INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection and methadone and buprenorphine monitoring inspection conducted on January 14, 2020 through January 16, 2020 by staff from the Department of Drug and Alcohol Programs, Bureau of Quality Assurance for Prevention and Treatment. 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
The facility failed to provide documentation of an individual training plan, which is to be developed with input from both the employee and the supervisor for employee numbers 17 through 24.
The findings were discussed with facility staff during the licensing process.
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Plan of Correction
The program director will be responsible for the completion of written individual training plans for each employee according to their skill level within the first 7 days of employment. Individual training plans will be updated by the end of each training plan year. Oversight for compliance will be conducted by the Senior Director of Acute Recovery Services. The program will be in full compliance by April 1, 2020. |
709.23 LICENSURE Project Director
§ 709.23. Project director.
Project directors shall prepare, annually update and sign a written manual delineating project policies and procedures.
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Observations
The facility failed to document that the project director had prepared, annually updated and signed the facility's written manual, which delineates the project policies and procedures.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Policy and Procedure Manual was reviewed and approved by the Associate VP of Addiction Outpatient Services. A page indicating the annual review and approval was added to the manual and signed by Associate VP of Addiction Outpatient Services. Ongoing compliance with standard will be monitored by the CEO. The facility is in compliance with the standard as of 2/7/2020. |
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
The facility failed to ensure that every consent to release information form in each client record noted contained the name of the person, agency or organization to whom the disclosure was to be made to.
Patient #16 was admitted on January 14, 2020 and was active at the time of inspection.
Patient #17 was admitted on January 15, 2020 and was active at the time of inspection.
Patient #18 was admitted on January 7, 2020 and was discharged January 8, 2020.
Patient #19 was admitted on January 7, 2020 and was discharged January 8, 2020.
Patient #20 was admitted on January 13, 2020 and was discharged January 14, 2020.
Patient #21 was admitted on January 12, 2020 and was discharged January 13, 2020.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Behavioral Health Associate will be responsible for ensuring that the consent to disclose information contained in the client records is completed in its entirety. Oversight of compliance will be monitored by a new quality assurance process established by the program director. . Retraining of staff will occur by April 1, 2020. |
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
The facility failed to ensure that every consent to release information form to the client's funding source, in the client record noted, were kept within the restrictions of 4 PA code 255.5.
Patient #1 was admitted on May 1, 2019 and was active at the time of inspection.
The findings were discussed with facility staff during the licensing process.
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Plan of Correction
The release to consent will be kept within the bounds of PA 255.5.
The Program Director emailed the new form to the program staff and provided training about confidentiality and the appropriate amount of information to be released to government officials, law enforcement units and insurance providers. Ongoing supervision will be provided by the Clinical Supervisor. Ongoing oversight will be provided by medical records. The program is in compliance as of 2/3/2020. |
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
The facility failed to document the results of an annual physical examination given by the narcotic treatment program and includes an annual reevaluation by the narcotic treatment physician in the applicable client records noted.
Patient #8 was admitted on December 12, 2017 and was active at the time of inspection.
Patient #10 was admitted on February 16, 2018 and was active at the time of inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Program Director gave training to the Program Physician and Behavioral Health Associate (BHA) assigned to assist the physician regarding the standard on 1/17/2020. The Program Physician designed an Annual Physical form on 1/17/2020. The Program Physician and BHA designed a tracking form for annual physical evaluations. Ongoing supervision and oversight will be provided by the Program Director. The program is in compliance as of 1/23/2020. |
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
The facility failed to document an annual evaluation of the patient's status in the applicable client records noted.
Patient #8 was admitted on December 12, 2017 and was active at the time of inspection.
Patient #10 was admitted on February 16, 2018 and was active at the time of inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Program Director added an Annual Evaluation form to the EHR. Program Director will provide training regarding the form to the Counselors and Supervisors on 2/27/2020. Ongoing supervision will be provided by the Clinical Supervisors. Ongoing oversight will be provided by the Quality Assurance personnel. The program will be in compliance as of 3/6/2020. |
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
The facility failed to provide treatment plan updates within the regulatory timeframe in 9 of 21 outpatient client records reviewed.
Patient #1 was admitted on May 1, 2019 and was active at the time of inspection.
A treatment plan update was completed on May 5, 2019 and a treatment plan update was due no later than July 8, 2019. However, the update was not completed at the time of inspection.
Patient #2 was admitted on September 23, 2016 and was active at the time of inspection.
A treatment plan update was completed on May 9, 2019 and a treatment plan update was due no later than July 9, 2019. However, the update was not completed until July 18, 2019. Additionally, a treatment plan update was completed September 25, 2019 and a treatment plan update was due no later than November 25, 2019. However, the treatment plan was not completed until December 12, 2019.
Patient #4 was admitted on January 10, 2019 and was discharged August 23, 2019.
A treatment plan update was completed on March 19, 2019 and a treatment plan update was due no later than May 19, 2019. However, the update was not completed until June 4, 2019. Additionally, a treatment plan update was completed June 4, 2019 and a treatment plan update was due no later than August 4, 2019. However, the treatment plan was not completed at the time of inspection.
Patient #6 was admitted on February 27, 2019 and was discharged on August 15, 2019.
A treatment plan update was completed on April 5, 2019 and a treatment plan update was due no later than June 5, 2019. However, the update was not completed at the time of inspection.
Patient #8 was admitted on December 12, 2017 and was active at the time of inspection.
A treatment plan update was completed on June 13, 2019 and a treatment plan update was due no later than August 13, 2019. However, the update was not completed until October 15, 2019.
Patient #9 was admitted on January 23, 2019 and was active at the time of inspection.
A treatment plan update was completed on January 23, 2019 and a treatment plan update was due no later than March 23, 2019. However, the update was not completed until April 11, 2019. Additionally, a treatment plan update was completed April 11, 2019 and a treatment plan update was due no later than June 11, 2019. However, the treatment plan was not completed until August 28, 2019. Also, a treatment plan update was completed on October 23, 2019 and a treatment plan update was due no later than December 23, 2019. However, the treatment plan was not completed at the time of inspection.
Patient #10 was admitted on February 16, 2018 and was active at the time of inspection.
A treatment plan update was completed on June 6, 2019 and a treatment plan update was due no later than August 6, 2019. However, the update was not completed until October 10, 2019. Additionally, a treatment plan update was completed October 10, 2019 and a treatment plan update was due no later than December 10, 2019. However, the treatment plan was not completed at the time of inspection.
Patient #11 was admitted on January 24, 2019 and was discharged on April 12, 2019.
A treatment plan update was completed on February 4, 2019 and a treatment plan update was due no later than May 5, 2019. However, the update was not completed at the time of inspection.
Patient #12 was admitted on August 21, 2018 and was discharged on August 29, 2019.
A treatment plan update was completed on April 30, 2019 and a treatment plan update was due no later than June 30, 2019. However, the update was not completed until July 9, 2019.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Program Director will provide training regarding treatment plans and the timing of treatment plan updates to the Counselors and Supervisors on 2/27/2020. Ongoing supervision will be provided by the Clinical Supervisors. Ongoing oversight will be provided by the Quality Assurance personnel. The program will be in compliance as of 3/13/2020. |