INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection and buprenorphine monitoring inspection conducted on January 7, 2025 through January 8, 2025 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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705.2 (2) LICENSURE Building exterior and grounds.
705.2. Building exterior and grounds.
The residential facility shall:
(2) Keep the grounds of the facility clean, safe, sanitary and in good repair at all times for the safety and well-being of residents, employees and visitors. The exterior of the building and the building grounds or yard shall be free of hazards.
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Observations
Based on a physical plant inspection, conducted on January 8, 2025, the facility failed to keep the facility safe, in good repair, and free from danger to the safety and well-being of clients, employees, and visitors.
At the time of the inspection, there was an electrical junction box, located in the middle of the client bedroom hallway next to the emergency pull station, that was exposed and had easy access to the electrical wiring inside the box.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
On 1/8/2025, the facilities maintenance staff installed a cover plate for the junction box. The repair was confirmed by the Program Director.
The program director will create a facilities checklist to be completed weekly by support staff that makes observations of the physical plant looking for any potential safety or hazardous areas and or materials. The program director will be responsible for reviewing checklist randomly and biweekly bases.
The program will be in compliance by 2/19/2025 |
705.6 (7) LICENSURE Bathrooms.
705.6. Bathrooms.
The residential facility shall:
(7) Maintain each bathroom in a functional, clean and sanitary manner at all times.
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Observations
Based on a physical plant inspection, conducted on January 8, 2025, the facility failed to maintain each bathroom in a functional, clean, and sanitary manner at all times.
At the time of the inspection, the intake bathroom shower, the female's bathroom shower, and the male's bathroom shower all had dirt, grime, and what appeared to be mold or mildew along the bottom of the showers. Additionally, the female's bathroom shower drain appeared to be clogged with dirt, grime, and/or hair.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Facilities management performed an inspection, repair and deep clean of all bathrooms and individual stalls within the facility between 1/9/2025 and 1/14/2025. The program director has created and implemented a facilities check list for BHA staff to complete on a weekly bases to verify cleanliness or necessity maintenance of bathrooms and shower. The program director will monitor the completion of the facilities checklist and cleanliness of bathrooms/ showers randomly and on a bi weekly bases to ensure compliance and safety. The program is in compliance as of 1/14/2025. Photographs emailed. |
705.10 (c) (3) LICENSURE Fire safety.
705.10. Fire safety.
(c) Fire extinguisher. The residential facility shall:
(3) Ensure fire extinguishers are inspected and approved annually by the local fire department or fire extinguisher company. The date of the inspection shall be indicated on the extinguisher or inspection tag. If a fire extinguisher is found to be inoperable, it shall be replaced or repaired within 48 hours of the time it was found to be inoperable.
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Observations
Based on the physical plant inspection, conducted on January 8, 2025, the facility failed to ensure all fire extinguishers were inspected and approved annually by the local fire department or fire extinguisher company.
At the time of the inspection, the fire extinguisher located in the Intake, Evaluation and Referral lower-level area, was not recently inspected and/or annually approved. The inspection tag on the extinguisher indicated the date of the last inspection occurred was in August 2023.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
The program uses an outside company to inspect the fire extinguishers. During the routine fire extinguisher inspection , one fire extinguisher was over looked. On 1/9/2025, the Senior Director submitted a work order requesting to have the omitted fire extinguisher inspected and appropriately identified. On 1/10/2025 the organization's facilities director provided a newly inspected fire extinguisher to the program. The program was in compliance as of 1/10/2025.
The program director and facilities director will complete a quarterly inspection of all fire extinguishers and monitor for compliance and safety.
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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 the project's written procedures for the management of treatment/rehabilitation services in two of seventeen client records reviewed.
The facility's policy and procedure manual stated that the emergency contact will be contacted within 12 hours after a client is discharged from the facility against medical advice, per the requirement in Licensing Alert 02-21. Additionally, the policy and procedure manual stated the individual comprehensive treatment and rehabilitation plan will be completed within 15 days of the initial (preliminary) treatment plan.
Client #13 was admitted on October 30, 2024 and left against medical advice on November 11, 2024. Upon the client's discharge, there was documentation indicating there was no emergency contact to notify as the client left against medical advice. However, in the record, there was an emergency contact release of information form signed and dated by the client on October 30, 2024 and included a name and phone number of the emergency contact.
