INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on February 2, 2022 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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705.28 (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.
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Observations
Based on a review of the facility's January 2021 through December 2021 fire drill logs, the facility failed to identify, on the log, which exit route was used during the June 2021 fire drill.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Program Director reported the need to document which exit routes are used during fire drills to the Director of Compliance. The fire drill training will be updated to address this need when training future staff. Current staff received training on 2/3/2022 regarding the regulation. The Program Director will monitor for compliance. The program will be in compliance by 2/28/2022. |
705.28 (d) (5) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(5) Prepare alternate exit routes to be used during fire drills.
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Observations
Based on a review of the facility's January 2021 through December 2021 fire drill log, the facility failed to prepare alternate exit routes to be used during fire drills. Every fire drill conducted during the reviewed period utilized the rear street exit. These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Program Director reported the need to use alternate exit routes to be used during fire drills to the Director of Compliance. The fire drill training will be updated to address this need when training future staff. Current staff received training on 2/3/2022 regarding the regulation. The Site Director will monitor for compliance. The program will be in compliance by 2/28/2022. |
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, the facility failed to follow the project's written procedures for the management of treatment/rehabilitation services in six of seven client records reviewed.Client #2 was admitted on March 17, 2021 and was active at the time of inspection. The written procedure manual stated that the comprehensive treatment plan will be completed within 30 days of the initial treatment plan. The initial treatment plan was completed on March 17, 2021 and the comprehensive treatment plan was due no later than April 17, 2021; however, the comprehensive treatment plan was signed and completed by the counselor on April 20, 2021. Client #3 was admitted on July 22, 2021 and was active at the time of inspection. The written procedure manual stated that the comprehensive treatment plan will be completed within 30 days of the initial treatment plan. The initial treatment plan was completed on July 22, 2021 and the comprehensive treatment plan was due no later than August 22, 2021; however, the comprehensive treatment plan was signed and completed by the counselor on August 24, 2021. Client #4 was admitted on March 8, 2021 and was discharged on June 17, 2021. The written procedure manual stated that the aftercare plan will be completed prior to discharge. The aftercare plan was documented by the counselor on June 28, 2021.Client #5 was admitted on May 18, 2021 and was discharged on September 3, 2021. The written procedure manual stated that the aftercare plan will be completed prior to discharge. The aftercare plan was documented by the counselor on September 10, 2021.Client #6 was admitted on May 17, 2021 and was discharged on October 20, 2021. The written procedure manual stated that the aftercare plan will be completed prior to discharge. The aftercare plan was documented by the counselor on October 22, 2021.Client #7 was admitted on March 5, 2021 and was discharged on May 22, 2021. The written procedure manual stated that the aftercare plan will be completed prior to discharge. The aftercare plan was documented by the counselor on June 8, 2021.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Program uses a spreadsheet to monitor the timing of Comprehensive Treatment Plans. The spreadsheet is monitored, updated and emailed to Counselors by the Quality Assurance Staff. The Site Director will provide training to counselors on 2/17/2022 regarding the timing of Comprehensive Treatment Plans and the use of internal monitoring systems. The Director of Quality Assurance will monitor for compliance. The program will be in compliance on 2/28/2022.
Client #2 treatment plan completed 4/20/2021
Client #3 treatment plan completed 8/24/2021
Client #4 was aftercare plan was completed 6/28/2021
Client #5 was aftercare plan was completed 9/10/2021
Client #6 was aftercare plan was completed 10/22/2021
Client #7 was aftercare plan was completed 6/8/2021
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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 a written informed and voluntary consent from the client for the disclosure of information contained in the client record in two of seven client records reviewed. Client #5 was admitted on May 18, 2021 and was discharged on September 3, 2021. The release of information form to the funding source was signed and dated by the client on August 3, 2021; however, there was documentation of disclosures to the funding source from May 18, 2021 through August 2, 2021, prior to when the client signed the consent form.Client #6 was admitted on May 17, 2021 and was discharged on October 20, 2021. The release of information form to the funding source was signed and dated by the client on August 10, 2021; however, there was documentation of disclosures to the funding source from May 17, 2021 through August 9, 2021, prior to when the client signed the consent form.This is a repeat citation from the January 6, 2021 annual licensing renewal inspection.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Consents to Release of Information are completed with the client by the Care Manager at the time of intake. On 2/17/2022, the Program Director will provide training regarding the need obtain the client's signature on the ROIs. The Clinical Supervisor will monitor for compliance. The Clinical Supervisor will spot check ROIs for compliance when signing off on the client's Initial Treatment Plan. The program will be in compliance as of 2/28/2022.
