INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection and buprenorphine monitoring inspection conducted on February 1, 2023 through February 2, 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 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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704.9(c) LICENSURE Supervised Period
704.9. Supervision of counselor assistant.
(c) Supervised period.
(1) A counselor assistant with a Master's Degree as set forth in 704.8 (a)(1) (relating to qualifications for the position of counselor assistant) may counsel clients only under the close supervision of a trained counselor or clinical supervisor for at least the first 3 months of employment.
(2) A counselor assistant with a Bachelor's Degree as set forth in 704.8 (a)(2) may counsel clients only under the close supervision of a trained counselor or clinical supervisor for at least the first 6 months of employment.
(3) A registered nurse as set forth in 704.8 (a)(3) may counsel clients only under the close supervision of a trained counselor or clinical supervisor for at least the first 6 months of employment.
(4) A counselor assistant with an Associate Degree as set forth in 704.8 (a)(4) may counsel clients only under the close supervision of a trained counselor or clinical supervisor for at least the first 9 months of employment.
(5) A counselor assistant with a high school diploma or GED equivalent as set forth in 704.8 (a)(5) may counsel clients only under the direct observation of a trained counselor or clinical supervisor for the first 3 months of employment. For the next 9 months, the counselor assistant may counsel clients only under the close supervision of a lead counselor or a clinical supervisor.
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Observations
Based on a review of personnel records, the facility failed to ensure that a counselor assistant, with a bachelor ' s degree, counseled clients only under the close supervision of a trained counselor or clinical supervisor for at least the first 6 months of employment in one of one applicable personnel record reviewed.
Employee #6 was hired as a counselor assistant with a bachelor's degree on April 4, 2022. Documentation of close supervision notes were missing for the entire month of May 2022 and for the weeks of June 5, 2022, July 3, 2022, September 18, 2022, and October 16, 2022.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Clinical Supervisor will provide weekly supervision for Counselor Assistants for at least the minimum time required by the regulation. The Clinical Supervisor will receive training on the regulation on 3/2/2023 provided by the Program Director. The Program Director will provide oversight to ensure that adequate supervision is provided and documented for all future Counselor Assistants.
Employee #6 passed the performance evaluation on 12/20/2022 and no longer requires weekly supervision.
The program will be in compliance on 3/3/2023.
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705.10 (d) (3) LICENSURE Fire safety.
705.10. Fire safety.
(d) Fire drills. The residential facility shall:
(3) Ensure that all personnel on all shifts are trained to perform assigned tasks during emergencies.
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Observations
Based on a review of personnel records, the facility failed to ensure that all personnel on all shifts were trained to perform assigned tasks during emergencies in one of six personnel records reviewed.
Employee #4 was hired as a clinical supervisor at this facility on March 25, 2022. The emergency preparedness training, documented in the record, was provided to the employee at a different facility within the project on May 23, 2018 and was not updated to coincide with the new work location.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Employee #4 was trained to perform assigned tasks during emergencies by the Senior Director on 2/28/2023. The Program Director will provide oversight for all future hires ensuring that all staff are trained to perform assigned tasks during emergencies at the site.
The program is in compliance as of 2/28/2023.
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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 an informed and voluntary consent to release information form prior to the disclosure of information in four of fourteen client records reviewed.
Client #8 was admitted on July 27, 2022 and discharged on July 27, 2022. There was evidence of disclosure to an external treatment facility during the client's treatment episode; however, there was no consent to release information form signed by the client documented in the record prior to the disclosure.
Client #9 was admitted on September 2, 2022 and discharged on September 3, 2022. There was evidence of disclosure to an external treatment facility during the client's treatment episode; however, there was no consent to release information form signed by the client documented in the record prior to the disclosure.
Client #10 was admitted on October 15, 2022 and discharged on October 15, 2022. There was evidence of disclosure to an external treatment facility during the client's treatment episode; however, there was no consent to release information form signed by the client documented in the record prior to the disclosure.
