INITIAL COMMENTS
|
This report is a result of an on-site licensure renewal inspection and methadone monitoring conducted on May 22, 2023 through May 23, 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 Family Healthcare, LLC 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
|
704.10 LICENSURE Counselor Asst Promotion
704.10. Promotion of counselor assistant.
(a) A counselor assistant who satisfactorily completes one of the sets of qualifications in 704.7 (relating to qualifications for the position of counselor) may be promoted to the position of counselor.
(b) A counselor assistant shall document to the facility director that he is working toward counselor status. This information shall be documented upon completion of each calendar year.
(c) A counselor assistant shall meet the requirements for counselor within 5 years of employment. A counselor assistant who has accumulated less than 7,500 hours of employment during the first 5 years of employment will have 2 additional years to meet the requirements for counselor.
(d) A counselor assistant who cannot meet the time requirements in subsection (c) may submit to the Department a written petition requesting an exception. The petition shall describe the circumstances that make compliance with subsection (c) impracticable and shall be approved by both the clinical supervisor or lead counselor and the project director. Granting of the petition will be within the discretion of the Department.
|
Observations
Based on a review of personnel records, the facility failed to ensure that counselor assistants documented to the facility director, upon the completion of each calendar year, that they are continuing to work towards counselor status in two of three applicable personnel records reviewed.
Employee #7 was hired as a counselor assistant on July 25, 2022. There was no documentation to the facility director that they were working toward counselor status by the end of the 2022 calendar year as of the date of inspection.
Employee #8 was hired as a counselor assistant on September 9, 2022. There was no documentation to the facility director that they were working toward counselor status by the end of the 2022 calendar year as of the date of inspection.
These findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
The Executive Director and Clinical Supervisor reviewed the citation.Effective 6/1/2023, all Counselor Assistants are required every 6 months from January to December to create a letter stating what their plan is to obtain status of Counselor within the required timeframe. NEFHC requires Counselor Assistants to have completed a 4 year degree at the time of hire and within 1 year of hire they will have 1 full year experience substance abuse counseling along with necessary supervision from the CS and will be qualified for Counselor. |
704.12(a)(6) LICENSURE OutPatient Caseload
704.12. Full-time equivalent (FTE) maximum client/staff and client/counselor ratios.
(a) General requirements. Projects shall be required to comply with the client/staff and client/counselor ratios in paragraphs (1)-(6) during primary care hours. These ratios refer to the total number of clients being treated including clients with diagnoses other than drug and alcohol addiction served in other facets of the project. Family units may be counted as one client.
(6) Outpatients. FTE counselor caseload for counseling in outpatient programs may not exceed 35 active clients.
|
Observations
Based on a review of personnel records and the Staffing Requirements Facility Summary Report, the facility failed to ensure that the Full Time Equivalent (FTE) counselor caseload in outpatient programs did not exceed 35 active clients in one of nine applicable counselor personnel records reviewed.
The counselor Full Time Equivalent (FTE) is determined by dividing the total number of hours the counselor devotes to their clients by the facility's workweek. Then, to obtain the counselor's ratio, the total number of clients on the counselor's outpatient caseload is divided by the FTE.
Employee # 3 was hired as a clinical supervisor on November 1, 2022. The employee's ratio calculation was as follows: 20/40 = .5 (FTE); 21/.5 = 42, which equals to a client/counselor FTE ratio of 42:1.
This finding was reviewed with facility staff during the licensing process.
|
Plan of Correction
The Executive Director and Clinical Supervisor reviewed the citation.Effective 5/30/23 patient caseloads were adjusted and our caseloads were decreased to meet the ration needs of our patient census, 2 new counselors were hired to assist with this adjustment as of 5/30/23.Clinical Supervisor caseload also adjusted to adhere to DDAP requirements.Effective 6/7/23 and ongoing, clinic Director and Clinical Supervisor will maintain the appropriate number of counselors/counselor assistants in regard to ratio of the patient census so each clinical staff ratio does not exeed 35 active clients.This change occured on 6/7/2023 and was discussed with clinic staff in a staff meeting 6/7/23. |
705.26 (2) LICENSURE Heating and cooling.
705.26. Heating and cooling.
The nonresidential facility:
(2) May not permit in the facility heaters that are not permanently mounted or installed.
|
Observations
Based on a physical plant inspection conducted on May 23, 2022 between 10:00 am and 11:00 am, the facility failed to ensure that all heaters were permanently mounted or installed as there was a space heater located in the nurse practitioner's office.
This finding was reviewed with facility staff during the licensing inspection.
|
Plan of Correction
The citation has been reviewed by the Executive Director and Clinical Supervisor. Effective 5/24/2023, the space heater in the CRNP office was disposed of and a directive from the ED to all staff was executed that there shall be no space heaters located within the clinic at any time. Daily CS or ED will be responsible to do weekly checks throughout the clinic to ensure there are no space heaters located within any office/clinic space, the corrective action went into effect 5/24/2023 and ongoing. Discussion was held with staff regarding this procedure on 5/24/23 in our weekly staff meeting. |
705.28 (d) (4) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(4) 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.
|
Observations
Based on a review of the May 2022 through May 2023 fire drill logs the facility to provide, during the inspection, written fire drill logs that included the amount of time it took for evacuation, the exit route used, the number of persons in the facility at the time of drill, problems encountered and whether the fire alarm or smoke detector was operative for every fire drill conducted during the reviewed timeframe.
These findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
The Executive Director and Clinical Supervisor reviewed the citation. The fire alarms logs that we have in place document time frames for evacuation, number of people in the building, participating in the drill, location of fire, whether fire company was nofitied etc. Fire alarms are tested monthly to ensure appropriate operation. This process was in effect prior to the inspection. The ED will complete monthly fire drill inspections and complete a fire drill inspection logs each month, a form was implemented to detail the amount of time it took for evacuation, the exit route use, problems encountered if detector were operable. This process will ocurr effective 6/7/23 and ongoing. |
709.33 (b) LICENSURE Notification of termination.