Client #14 was admitted on May 29, 2024 and was discharged on June 28, 2024. The preliminary treatment plan was completed on May 31, 2024 and the individual comprehensive treatment plan was due to be completed by June 15, 2024; however, the plan was completed on June 20, 2024.
This is a repeat citation from the January 18, 2024 annual licensing renewal inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The AMA Follow Up policy was resent to program staff via email. The program director provided training regarding the policy , implementation of the policy , and documentation of the follow up call to the emergency contact to the treatment team during an all staff meeting on 2/13/2025. The program director will provide additional training during individual supervision sessions on biweekly bases. The care coordinator will monitor AMA discharge charts daily for completion of emergency contact outreach for compliance with the policy.
A treatment plan documentation timeline review will be added to clinical staff's onboarding plan. At time of hire and onboarding the program director will review the timeline for required documentation to ensure understanding of policy. Through review of caseload report, the program director will monitor compliance of this policy and address with staff during individual and group supervision as necessary to ensure compliance. The program will be in compliance by 2/19/2025 |
709.25 LICENSURE Fiscal Management
§ 709.25. Fiscal management.
The project shall obtain the services of an independent certified public accountant for an annual financial audit of activities associated with the project ' s drug/alcohol abuse services, in accordance with generally accepted accounting principles which include reference to the drug and alcohol treatment activities.
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Observations
Based on an administrative review, the project failed to obtain the services of an independent certified public accountant for the completion of an annual financial audit of activities associated with the project's drug/alcohol abuse services, in accordance with generally accepted accounting principles which include reference to the drug and alcohol treatment activities, for the project's fiscal year ending June 2023.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
NET did obtain the services of an independent certified public accounting firm for the Fiscal period ending June 2023 however the audit has not yet been completed. The audit is taking so long because NET (although they were searching/recruiting) was without a CFO for a period for over a year. NET has had a new CFO for the past year and has been able to manage and put safeguards in place so that this does not happen again. NET's CFO, and NETs fiscal department has been working closely with the public accounting firm to complete this audit. The audit will be completed by March 31st, 2025. NET will send the results of the audit to DDAP by 3/31/25.
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709.26 (b) (3) LICENSURE Personnel management.
§ 709.26. Personnel management.
(b) The personnel records must include, but are not limited to:
(3) Annual written individual staff performance evaluations, copies of which shall be reviewed and signed by the employee.
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Observations
Based on a review of personnel records, the facility failed to document annual written individual staff performance evaluations, copies of which shall be reviewed and signed by the employee, in three of five applicable personnel records reviewed.
Employee #1 was hired as the Project Director on April 21, 2021. The annual written individual staff performance evaluation, completed on November 12, 2024, was not signed by the employee.
Employee #2 was hired as the Facility Director on April 21, 2021. The annual written individual staff performance evaluation, completed on November 7, 2024, was not signed by the employee.
Employee #5 was hired as a counselor on July 7, 2023. The annual written individual staff performance evaluation, completed on September 20, 2024, was not signed by the employee.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Senior Director reviewed the Annual Performance Evaluation Policy. The Senior Director will work with Human Resource director to ensure the software and accommodate the need for signatures to be present on the Annual Performance Evaluation. The Human Resource Director will monitor for compliance.
The program will be in compliance by 2/14/2025 |
709.28 (c) 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.
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Observations
Based on a review of client records, the facility failed to obtain a written informed and voluntary consent from the client for the disclosure of information contained in the client record in three of fifteen applicable client records reviewed.
Client #5 was admitted to the intake, evaluation and referral activity on July 2, 2024 and was discharged on July 2, 2024. The client was referred and transported to another treatment provider; however, there was no consent to release information form signed by the client documented in the record prior to the disclosure to the other treatment provider.
Client #6 was admitted to the intake, evaluation and referral activity on July 16, 2024 and was discharged on July 16, 2024. The client was referred and transported to another treatment provider; however, there was no consent to release information form signed by the client documented in the record prior to the disclosure to the other treatment provider.
Client #7 was admitted to the intake, evaluation and referral activity on July 23, 2024 and was discharged on July 23, 2024. The client was referred and transported to another treatment provider; however, there was no consent to release information form signed by the client documented in the record prior to the disclosure to the other treatment provider.
