INITIAL COMMENTS
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This report is a result of an on-site inspection conducted for the approval to use a narcotic agent, specifically buprenorphine, in the treatment of narcotic addiction. This inspection was conducted on March 12-13, 2013 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Conewago - Pottsville was found not to be in compliance with the applicable chapters of 4 PA Code and 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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715.22(c) LICENSURE Patient grievance procedures
(c) Penalties may not be initiated prior to final resolution with the exception that penalties may be initiated against patients who have committed acts of physical violence or who have threatened to commit acts of physical violence in or around the narcotic treatment program premises.
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Observations
Based on a review of patient records and administrative documentation, the facility failed to provide sufficient documentation to determine the patient had the ability to utilize the grievance/appeal process prior to the initiation of the penalty in three of three patient records reviewed.
The findings include:
Ten patient records were reviewed March 12-13, 2013. Three patient records were reviewed for administrative discharges.
Patient # 5 contained documentation the patient was administratively discharged for refusal to participate in sessions. There was a written notice dated July 7, 2012. There was no patient signature to demonstrate the patient received the notice. There were no progress notes documenting that the notice had been given to the patient. The patient was discharged July 7, 2012. The written notice gave the patient 15 days to request an appeal however the discharge had already been initiated.
Patient #6 was admitted December 8, 2012. The patient was administratively discharged for smoking during non-designated times. There was no written notice found in the patient record demonstrating the patient had an opportunity to go through the grievance and appeal process.
Patient #7 was admitted December 8, 2012. The patient was administratively discharged for two different smoking incidents. There was no written notice found in the patient record demonstrating the patient had an opportunity to go through the grievance and appeal process.
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Plan of Correction
All facility clinical staff will be retrained on 4/10/13 by the facility senior counselor,on the discharge policy # 6-095D Resident Termination Narcotic Treatment Program; specifically focusing on the completion of a written termination notice to clients administratively discharged.
The corporate compliance officer, will monitor the completion of the written termination notices during his regular monthly client chart reviews beginning on 4/30/13 to ensure ongoing compliance.
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715.23(b)(11) LICENSURE Patient records
(b) Each patient file shall include the following information:
(11) Counselor notes regarding patient progress and status.
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Observations
Based on the review of patient records, the facility failed to maintain current progress notes in three of eight patient records and did not document complete group progress notes in ten of ten patient records.
The findings include:
Ten patient records were reviewed for documentation of patient's clinical progress.
Patient records # 1, 3 and 4 had an intake note only.
Patient record # 5 had a discharge note only.
Patient # 6 had 2 contained documentation of partial progress notes; one on December 10 and another on December 11, 2012, neither note contained data, assessment or plan.
Patient records 9 and 10 each had an intake note and a discharge note only.
Patient # 2 had no progress notes documented.
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Plan of Correction
All pertinent facility staff will be retrained on the appropriate completion of client progress notes on 4/10/13 by the facility senior counselor,specifically focusing on completion of group notes utilizing the DAP format.
The corporate compliance officer, will monitor the completion of the client progress notes during his regular monthly client chart reviews beginning on 4/30/13 to ensure ongoing compliance.
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715.23(b)(23) LICENSURE Patient records
(b) Each patient file shall include the following information:
(23) Discharge summary.
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Observations
Based on the review of patient records and discussion with facility staff, the facility failed to complete a discharge summary for two of six patient records reviewed.
The findings include:
Ten patient records were reviewed March 12-13, 2013. Six of the patient records were reviewed for discharge summary documentation.
Patient # 9 was discharged as having completed treatment October 1, 2012. There was no discharge summary documented.
Patient # 10 was discharged as having completed treatment September 3, 2012. There was no discharge summary documented.
Discussion with facility staff revealed that the facility staff do not complete discharge summaries for patients who complete detoxification services and transition to the inpatient program on the grounds. However, the two records reviewed demonstrated the patients reviewed did not transition to the inpatient program on the grounds.
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Plan of Correction
All facility clinical staff will be retrained on 4/10/13 by the facility senior counselor,on the appropriate completion of client discharge summaries; specifically focusing on ensuring that every client has a discharge summary completed in their client chart per policy.
The corporate compliance officer,will monitor the completion of the client discharge summaries during his regular monthly client chart reviews beginning on 4/30/13 to ensure ongoing compliance.
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