The comprehensive treatment plan was completed on April 29, 2022, and the first update was due no later than June 29, 2022; however, the update was completed on August 11, 2022. Additionally, the next update was due no later than October 11, 2022; however, the update was completed on November 3, 2022. Client #2 was admitted on July 28, 2022 and was active at the time of inspection. The comprehensive treatment plan was completed on August 10, 2022, and the first update was due no later than October 10, 2022; however, the update was completed on October 31, 2022. Client #3 was admitted on August 1, 2022 and was active at the time of inspection. The comprehensive treatment plan was completed on August 25, 2022, and the first update was due no later than October 25, 2022; however, the update was completed on November 4, 2022. Client #4 was admitted on May 31, 2022 and was discharged on October 17, 2022. The comprehensive treatment plan was completed on June 7, 2022, and the first update was due no later than August 7, 2022; however, the update was completed on August 9, 2022. Additionally, the next update was due no later than October 9, 2022; however, the update was completed on October 13, 2022.Client #5 was admitted on April 28, 2022 and was discharged on December 16, 2022. The comprehensive treatment plan was completed on June 24, 2022, and the first update was due no later than August 24, 2022; however, the update was not completed prior to discharge. Client #7 was admitted on September 21, 2022 and was discharged on December 28, 2022. The comprehensive treatment plan was completed on September 28, 2022, and the first update was due no later than November 28, 2022; however, the update was completed on December 1, 2022.This is a repeat citation from the January 6, 2021 and February 2, 2022 annual licensing renewal inspection.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
All staff will be re-trained on treatment planning. Specifically, that treatment plans need to be completed at least every 60 days. This will be monitored through the use of a caseload report. The program director manages the case load report and shares it with all staff on a weekly basis. The training will be held by 2/10/23 by the program director. Ongoing treatment plan updates will be monitored for compliance by the program director. |
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 assure that counseling services were being provided according to the individual treatment and rehabilitation plan in four of seven applicable client records reviewed. Client #1 was admitted on March 24, 2022 and was active at the time of inspection. The comprehensive treatment plan completed on April 29, 2022, indicated weekly individual counseling sessions; however, there was no documentation of individual counseling sessions occurring during the week of May 22, 2022 - May 28, 2022.Client #4 was admitted on May 31, 2022 and was discharged on October 17, 2022. The comprehensive treatment plan completed on June 7, 2022, and the treatment plan update completed on August 9, 2022 indicated weekly individual counseling sessions; however, there was no documentation of individual counseling sessions occurring during the weeks of June 12, 2022 - July 2, 2022, July 10, 2022 - August 6, 2022, and August 14, 2022 - September 3, 2022. Client #7 was admitted on September 21, 2022 and was discharged on December 28, 2022. The comprehensive treatment plan completed on September 28, 2022, indicated bi-weekly individual counseling sessions; however, there was no documentation of individual counseling sessions occurring during the weeks of October 9, 2022 - October 22, 2022 and October 30, 2022 - November 12, 2022. Client #8 was admitted on May 6, 2022 and was discharged on December 27, 2022. A treatment plan update completed on November 4, 2022, indicated bi-weekly individual counseling sessions; however, there was no documentation of individual counseling sessions occurring during the weeks of November 6, 2022 - December 3, 2022.This is a repeat citation from the February 2, 2022 annual licensing renewal inspection.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
All staff will be re-trained on how the treatment plan should correspond with the recommended frequency of individual and/or group therapy. They will be re-trained on documenting that if a client does not show for their scheduled individual therapy appointment, they will document that in the chart when they complete outreach to the client. The training will be held by the program director by 2/10/23. This will be monitored by the program director for compliance. |
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 client records, the facility failed to comply with plans of correction that were approved by the Department. A plan of correction for completing treatment plan updates within the regulatory timeframe was submitted and approved by the Department for the January 6, 2021 and February 2, 2022 annual licensing inspections. Not completing treatment plan updates within the regulatory timeframe was again found to be a deficiency in the January 4, 2023, licensing inspection.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
This facility is now under the leadership of a new facility director. The new facility director, and the program director, will ensure that treatment plans will be completed and signed in the regulatory time frame.
The program director will use the caseload report to manage when a treatment plan is due. She will share this with all of the counselors on a weekly basis. The program director will check on a weekly basis to ensure that the treatment plan was completed by the counselor in order to monitor compliance. |