Client #5 signed the consent on 8/3/2021
Client #6 signed the consent on 8/10/2021
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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 seven client records reviewed.Client #7 was admitted on March 5, 2021 and discharged on May 22, 2021. A release of information form was signed and dated by the client on March 4, 2021; however, the name of the person, agency or organization to whom the disclosure was to be made to was not documented. This is a repeat citation from the January 6, 2021 annual licensing renewal inspection.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Consents to Release of Information are completed with the client by the Care Manager at the time of intake. On 2/17/2022, the Program Director will provide training regarding the need to document the name of the person, agency, or organization to whom a disclosure is to be made on the ROIs. The Clinical Supervisor will monitor for compliance. The Clinical Supervisor will spot check ROIs for compliance when signing off on the client's Initial Treatment Plan. The program will be in compliance as of 2/28/2022.
Client #7 was discharged 5/22/2021
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709.28 (d) LICENSURE Confidentiality
§ 709.28. Confidentiality.
(d) A copy of a client consent shall be offered to the client and a copy maintained in the client record.
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Observations
Based on a review of client records, the facility failed to ensure that a copy of a client consent was offered to the client in seven of seven client records reviewed.Client #1 was admitted on March 11, 2021 and was active at the time of inspection. A release of information form to a managed care organization was signed and dated by the client on March 11, 2021; however, there was no documentation that a copy of the form was offered to the client.Client #2 was admitted on March 17, 2021 and was active at the time of inspection. A release of information form to a managed care organization was signed and dated by the client on March 17, 2021; however, there was no documentation that a copy of the form was offered to the client.Client #3 was admitted on July 22, 2021 and was active at the time of inspection. A release of information form to a managed care organization was signed and dated by the client on August 3, 2021; however, there was no documentation that a copy of the form was offered to the client.Client #4 was admitted on March 8, 2021 and was discharged on June 17, 2021. A release of information form to a managed care organization was signed and dated by the client on March 8, 2021; however, there was no documentation that a copy of the form was offered to the client.Client #5 was admitted on May 18, 2021 and was discharged on September 3, 2021. A release of information form to a managed care organization was signed and dated by the client on August 3, 2021; however, there was no documentation that a copy of the form was offered to the client.Client #6 was admitted on May 17, 2021 and was discharged on October 20, 2021. A release of information form to a managed care organization was signed and dated by the client on August 10, 2021; however, there was no documentation that a copy of the form was offered to the client.Client #7 was admitted on March 5, 2021 and was discharged on May 22, 2021. A release of information form to a managed care organization was signed and dated by the client on March 4, 2021; however, there was no documentation that a copy of the form was offered to the client.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
On 1/31/2022, the Program Director amended the specific ROI form by adding check boxes for "Copy of release given" and Copy of release denied." On 2/17/2022, the Program Director will provide training regarding the added check boxes and requirement to offer a copy of the ROI. The Clinical Supervisor will monitor for compliance. The Clinical Supervisor will spot check ROIs for compliance when signing off on the client's Initial Treatment Plan. The Care Manager will complete new ROIs for clients who are active in the program. The program will be in compliance as of 2/28/2022.
Client #1 will be in compliance as of 2/28/2022.
Client #2 will be in compliance as of 2/28/2022.
Client #3 will be in compliance as of 2/28/2022.