This is a repeat citation from the February 2, 2023 and January 18, 2024 annual licensing renewal inspections.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
The Program Director will provide additional training to the support staff regarding the use of the Release of Information form on 2/13/2025. The training will include how and why the program must obtain a written informed and voluntary consent from the client for the disclosure of information contained in the client record. The senior director will add individual consent training to the new hire onboarding plan. The Records Management Supervisor will monitor charts for compliance. The Program Director will follow up during individual supervision as needed.
The program will be in compliance on 2/20/2025 |
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 a review of client records, the facility failed to document the name of the person, agency, or organization to whom a disclosure was to be made to on release of information forms in one of fifteen applicable client records reviewed.
Client #5 was admitted to the intake, evaluation and referral activity on July 2, 2024 and was discharged on July 2, 2024. There were two blank release of information forms signed and dated by the client on July 2, 2024; however, there was no name of the person, agency, or organization to whom the disclosures were to be made included on either of the release forms.
This is a repeat citation from the January 18, 2024 annual licensing renewal inspection.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
The program director will provide training to the support staff regarding the use of the release of information form on 2/19/2025. The training will include how and why the program must obtain a written informed and voluntary consent from the disclosure of information contained in the client record writing and include, but not limited to : ( 1) name of the person, agency or organization to whom disclosure is made. The records management supervisor will monitor charts for compliance. The Program Director will follow up during individual supervision as needed. |
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 the disclosure on consent to release information forms in fourteen of fifteen applicable client records reviewed.
Client #1 was admitted to the intake, evaluation and referral activity on April 25, 2024 and was discharged on April 25, 2024. There were release of information forms to a funding source, a treatment provider, an emergency contact, a urinalysis laboratory, a government agency, and a pharmacy signed and dated by the client on April 25, 2024; however, there was no purpose of the disclosure included on any of the release forms.
Client #2 was admitted to the intake, evaluation and referral activity on July 9, 2024 and was discharged on July 9, 2024. A release of information form to a funding source was signed and dated by the client on July 9, 2024; however, there was no purpose of the disclosure included on the release form.
Client #3 was admitted to the intake, evaluation and referral activity on June 24, 2024 and was discharged on June 24, 2024. A release of information form to a funding source was signed and dated by the client on June 24, 2024; however, there was no purpose of the disclosure included on the release form.
Client #4 was admitted to the intake, evaluation and referral activity on September 7, 2024 and was discharged on September 7, 2024. A release of information form to a funding source was signed and dated by the client on September 7, 2024; however, there was no purpose of the disclosure included on the release form.
Client #5 was admitted to the intake, evaluation and referral activity on July 2, 2024 and was discharged on July 2, 2024. There were release of information forms to a funding source and two blank release forms signed and dated by the client on July 2, 2024; however, there was no purpose of the disclosure included on either release form.
Client #6 was admitted to the intake, evaluation and referral activity on July 16, 2024 and was discharged on July 16, 2024. There were release of information forms to a funding source and an emergency contact signed and dated by the client on July 16, 2024; however, there was no purpose of the disclosure included on either release form.
Client #7 was admitted to the intake, evaluation and referral activity on July 23, 2024 and was discharged on July 23, 2024. A release of information form to a funding source was signed and dated by the client on July 23, 2024; however, there was no purpose of the disclosure included on the release form.
Client #9 was admitted to the inpatient non-hospital activity on May 7, 2024 and was discharged on June 6, 2024. There were release of information forms to another treatment provider, a funding source, two government agencies, a urinalysis laboratory, an emergency contact, and a pharmacy signed and dated by the client on May 7, 2024; however, there was no purpose of the disclosure included on any of the release forms. Additionally, there was a release form to another treatment provider signed and dated by the client on June 5, 2024; however, there was no purpose of the disclosure included on the release form.
Client #10 was admitted to the inpatient non-hospital activity on July 9, 2024 and was discharged on July 19, 2024. There were release of information forms to a funding source, a government agency, a urinalysis laboratory, and a pharmacy signed and dated by the client on July 9, 2024; however, there was no purpose of the disclosure included on any of the release forms.
Client #11 was admitted to the inpatient non-hospital activity on June 23, 2024 and was discharged on August 23, 2024. There were release of information forms to a funding source, another treatment provider, two government agencies, a urinalysis laboratory, and a pharmacy signed and dated by the client on June 24, 2024; however, there was no purpose of the disclosure included on any of the release forms.
