INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on December 10, 2018 through December 12, 2018 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 ensure that the project director, who was hired on December 1, 2003, received an annual training plan for the current training year, based on a review of the facility's Staffing Requirement Facility Report and the employee personnel files.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The NET Project Director, in conjunction with the NET Board will ensure an annual training plan will be developed and implemented for the by the due date. The Project Director's Administrative Assistant will issue a status report 1 month before the due date. |
704.11(c)(1) LICENSURE Mandatory Communicable Disease Training
704.11. Staff development program.
(c) General training requirements.
(1) Staff persons and volunteers shall receive a minimum of 6 hours of HIV/AIDS and at least 4 hours of tuberculosis, sexually transmitted diseases and other health related topics training using a Department approved curriculum. Counselors and counselor assistants shall complete the training within the first year of employment. All other staff shall complete the training within the first 2 years of employment.
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Observations
The facility failed to ensure that 2 staff persons received the mandatory communicable disease training within the regularity time frame. This was based on a review of the facility's Staffing Requirement Facility Report and the employee's personnel file.
Employee #4 was hired as an administrative assistant on May 15, 2017.
Employee #8 was hired as an administrative assistant on April 17, 2017.
The findings were discussed with facility staff during the licensing process.
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Plan of Correction
The Director of Clinical Operations in conjunction with the Director of Operations will ensure that all staff receive the mandatory communicable disease training within the required time frame. They will work with the NET Administrative Assistant and HR to audit the staff files for compliance and send out status reports quarterly. |
705.11 (2) (iii) LICENSURE Child care.
705.11. Child care.
(2) Interior space. The residential facility shall:
(iii) Maintain protective caps over each electrical outlet.
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Observations
The facility failed to ensure that all of the electrical outlets in the child care area were covered with protective caps, based on the physical plant inspection
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
On 12/12/18, the maintenance staff replaced the protective outlet caps that were missing in the children's playroom. The playroom attendants will monitor this daily and communicate to the maintenance staff immediately if caps are missing. |
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 in three of eight outpatient client charts within the regulatory timeframe.
Client #9 was admitted on April 18, 2016 and was active at the time of inspection. A treatment plan update was completed on February 16, 2018 and the next update was due no later than April 16, 2018. However, the update was not completed until May 29, 2018.
Client #12 was admitted on May 16 2017 and discharged on August 17, 2018. A treatment plan update was completed on February 19, 2018 and the next update was due no later than April 19, 2018. However, the update was not completed until May 1, 2018.
Client #13 was admitted on January 25, 2018 and was discharged on May 18, 2018. A treatment plan update was completed on January 25, 2018 and the next update was due no later than March 25, 2018. However, the update was not completed until April 5, 2018.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Director of Clinical Operations in conjunction with the Clinical Supervisors will check the treatment plans due report weekly and communicate this to the counselors for follow up. The QA Department will send the treatment plan status report to the VP and Director of Clinical Operations and NET VP at the beginning and end of each week for follow up. |