Client #4 was discharged on 6/17/2021
Client #5 was discharged on 9/3/2021
Client #6 was discharged on 10/20/2021
Client #7 was discharged on 5/22/2021
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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 that treatment and rehabilitation plans are reviewed and updated at least every sixty days in six of seven client records reviewed.Client #1 was admitted on March 11, 2021 and was active at the time of inspection. A treatment plan update was completed on April 16, 2021, and the next update was due no later than June 16, 2021; however, the update was completed on July 6, 2021. Also, the next update was due no later than September 6, 2021; however, the update was completed on September 13, 2021. Additionally, the next treatment plan update was due no later than November 13, 2021; however, the update was completed on November 18, 2021. Finally, the next treatment plan update was due no later than January 18, 2022; however, the update was completed on January 20, 2022.Client #2 was admitted on March 17, 2021 and was active at the time of inspection. The comprehensive treatment plan was completed on April 20, 2021, and the first update was due no later than June 20, 2021; however, the update was completed on June 24, 2021. Also, the next update was due no later than August 24, 2021; however, the update was completed on September 20, 2021. Additionally, a treatment plan update was completed on November 15, 2021, and the next update was due no later than January 15, 2022; however, the update was completed on January 18, 2022. Client #3 was admitted on July 22, 2021 and was active at the time of inspection. A treatment plan update was completed on October 22, 2021, and the next update was due no later than December 22, 2021; however, the update was completed on January 10, 2022. Client #4 was admitted on March 8, 2021 and was discharged on June 17, 2021. The comprehensive treatment plan was completed on April 1, 2021, and the first update was due no later than June 1, 2021; however, the update was not completed prior to discharge. Client #6 was admitted on May 17, 2021 and was discharged on October 20, 2021. The comprehensive treatment plan was completed on June 2, 2021, and the first update was due no later than August 2, 2021; however, the update was completed on August 24, 2021. Client #7 was admitted on March 5, 2021 and was discharged on May 22, 2021. The comprehensive treatment plan was completed on March 12, 2021, and the first update was due no later than May 12, 2021; however, the update was not completed prior to discharge. This is a repeat citation from the January 6, 2021 annual licensing renewal inspection.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Program uses a spreadsheet to monitor the timing of Treatment Plan Updates. The spreadsheet is monitored, updated and emailed to Counselors by the Quality Assurance Staff. The Clinical Supervisor will provide training to counselors on 2/25/2022 regarding the timing on Treatment Plan Updates and the use of internal monitoring systems. The Director of Quality Assurance will monitor for compliance. The facility will be in compliance on 3/20/2022.
Client #1 will be in compliance as of 3/20/2022.
Client #2 will be in compliance as of 3/18/2022.
Client #3 will be in compliance as of 3/10/2022.
Client #4 was discharged on 6/17/2021
Client #5 was discharged on 9/3/2021
Client #6 was discharged on 10/20/2021
Client #7 was discharged on 5/22/2021
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709.92(c) LICENSURE Treatment and rehabilitation services
709.92. 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 that counseling services were being provided according to the individual treatment and rehabilitation plan in five of seven client records reviewed. Client #1 was admitted on March 11, 2021 and was active at the time of inspection. A treatment plan update completed on September 13, 2021 specified bi-weekly individual counseling sessions; however, there was no documentation of individual counseling sessions occurring during the weeks of September 19, 2021 - October 2, 2021 and October 10, 2021 - November 13, 2021. Client #2 was admitted on March 17, 2021 and was active at the time of inspection. The comprehensive treatment plan completed on April 20, 2021 specified bi-weekly individual counseling sessions; however, there was no documentation of individual counseling sessions occurring during the weeks of May 2, 2021 - June 5, 2021.Client #4 was admitted on March 8, 2021 and was discharged on June 17, 2021. The comprehensive treatment plan completed on April 1, 2021 specified bi-weekly individual counseling sessions; however, there was no documentation of individual counseling sessions occurring during the weeks of April 11, 2021 - May 15, 2021. Client #5 was admitted on May 18, 2021 and was discharged on September 3, 2021. The comprehensive treatment plan completed on June 8, 2021 specified bi-weekly individual counseling sessions; however, there was no documentation of individual counseling sessions occurring during the weeks of June 27, 2021 - July 31, 2021. Client #7 was admitted on March 5, 2021 and was discharged on May 22, 2021. The comprehensive treatment plan completed on March 12, 2021 specified bi-weekly individual counseling sessions; however, there was no documentation of individual counseling sessions occurring during the weeks of March 21, 2021 - May 22, 2021. These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
On 2/25/2022, the Clinical Supervisor will provide training to staff about the need to write treatment plans that are congruent to the treatment that is provided to the clients and how to provide treatment that is outlined in the treatment plan. The Clinical Supervisor will monitor charts for compliance and address issues during clinical supervision sessions. The program will be in compliance by 3/20/2022.
Client #1 will be in compliance as of 3/20/2022.
Client #2 will be in compliance as of 3/18/2022.
Client #4 was discharged on 6/17/2021
Client #5 was discharged on 9/3/2021
Client #7 was discharged on 5/22/2021
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