Client #12 was admitted to the inpatient non-hospital activity on September 7, 2024 and was discharged on September 18, 2024. There were release of information forms to a funding source, another treatment provider, a government agency, a urinalysis laboratory, and a pharmacy signed and dated by the client on September 7, 2024; however, there was no purpose of the disclosure included on any of the release forms. Additionally, a release of information form to another treatment provider was signed and dated by the client on September 16, 2024; however, there was no purpose of the disclosure included on the release form.
Client #13 was admitted to the inpatient non-hospital activity on October 30, 2024 and was discharged on November 11, 2024. There were release of information forms to a funding source, another treatment provider, two government agencies, an emergency contact, and a urinalysis laboratory signed and dated by the client on October 30, 2024; however, there was no purpose of the disclosure included on any of the release forms.
Client #14 was admitted to the inpatient non-hospital activity on May 29, 2024 and was discharged on June 28, 2024. There were release of information forms to a funding source, another treatment provider, two government agencies, an emergency contact, a pharmacy, and a urinalysis laboratory signed and dated by the client on May 29, 2024; however, there was no purpose of the disclosure included on any of the release forms. Additionally, there was a release of information form to a physician signed and dated by the client on June 7, 2024; however, there was no purpose of the disclosure included on the release form.
Client #15 was admitted to the inpatient non-hospital activity on December 27, 2024 and was active at the time of the inspection. There were release of information forms to a funding source, another treatment provider, two government agencies, an emergency contact, a pharmacy, and a urinalysis laboratory signed and dated by the client on December 27, 2024; however, there was no purpose of the disclosure included on any of the release forms.
This is a repeat citation from the January 18, 2024 annual licensing renewal inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The program staff were retrained by the program director on 2/13/2025 on confidentiality and Releases of Information. The training included the importance of obtaining written and informed consent. The program director coordinated with quality and compliance to add purpose disclosure to release forms.
The program director will monitor the update and correct use of release form on a weekly bases. |
709.28 (c) (4) 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:
(4) Dated signature of client or guardian as provided for under 42 CFR 2.14(a) and (b) and 2.15 (relating to minor patients; and incompetent and deceased patients).
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Observations
Based on a review of client records, the facility failed to include the dated signature of the client on release of information forms in one of fifteen applicable client records reviewed.
Client #9 was admitted to the inpatient non-hospital activity on May 7, 2024 and was discharged on June 6, 2024. There were release of information forms to a funding source and another treatment provider signed and dated by facility staff on May 7, 2024; however, the dated signature of the client was not included on either release form.
This is a repeat citation from the January 18, 2024 annual licensing renewal inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Program Director will provide staff with education on 2/12/2025 regarding release of information form and the need to include the dated signature of the client or guardian as provided for under CFR 2.14(a) and (b) and 2.15 ( relating to minor patients: and incompetent and deceased patients ) The program Director will provide oversight through supervision and chart reviews. The program will be in compliance on 2/13/2025 |
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 include a date, event, or condition upon which the consent will expire on consent to release information forms in three of fifteen applicable client records reviewed.
Client #10 was admitted to the inpatient non-hospital activity on July 9, 2024 and was discharged on July 19, 2024. A release of information form to a pharmacy was signed and dated by the client on July 9, 2024; however, the date, event, or condition upon which the consent will expire was not included on the release form.
Client #13 was admitted to the inpatient non-hospital activity on October 30, 2024 and was discharged on November 11, 2024. There were release of information forms to another treatment provider, two government agencies, and a urinalysis laboratory signed and dated by the client on October 30, 2024; however, the date, event, or condition upon which the consent will expire was not included on any of the release forms.
Client #14 was admitted to the inpatient non-hospital activity on May 29, 2024 and was discharged on June 28, 2024. A release of information form to another treatment provider was signed and dated by the client on May 29, 2024; however, the date, event, or condition upon which the consent will expire was not included on the release form.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Program Director will provide staff with education on 2/12/2025 regarding the release of information form and the need to include the date, event or condition upon which consent will expire. The program director will provide oversight through supervision and chart reviews.
The program will be in compliance on 2/13/2025. |
715.12(1-5) LICENSURE Informed patient consent
A narcotic treatment program shall obtain an informed, voluntary, written consent before an agent may be administered to the patient for either maintenance or detoxification treatment. The following shall appear on the patient consent form:
(1) That methadone and LAAM are narcotic drugs which can be harmful if taken without medical supervision.