Client #14 was admitted on December 15, 2022 and discharged on December 15, 2022. There was evidence of disclosure to an external treatment facility during the client's treatment episode; however, there was no consent to release information form signed by the client documented in the record prior to the disclosure.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Program Director created and implemented additional consent to release information forms to be completed by support staff with clients at the time of their admission. The release of information form obtains consent from the client to share pertinent information to potential treatment facilities. The Program Director conducted training and education to staff on 2/28/2023. The Program Director will monitor the completion of the forms through random sampling and chart audits. The facility will be in full compliance on 3/3/2023 |
709.34 (c) (4) LICENSURE Reporting of unusual incidents
§ 709.34. Reporting of unusual incidents.
(c) To the extent permitted by State and Federal confidentiality laws, the project shall file a written unusual incident report with the Department within 3 business days following an unusual incident involving:
(4) Event at the facility requiring the presence of police, fire or ambulance personnel.
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Observations
Based on a review of the February 2022 through February 2023 unusual incident report logs, the facility failed to file a written unusual incident report with the Department within 3 business days following an event that required the presence of police, fire, or ambulance personnel.
Two incidents that involved the presence of ambulance personnel occurred on August 2, 2022 and October 1, 2022; however, neither incident was reported to the Department until February 1, 2023.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
It is the policy of NET Centers to document, review, and report all incidents that involve persons-served and
staff to the appropriate internal parties and in accordance with corresponding regulatory and contracting
bodies. The Program director is responsible for the completion and timely submission of all incident reports to the appropriate parties.
The Senior Director has reviewed and reeducated The Program Director on this policy and guidelines related to NET's reportable incidents and corresponding licensing guideline requirements.
The Senior Director will monitor timely submission of incident reports through verification indicated on the initial internal incident report.
The facility is in compliance with this standard as of 3/3/2023
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709.44(a)(3) LICENSURE Psychosocial evaluation
709.44. Client records.
(a) The project shall maintain a client record on an individual which shall include, but not be limited to:
(3) Psychosocial evaluation.
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Observations
Based on a review of client records, the facility failed to document a complete client record, which is to include the documentation of a psychosocial evaluation, in seven of seven applicable client records reviewed.
Every record reviewed from the Intake, Evaluation, and Referral activity failed to include documentation of a psychosocial evaluation.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Program Director will restructure the current assessment tools to include the following information : predisposing factors, precipitating factors , perpetuating factors , predictive factors , and a clinical summary and recommend.
The Senior Director will provide training and education to the staff in reference to the additional information included on the form . The Program Director will monitor ongoing completion through random weekly chart audits for the first two weeks after implementation and continuous random chart audits thereafter.
The facility will be in compliance on 3/10/2023.
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709.44(b)(4) LICENSURE Follow-up Information
709.44. Client records.
(b) If applicable, the project shall also include the following items in the client record:
(4) Follow-up information.
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Observations
Based on a review of client records, the facility failed to a maintain a complete client record on an individual, which is to include follow-up information, in four of four applicable client records reviewed.
Client #8 was admitted on July 27, 2022 and discharged on July 27, 2022. There was no follow-up information documented as of the date of the inspection.
Client #9 was admitted on September 2, 2022 and discharged on September 3, 2022. There was no follow-up information documented as of the date of the inspection.
Client #10 was admitted on October 15, 2022 and discharged on October 15, 2022. There was no follow-up information documented as of the date of the inspection.
Client #14 was admitted on December 15, 2022 and was discharged on December 15, 2022. There was no follow-up information documented 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
It is the policy of this facility to provide follow up services to clients successfully discharged from the program. Follow up must be completed and documented within 7 days of successful discharge.
The Senior Director will implement a process by which follow up is completed for each client within 7 days of discharge. The care coordinator will be responsible for reviewing each client's chart from the day before to identify which facility the client has been discharged to. After the care coordinator has identified the client's receiving facility he or she will make an outreach call to the facility's admissions department and document the outcome of the call in the client's chart. The Senior Director will monitor the completion of the follow up service through random chart audits.
The facility will be in compliance by 3/10/2023
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