§ 709.33. Notification of termination.
(b) The client shall have an opportunity to request reconsideration of a decision terminating treatment.
|
Observations
Based on a review of client records, the facility failed to provide the client an opportunity to request reconsideration of a decision to terminate treatment in one of one applicable client record reviewed.
Client #5 was admitted on June 14, 2019 and was administratively discharged on March 24, 2023. There was no documentation in the record that the client was given the opportunity to appeal the termination decision at the time of the inspection.
These findings were discussed with facility staff during the licensing process.
|
Plan of Correction
The Executive Director and Clinical Supervisor reviewed the Citation. Client #5 was administratively discharged effective immediately due to a physical assault against the Executive Director. Effective 6/7/23, in a clinical staff meeting all staff were educated and trained on the discharge process and the appeal process of the patient when they are administratively discharged for whatever that reason. A form is included in the intake packet stating what their rights are and appeal directives and options. At time of discharge, a letter will be given to the patient stating they have the right to appeal and the clinical staff will review said form with patient. This is effective 6/7/23 and ongoing. |
715.6(d) LICENSURE Physician Staffing
(d) A narcotic treatment program shall provide narcotic treatment physician services at least 1 hour per week onsite for every ten patients
|
Observations
Based on an administrative review, the facility failed to ensure that a narcotic treatment program provided narcotic treatment physician services at least 1 hour per week onsite for every ten patients.
During the week of May 5, 2023 through May 12, 2023 the patient census was 291, which required 29.1 total narcotic treatment physician hours. The narcotic treatment physician provided only 10 of the required 29.1 required hours and the nurse practitioner provided 0 hours.
These findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
The Executive Director and Clinical Supervisor reviewed the Citation. Effective 6/1/2023, The ED will implement and secure documention for all physician program hours that occur for vacation and time off coverages to ensure all physician hours required are provided and accounted for. Our Medical Director will assist the ED in securing coverage when necessary. This was put into effect 6/1/23 and ongoing. |
715.23(b)(24) LICENSURE Patient records
(b) Each patient file shall include the following information:
(24) Follow-up information regarding the patient.
|
Observations
Based on a review of patient records, the facility failed to document follow-up information regarding the patient in the patient record in one of one applicable client record reviewed.
Client #7 was admitted on April 13, 2015 and was discharged December 16, 2022. There was no documentation of follow-up information in the record as of the date of the inspection.
This finding was reviewed with facility staff during the licensing process.
|
Plan of Correction
The Executive Director and Clinical Supervisor reviewed the Citation. Effective 6/1/2023, staff were reminded and educated on the follow up documentation process post discharge. Follow up post discharge will occur within 30 days and documented in patients chart. Clinical Supervisor and Executive Director witll follow up to ensure follow up procedures are completed . Effective 6/1/23 and ongoing. |
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 facility failed to ensure that the counselor completed an annual evaluation of each patient's status, which is to be reviewed, dated, and signed by the medical director, in two of seven patient records reviewed.
Patient #5 was admitted on June 14, 2019 and was discharged on March 24, 2023. An annual evaluation of the patient's status was completed on June 8, 2021, and the next evaluation was due no later than June 8, 2022; however, there was no annual evaluation documented prior to discharge.
Patient #6 was admitted on May 13, 2019 and was discharged on March 22, 2023. An annual evaluation of the patient's status was completed on May 7, 2021, and the next evaluation was due no later than May 7, 2022; however, there was no annual evaluation documented prior to discharge.
This finding was reviewed with facility staff during the licensing process.
|
Plan of Correction
The Citation was reviewed by the Executive Director and Clinical Supervisor. Effective 6/7/2023 procedure for 6 month and annual evaluations was discussed and reviewed within the interdisciplinary staff meeting to ensure procedure is understood and carried out for all patients. Clinical Supervisor will follow up for appropriate and timely completion of documentation. Medical Director will follow up on medical staff and medical documention to ensure completion in timeframe. This occurs effective 6/7/23 and ongoing. |
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 four of seven client records reviewed.
Client #1 was admitted on June 4, 2018 and was still active at the time of the inspection. A treatment plan update was completed on February 14, 2023 and the next update was due no later than April 14, 2023; however, the update was not completed as of the date of the inspection.
Client #2 was admitted on October 15, 2020 and was still active at the time of the inspection. A treatment plan update was completed on February 15, 2023 and the next update was due no later than April 15, 2023; however, the update was not completed as of the date of the inspection.
Client #3 was admitted on March 23, 2022 and was still active at the time of the inspection. A treatment plan update was completed on February 6, 2023 and the next update was due no later than April 6, 2023; however, the update was not completed as of the date of the inspection.
Client #5 was admitted on June 14, 2019 and was discharged on March 24, 2023. A treatment plan update was completed on December 18, 2022 and the next update was due no later than February 18, 2023; however, the update was not completed prior to discharge.
This is a repeat citation from the June 9, 2022 annual licensing renewal inspection.
This finding was reviewed with facility staff during the licensing process.
|
Plan of Correction
The citation was reviewed by the Executive Director and Clinical Supervisor. Effective 6/12/2023, Clinical Supervisor trained clinical staff on treatment plan timelines. Specific instructions, education and guidelines for treatment plan timelines were implemented and an audit was completed to ensure all treatment plans were completed and up to date presently and ongoing. Clinical supervisor implemented a weekly checklist for clinical staff to ensure all documentation is completed. This checklist is reviewed weekly by clinical supervisor.This went into effect 6/12/23 and ongoing. |