(2) That methadone and LAAM are addictive medications and may, like other drugs used in medical practices, produce adverse results.
(3) That alternative methods of treatment exist.
(4) That the possible risks and complications of treatment have been explained to the patient.
(5) That methadone is transmitted to the unborn child and will cause physical dependence.
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Observations
Based on a review of patient records, the facility failed to obtain an informed, voluntary, written consent before an agent may be administered to the patient for maintenance or detoxification treatment in one of six applicable patient records reviewed.
Patient #11 was admitted to the inpatient non-hospital activity on June 23, 2024 and was discharged on August 23, 2024. The initial dose of maintenance medication was provided to the patient on June 24, 2024; however, the consent to treat with an agent was signed and dated by the patient on June 24, 2024, after the initial dose of the medication.
This is a repeat citation from the January 18, 2024 annual licensing renewal inspection.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
The Program Director had the Consent Form added to the intake form group and provided training to the staff on 2/21/2024 regarding the change in procedure. On 1/28/2025, Program Director provided follow up training to BHA staff. Program Director will monitor the charts for compliance will monitor charts for compliance.
The program is in compliance as of 1/28/2025.
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715.14(a) LICENSURE Urine testing
(a) A narcotic treatment program shall complete an initial drug-screening urinalysis for each prospective patient and a random urinalysis at least monthly thereafter.
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Observations
Based on a review of patient records, the facility failed to document the completion of an initial drug-screening analysis for each prospective patient in two of six applicable patient records reviewed.
The facility policy and procedure manual stated that an initial drug screening toxicology test would be completed for each prospective patient and prior to the administration of medication.
Patient #9 was admitted to the inpatient non-hospital activity on May 7, 2024 and was discharged on June 6, 2024. There was no initial drug-screen completed and documented in the record prior to the first medication dose, which was on May 7, 2024.
Patient #14 was admitted to the inpatient non-hospital activity on May 29, 2024 and was discharged on June 28, 2024. There was no initial drug-screen completed and documented in the record prior to the first medication dose, which was on May 29, 2024.
This is a repeat citation from the January 18, 2024 annual licensing renewal inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
On 2/5/2025, the Program Director will provide the staff education regarding the policy of complete an initial drug-screening urinalysis for each prospective patient and a random urinalysis at least monthly thereafter. The BHAs are responsible for obtaining and documenting the drug-screening urinalysis. The Program Director will provide oversight through chart checks.
The program will be in compliance on 2/6/2025.
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715.15(b) LICENSURE Medication dosage
(b) The narcotic treatment physician shall determine the proper dosage level for a patient, except as otherwise provided in this section. If the narcotic treatment physician determining the initial dose is not the narcotic treatment physician who conducted the patient examination, the narcotic treatment physician shall consult with the narcotic treatment physician who performed the examination before determining the patient 's initial dose and schedule.
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Observations
Based on a review of patient records, the facility failed to ensure the narcotic treatment physician who determined the initial dose for a patient and who was not the physician who conducted the patient examination consulted with the narcotic treatment physician who performed the examination before determining the patient's initial dose and schedule in three of six applicable patient records reviewed.
Patient #9 was admitted to the inpatient non-hospital activity on May 7, 2024 and was discharged on June 6, 2024. The certified registered nurse practitioner completed the initial physical examination and face-to-face determination on May 7, 2024; however, there was no documentation, in the record, indicating a consultation was conducted with the dose-determining physician prior to the patient ' s initial dose.
Patient #12 was admitted to the inpatient non-hospital activity on September 7, 2024 and was discharged on September 18, 2024. The certified registered nurse practitioner completed the initial physical examination and face-to-face determination on September 8, 2024; however, there was no documentation, in the record, indicating a consultation was conducted with the dose-determining physician prior to the patient ' s initial dose.
Patient #14 was admitted to the inpatient non-hospital activity on May 29, 2024 and was discharged on June 28, 2024. The certified registered nurse practitioner completed the initial physical examination and face-to-face determination on May 29, 2024; however, there was no documentation, in the record, indicating a consultation was conducted with the dose-determining physician prior to the patient ' s initial dose.
