INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on January 22, 2024 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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709.24 (a) (3) LICENSURE Treatment/rehabilitation management.
§ 709.24. Treatment/rehabilitation management.
(a) The governing body shall adopt a written plan for the coordination of client treatment and rehabilitation services which includes, but is not limited to:
(3) Written procedures for the management of treatment/rehabilitation services for clients.
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Observations
Based on review of client records and the policy and procedure manual, the facility failed to follow several of the project's written procedures for the management of treatment/rehabilitation services in five of seven client records reviewed.
First, the policy and procedure manual stated the comprehensive treatment plan will be completed within 30 days of the initial treatment plan. Next, the policy and procedure manual stated a discharge summary will be completed at the time of discharge. Finally, the policy and procedure manual stated follow-up information will be completed within 30 days of discharge.
Client #1 was admitted on June 21, 2023 and was discharged on October 27, 2023. The initial treatment plan was completed on June 21, 2023, and the comprehensive treatment plan was due to be completed no later than July 21, 2023; however, the treatment plan was completed on August 15, 2023. Additionally, the discharge summary was due to be completed no later than October 27, 2023; however, the summary was completed on November 17, 2023.
Client #2 was admitted on July 20, 2023 and was discharged on September 15, 2023. The discharge summary was due to be completed no later than September 15, 2023; however, the summary was completed on December 7, 2023. Additionally, the follow-up information was due to be completed no later than October 15, 2023; however, the follow-up information was completed on December 7, 2023.
Client #3 was admitted on July 31, 2023 and was discharged on December 7, 2023. The discharge summary was due to be completed no later than December 7, 2023; however, the summary was completed on December 11, 2023.
Client #4 was admitted on April 5, 2023 and was discharged on August 2, 2023. The initial treatment plan was completed on April 5, 2023, and the comprehensive treatment plan was due to be completed no later than May 5, 2023; however, the treatment plan was completed on June 1, 2023.
Client #7 was admitted on June 6, 2023 and was active at the time of inspection. The initial treatment plan was completed on June 6, 2023, and the comprehensive treatment plan was due to be completed no later than July 6, 2023; however, the treatment plan was completed on August 28, 2023.
This is a repeat citation from the January 17, 2023 annual licensing renewal inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
NET's policy and procedure manual has been updated to indicate that comprehensive treatment plans will be updated within 60 days of the initial treatment plan. This new time frame will give staff more time to devlop goals. This new time frame will be monitored through the caseload report by the clinical supervisor and director on a weekly basis. The change in policy will be reviewed with staff on 2/22/24 in the staff meeting. NETs discharge policy will be updated to indicate that discharge summaries will be completed within 7 days of the discharge date. Follow up information will be gathered within 30 days.
NET's staff will be re-trained on this policy and it will be reviewed in the staff meeting on 2/22/24. This will be monitored on the caseload report weekly by the clinical supervisor and director.
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709.92(a)(2) LICENSURE Treatment and rehabilitation services
709.92. Treatment and rehabilitation services.
(a) An individual treatment and rehabilitation plan shall be developed with a client. This plan shall include, but not be limited to, written documentation of:
(2) Type and frequency of treatment and rehabilitation services.
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Observations
Based on a review of client records, the facility failed to document the type and/or frequency of treatment and rehabilitation services in the client's comprehensive treatment plan in three of seven client records reviewed.
Client #1 was admitted June 21, 2023 and was discharged on October 27, 2023. The comprehensive treatment plan was completed on August 15, 2023; however, the plan did not include the frequency of treatment and rehabilitation services being provided to the client.
Client #2 was admitted July 20, 2023 and was discharged on September 15, 2023. The comprehensive treatment plan was completed on August 10, 2023; however, the plan did not include the frequency of treatment and rehabilitation services being provided to the client.
Client #3 was admitted July 31, 2023 and was discharged on December 7, 2023. The comprehensive treatment plan was completed on August 1, 2023; however, the plan did not include the frequency of treatment and rehabilitation services being provided to the client.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Staff will be re-trained in the 2/22/24 staff meeting by the clinical supervisor and director to be more specific and include the type and/or frequency of treatment and rehabilitation services in the comprehensive treatment plan. This will be monitored by the clinical supervisor and director by using the case load report and by completing quarterly chart audits. |
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 all treatment and rehabilitation plans are reviewed and updated at least every sixty days in five of five applicable client records reviewed.
Client #1 was admitted on June 21, 2023 and was discharged on October 27, 2023. The comprehensive treatment plan was completed on August 15, 2023, and the first update was due no later than October 15, 2023; however, the update was completed on October 26, 2023.
Client #3 was admitted on July 31, 2023 and was discharged on December 7, 2023. The comprehensive treatment plan was completed on August 1, 2023, and the first update was due no later than October 1, 2023; however, the update was completed on October 18, 2023.
Client #5 was admitted on April 5, 2023 and was active at the time of inspection. The comprehensive treatment plan was completed on May 3, 2023, and the first update was due no later than July 3, 2023; however, the update was completed on July 7, 2023. Additionally, the next treatment plan update was due no later than September 7, 2023; however, the update was completed on November 6, 2023. Finally, the next treatment plan update was due no later than January 6, 2024; however, the update was completed on January 16, 2024.
Client #6 was admitted on May 5, 2023 and was active at the time of inspection. The comprehensive treatment plan was completed on June 1, 2023, and the first update was due no later than August 1, 2023; however, the update was completed on September 8, 2023.
Client #7 was admitted on June 6, 2023 and was active at the time of inspection. The comprehensive treatment plan was completed on August 28, 2023, and the first update was due no later than October 28, 2023; however, the update was completed on October 31, 2023. Additionally, the next treatment plan update was due no later than December 31, 2023; however, the update was completed at the time of inspection.
This is a repeat citation from the January 17, 2023 and December 14, 2021 annual licensing renewal inspections.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Staff will now be notified weekly of upcoming treatment plans on a weekly basis by the clinical supervisor. The clincial supervisor will monitor this through the caseload report and chart audits. Staff will be re-trained in the staff meeting on 2/22/24 on documenting the frequency of completing comprehensive treatment plans. They will also be retrained on documenting their outreach attempts in an "outreach note" if the client has missed appointments. Staff will be re-trained by the clinical supervisor and director. |
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 ensuring treatment plan updates were completed within the regulatory timeframe was submitted and approved by the Department for the December 14, 2021 and January 17, 2023 annual licensing inspections. Not completing treatment plan updates within the regulatory timeframe was again found to be a deficiency in the January 22, 2024 licensing inspection.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
Due to NET failing to comply with previous approved plans of correction, NET's VP, director and clinical supervisor will review previous and current POC's to ensure that we are adressing all current and past deficiencies. In addition, NET will be reviewing policies in leadership and staff meetings as well as in supervision. Staff will be re-trained in the 2/22/24 staff meeting by the clinical supervisor and director on completing treatment plans within the regulatory time frame and these new policies. The clinical supervisor will be sending staff weekly updates on up comming treatment plans that will be due each week. The clinical supervisor and director will monitor this through chart reviews and the case load report. The director will report the status of the treatment plans being completed within the regulatory timeframes to the vice president on a weekly basis in supervision. |