INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection and methadone monitoring inspection conducted on January 10, 2017 through January 11, 2017 by staff from the Department of Drug and Alcohol Programs, Bureau of Quality Assurance for Prevention and Treatment, Program Licensure Division. 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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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 patient records, the facility failed to document an informed and voluntary consent to release information form prior to the disclosure of information in patient record #20.
Patient #20 was admitted on 3/28/16 and was discharged on 1/6/17. The record contained documentation of a facsimile sent to a hospital on 8/18/16, which included dosing information/history; however, there was not a client-signed consent to release information form to the hospital prior to the disclosure of information.
The findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
The Director of Nursing will review the deficiency with the nursing staff and provide training in supervision as to the procedure for completing a consent/release of information with the client before disclosing client information. The Director of Operations will audit client charts with the focus on ascertaining that all proper releases have been completed. We will continue to provide Confidentiality training to all staff annually. |
705.2 (1) LICENSURE Building exterior and grounds.
705.2. Building exterior and grounds.
The residential facility shall:
(1) Maintain all structures, fences and playground equipment, when applicable, on the grounds of the facility so as to be free from any danger to health and safety.
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Observations
Based on the physical plant inspection that was conducted on 1/11/17, the facility failed to ensure that the grounds of the facility was maintained in a clean, safe, and sanitary manner as evidenced by the following:
1.Graffiti was noticed in Dorm 1 - both sets of bunkbeds, Dorm 2 - all 8 sets of bunkbeds, and Dorm 3 - 5 of 7 sets of bunkbeds.
2.A large hole in the wall was observed below the window on the far left side of Dorm 2.
3.The floor/subfloor in the dining room/kitchen area in front of the small walk-in freezer was soft, dry rotted, and sank when the Licensing Specialist walked on it.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Residential Supervisor will closely monitor the facility to make sure that it is well maintained and the building is kept in the clean manner. All instances of needed repairs will be documented and reported to the maintenance team immediately so that the facility can be kept in good order. Residential staff will closely monitor the building and dormitories for any signs of graffiti and report any evidence to the maintenance crew for removal.
The removal of graffiti began on 1/16/17 and will continue until all of the graffiti removed.
The hole in the wall in Dorm 2 was repaired on 1/13/17.
The floor in the dining/kitchen area is scheduled for repair on 1/19/17.
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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
Based on a review of client records, the facility failed to document the 2016 annual evaluation of the patient in patient record # 18, who was admitted on 5/01/13 and was discharged on 11/16/16. The last annual evaluation completed was dated 05/01/2015.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Clinical Supervisor will audit each supervisee's caseload weekly and communicate all clinical annuals that are due. The Clinical Supervisor will review the timelines for which clinical annuals are due. |
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.
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Observations
Based on a review of the Staffing Requirements Facility Summary Report (SRFSR) and personnel records, the facility failed to document the completion of 25 clock hours of annual training required for counselors in employee #'s 10, 11, and 12 for the 01/01/16 through 12/31/16 training year.
Employee #10 was hired as a counselor on 2/12/2008 and was still in the position as of the date of the onsite inspection. The personnel record only included documentation of 24.75 hours of annual training.
Employee #11 was hired as a counselor on 8/6/2012 and was still in the position as of the date of the onsite inspection. The personnel record only included documentation of 21.5 hours of annual training.
Employee #12 was hired as a counselor on 8/17/2015 and was still in the position as of the date of the onsite inspection. The personnel record only included documentation of 4 hours of annual training.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Each counselor who was deficient will be placed on a plan of correction to ensure all required training hours are met. The Director of Operations will generate a training status report quarterly and submit it to the Clinical Supervisors to follow up with their counseling staff. |