This is a repeat citation from the January 18, 2024 annual licensing renewal inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Program Director will provide training to the medical providers and nursing staff regarding the policy that a narcotic treatment physician must make a face-to-face determination of whether an individual is currently physiologically dependent upon a narcotic drug prior to admission for maintenance treatment, and prior to the administration of a maintenance agent. If the physical examination is conducted by a provider other than the determining physician, the medical provider will consult with the determining physician prior to the administration of the maintenance agent. The dose consultation will be documented in the client record. The program will add a section to the Physical Evaluation form to document MAT Dosing Consultation. Training will be provided individually and will be completed by 2/28/2025. The Records Management Supervisor will monitor charts for compliance. |
715.17(c)(1)(i-vi)) LICENSURE Medication control
(c) A narcotic treatment program shall develop and implement written policies and procedures regarding the medications used by patients which shall include, at a minimum:
(1) Administration of medication.
(i) A narcotic treatment physician shall determine the patient 's initial and subsequent dose and schedule. The physician shall communicate the initial and subsequent dose and schedule to the person responsible for the administration of medication. Each medication order and dosage change shall be written and signed by the narcotic treatment physician.
(ii) An agent shall be administered or dispensed only by a practitioner licensed under the appropriate Federal and State laws to dispense agents to patients.
(iii) Only authorized staff and patients who are receiving medication shall be permitted in the dispensing area.
(iv) There shall be only one patient permitted at a dispensing station at any given time.
(v) Each patient shall be observed when ingesting the agent.
(vi) Administering and dispensing shall be conducted in a manner that protects the patient from disruption or annoyance from other individuals.
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Observations
Based on a review of patient records, the facility failed to ensure the initial and subsequent medication dose levels and schedule changes were written and signed by the narcotic treatment physician as appropriate under Federal and state laws in six of six applicable patient records reviewed.
Patient #9 was admitted to the inpatient non-hospital activity on May 7, 2024 and was discharged on June 6, 2024. The order for the initial dose of maintenance medication was documented in the record on May 7, 2024; however, the order only captured a drop-down listing of the ordering physician and did not include the documentation of the physician ' s signature. The only signature documented on the order was the signature of the licensed practical nurse.
Patient #11 was admitted to the inpatient non-hospital activity on June 23, 2024 and was discharged on August 23, 2024. The order for the initial dose of maintenance medication was documented in the record on June 24, 2024; however, the order only captured a drop-sown listing of the ordering physician and did not include the documentation of the physician ' s signature. The only signature documented on the order was the signature of the licensed practical nurse. Additionally, there were maintenance medication changes documented on July 17, 2024 and July 25, 2024; however, both change orders only captured a drop-down listing of the ordering physician and did not include the documentation of the physician ' s signature. The only signature documented on both orders was the signature of the licensed practical nurse.
Patient #12 was admitted to the inpatient non-hospital activity on September 7, 2024 and was discharged on September 18, 2024. The order for the initial dose of maintenance medication was documented in the record on September 8, 2024; however, the order only captured a drop-down listing of the ordering physician and did not include the documentation of the physician ' s signature. The only signature documented on the order was the signature of the licensed practical nurse.
Patient #13 was admitted to the inpatient non-hospital activity on October 30, 2024 and was discharged on November 11, 2024. The order for the initial dose of maintenance medication was documented in the record on October 31, 2024; however, the order only captured a drop-down listing of the ordering physician and did not include the documentation of the physician ' s signature. The only signature documented on the order was the signature of the licensed practical nurse.
Patient #14 was admitted to the inpatient non-hospital activity on May 29, 2024 and was discharged on June 28, 2024. The order for the initial dose of maintenance medication was documented in the record on May 29, 2024; however, the order only captured a drop-down listing of the ordering physician and did not include the documentation of the physician ' s signature. The only signature documented on the order was the signature of the licensed practical nurse. Additionally, there was a maintenance medication change documented on June 12, 2024; however, the change order only captured a drop-down listing of the ordering physician and did not include the documentation of the physician ' s signature. The only signature documented on the order was the signature of the licensed practical nurse.
Patient #15 was admitted to the inpatient non-hospital activity on December 27, 2024 and was active at the time of the inspection. The order for the initial dose of maintenance medication was documented on January 7, 2025; however, the order only captured a drop-down listing of the ordering physician and did not include the documentation of the physician ' s signature. The only signature documented on the order was the signature of the licensed practical nurse.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
On 2/13/2025 the Program Director provided training to the medical staff regrading the need for the ordering physician's signature to appear on all orders. The Program Director coordinated with the IT department to add a space for physician signature to occur in the electronic health record rather , drop down. The IT department will make an update to the orders form in the EHR by 3/14/2025. The program will revert to paper order forms ( and the EHR documentation) to capture the physician' signature. The program director will implement and monitor this process.
The program will be in compliance by 3/14/2025 |
715.20(1) LICENSURE Patient transfers
A narcotic treatment program shall develop written transfer policies and procedures which shall require that the narcotic treatment program transfer a patient to another narcotic treatment program for continued maintenance, detoxification or another treatment activity within 7 days of the request of the patient.
(1) The transferring narcotic treatment program shall transfer patient files which include admission date, medical and psychosocial summaries, dosage level, urinalysis reports or summary, exception requests, and current status of the patient, and shall contain the written consent of the patient.
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Observations
Based on a review of patient records, the narcotic treatment program failed to ensure patient files, including the admission date, medical and psychosocial summaries, dosage level, urinalysis reports or summary, exception requests, and current status of the patient, were transferred to another narcotic treatment program in one of one applicable patient record reviewed.
Patient #12 was admitted to the inpatient non-hospital activity on September 7, 2024 and was transferred out on September 18, 2024. There was no documentation, in the record, indicating the receiving narcotic treatment program was notified of the date of admission of the patient, medical and psychosocial summaries, dosage level, urinalysis reports or summary, exception requests, and current status of the patient.
This is a repeat citation from the January 18, 2024 annual licensing renewal inspection.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
The Program Director provided staff with education on 1/17/2025 regarding the transfer of NTP clients, specifically the need to forward the following information to be forwarded to the receiving program: the admission date, medical and psychosocial summaries, dosage level, urinalysis reports or summary, exception requests, and current status of the patient. The Program Director also provided education on how to complete the release of information for transfers. A record of the transfer of information will be kept in the chart. The Care Coordinator is responsible for transferring the information. The Program Director will provide oversight through supervision and chart reviews.
The program is in compliance with the regulation as of 1/17/2025.
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709.52(a) LICENSURE Individual TX and REHAB Plan
709.52. 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:
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Observations
Based on a review of client records, the facility failed to develop an individual treatment and rehabilitation plan with the client in two of five applicable client records reviewed.
Client #11 was admitted to the inpatient non-hospital activity on June 23, 2024 and was discharged on August 23, 2024. There was no documentation, in the record, that an individual treatment and rehabilitation plan was completed at the time of the inspection.
Client #16 was admitted to the inpatient non-hospital activity on November 7, 2024 and was active at the time of the inspection. There was no documentation, in the record, that an individual treatment and rehabilitation plan was completed at the time of the inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
On 1/10/2025, the Program Director provided the counselors with training regarding developing a treatment plan which includes timelines for completing Initial, Comprehensive, and Updated treatment plans. The Program Director will monitor charts for compliance and follow up with counselors during supervision. The program will be in compliance on 2/14/2025 |
709.52(c) LICENSURE Provision of Counseling Services
709.52. 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 counseling services were provided to a client according to the individual treatment and rehabilitation plan in one of one applicable client records reviewed.
Client #17 was admitted to the inpatient non-hospital activity on November 7, 2024 and was active at the time of the inspection. The individual treatment and rehabilitation plan, dated November 25, 2024, indicated the client was to receive weekly individual counseling sessions. As of the date of the inspection, there was one individual counseling session conducted on December 27, 2024.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
On 1/10/2025, The Program Director provided the counselors with training developing a treatment plan which includes developing individualized interventions and following through with the provision of the written interventions. The Program Director will monitor charts for compliance and follow up with counselors during supervision.
The program will be in compliance on 2/17/2025 |
709.52(d) LICENSURE Regularity of counseling provided
709.52. Treatment and rehabilitation services.
(d) Counseling shall be provided to a client on a regular and scheduled basis.
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Observations
Based on a review of client records, the facility failed to provide counseling on a regular and scheduled basis in three of six applicable client records reviewed.
Per the facility's daily programming schedule, all clients are to have a group counseling session with a counselor daily, Monday through Friday, from 10:30am to 12:00pm.
Client #11 was admitted to the inpatient non-hospital activity on June 23, 2024 and was discharged on August 23, 2024. There was no documentation, in the record, indicating the client received group counseling services, regularly and as scheduled, during the entire treatment episode.
Client #12 was admitted to the inpatient non-hospital activity on September 7, 2024 and was discharged on September 18, 2024. There was no documentation, in the record, indicating the client received group counseling services, regularly and as scheduled, during the entire treatment episode.
Client #13 was admitted to the inpatient non-hospital activity on October 30, 2024 and was discharged on November 11, 2024. There was no documentation, in the record, indicating the client received group counseling services, regularly and as scheduled, during the entire treatment episode.
These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
On 1/10/2025 the Program Director provided the counselors with training regarding need to document provided group therapy according to the program schedule and how to document the group therapy sessions in the clinical chart. The counselor was also given a success plan on the importance of documentation of group therapy sessions. The Program Director will monitor charts for compliance and follow up with counselors during individual supervision. The program will be in compliance by 2/15/2025 |
709.53(a)(8) LICENSURE Case Consultation Notes
709.53. Client records.
(a) There shall be a complete client record on an individual which includes information relative to the client's involvement with the project. This shall include, but not be limited to, the following:
(8) Case consultation notes.
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Observations
Based on a review of client records, the facility failed to maintain a complete client record on an individual, which is to include documentation of case consultation notes, in three of three applicable client records reviewed.
The facility's policy and procedure manual stated that case consultations will occur every 15 days.
Client #9 was admitted on May 7, 2024 and was discharged on June 6, 2024. There was no documentation of case consultation notes, in the record, as of the date of the inspection.
Client #11 was admitted on June 23, 2024 and was discharged on August 23, 2024. There was no documentation of case consultation notes, in the record, as of the date of the inspection.
Client #14 was admitted on May 29, 2024 and was discharged on June 28, 2024. There was no documentation of case consultation notes, in the record, as of the date of the inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
On 1/10/2025 the Program Director provided the counselors with training regarding the timing of and writing of case consultations. The Program Director will monitor charts for compliance and follow up with counselors during supervision.
The program will be in compliance by 2/14/2025 |
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 obtaining a written informed and voluntary consent form for the disclosure of information was submitted and approved by the Department for the February 2, 2023 and January 18, 2024 annual licensing inspections. Failing to obtain a written informed and voluntary consent form for the disclosure of information was again found to be a deficiency in the January 7, 2025 through January 8, 2025, annual licensing inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Program Director will provide training to the support staff regarding the use of the Release of Information form on 2/19/2025. The training will include how and why the program must obtain a written informed and voluntary consent from the client prior to the disclosure of information contained in the client record. The training we be added to the program's onboarding plan for all new staff and a quarterly refresher and retraining will be held for all current staff during staff meeting. The Records Management Supervisor will monitor charts for compliance through random chart audits . The Program Director will follow up during individual supervision as needed.
The Program Director and the records management supervisor will meet monthly to review findings and make adjustments to the POC if necessary.
The facility will submit all approved plans of correction to the VP of Compliance via share point. The VP of Compliance and The senior Director will review all plans of correction for successful implementation and compliance on a quarterly bases to ensure overall adherence to current plans of corrections.
The program will be in compliance on 3/1/2025. |
709.44(a)(4) LICENSURE Referral contact
709.44. Client records.
(a) The project shall maintain a client record on an individual which shall include, but not be limited to:
(4) Referral contact.
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Observations
Based on a review of client records, the facility failed to maintain a client record on an individual, which shall include referral contacts, in three of three applicable client records reviewed.
Client #5 was admitted to the intake, evaluation and referral activity on July 2, 2024 and was referred to another treatment provider on July 2, 2024. There was no documentation, in the record, of any referral contact with the outgoing referred treatment provider at the time of the inspection.
Client #6 was admitted to the intake, evaluation and referral activity on July 16, 2024 and was referred to another treatment provider on July 16, 2024. There was no documentation, in the record, of any referral contact with the outgoing referred treatment provider at the time of the inspection.
Client #7 was admitted to the intake, evaluation and referral activity on July 23, 2024 and was referred to an external provider on July 23, 2024. There was no documentation, in the record, of any referral contact with the outgoing referred treatment provider at the time of the inspection.
This is a repeat citation from the January 18, 2024 annual licensing renewal inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
On 1/10/2025 The Senior Director provided the support staff re-training regarding the need and how to utilize the exisisting care coordination note in the electronic health record to document the coordination of any referral contacts with the outgoing referral treatment providers. The operations manager will monitor the charts for compliance and adherence to this practice through random chart check.
The program will be in compliance on 2/15/2025 |