INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on June 12 - 13, 2018 by staff from the Department of Drug and Alcohol Programs, Bureau of Quality Assurance for Prevention and Treatment, Division of Accountability and Program Improvement. Based on the findings of the on-site inspection, The Guidance Center 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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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
The facility failed to document an informed and voluntary consent from the client prior to the disclosure of information contained in the client record in six of thirteen client records reviewed on June 12 - 13, 2018.The facility released the name and diagnosis of the client to the insurance company without the client's written consent in the following client records.Client # 4 was admitted on March 23, 2018.Client # 6 was admitted on January 18, 2018.Client # 8 was admitted on March 1, 2018. A fax was sent to the insurance company to obtain authorization for medication on April 25, 2018. Client # 9 was admitted on April 23, 2018. Electronic authorization for treatment services was documented on May 3, 2018. In addition, the facility released the client's date of admission to drug and alcohol treatment and the current dosage of Suboxone to a physician on May 3, 2018 without the client's written consent.Client # 12 was admitted on January 29, 2018 and discharged on April 18, 2018. Electronic authorization for treatment services was documented on February 1, 2018.Client # 13 was admitted on October 27, 2017. Electronic authorization for treatment services was documented on October 27, 2017.The facility did obtain a written informed and voluntary consent from the client for the disclosure of information contained in the client's record. However, the consent did not include the specific information to be disclosed in one of thirteen client records. Client # 8 was admitted on March 1, 2018. A consent to a physician dated March 14, 2018 indicated "all records" would be released. A consent to a provider dated March 22, 2018 indicated "all records" would be released. The facility exceeded the limitations imposed at 4 Pa. Code 255.5 in two of thirteen client records. A written consent for the insurance company included the following information to be released: "current treatment plan, progress notes, mental health intake record and verbal consultation regarding all areas of treatment provided by The Guidance Center". Client # 1 was admitted April 20, 2018. The consents were dated February 12 and June 13, 2018.Client # 8 was admitted on March 1, 2018. The consent was dated March 1, 2018. Also, the drug test results for client # 8 were faxed to the insurance company on April 25, 2018. In addition, the facility failed to adhere to the requirements outlined in the federal confidentiality regulations by requiring the patient to revoke the consent to release information in writing in client records # 1 and 8.The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The agency has implemented a new process on 6/26/18 whereas the required insurance company consents are now part of the form group of documentation that is to be completed at the initial appointment. It is a required document so that a session can not be completed until it is signed.
All drug and alcohol therapists have been trained by the Program Director regarding documentation required at initial appointment. This training occurred on 6/26/18.
Program Director has also developed a checklist to be used for opening clients in the Electronic Health Record which includes the Consent.
All staff members in the Drug and Alcohol program will review confidentiality standards on 7/10/18.
Program Director will complete a record review of all new clients monthly.
Drug and Alcohol staff will complete routine chart audits to ensure compliance.
All clients who were missing proper consents will have consents obtained in their next scheduled appointment.
This new process was implemented June 26 , 2018.
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715.9(a)(1) LICENSURE Intake
(a) Prior to administration of an agent, a narcotic treatment program shall screen each individual to determine eligibility for admission. The narcotic treatment program shall:
(1) Verify that the individual has reached 18 years of age.
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Observations
The facility failed to document verification the patient was 18 years of age prior to the administration of a narcotic agent in one of three patient records reviewed on June 12 - 13, 2018.Patient # 9 was admitted on April 23, 2018. The patient was prescribed Suboxone on May 2, 2018.The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
All clients are required to provide photo identification at the time of intake. If a photo identification is not available, the client will be rescheduled until such time as to when identification can be verified.
Receptionist have been trained to request photo ids. Re-training will occur on 7/11/18 for new receptionists.
Drug and alcohol therapists were also provided with training on 6/26/18 during group supervision with Program Director to verify that the photo ids of their assigned clients are stored on the profile page in the electronic health record.
Program Director will be responsible for ensuring that this requirement is completed and will do monthly reviews of patient records. |
715.9(a)(2) LICENSURE Intake
(a) Prior to administration of an agent, a narcotic treatment program shall screen each individual to determine eligibility for admission. The narcotic treatment program shall:
(2) Verify the individual 's identity, including name, address, date of birth, emergency contact and other identifying data.
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Observations
The facility failed to document verification of the individual's emergency contact prior to the administration of a narcotic agent in three of three patient records reviewed on June 12 - 13, 2018.Patient # 1 was admitted on April 20, 2018. The patient was prescribed Suboxone on April 28, 2018.Patient # 8 was admitted on March 1, 2018. The patient was prescribed Suboxone on April 24, 2018.Patient # 9 was admitted on April 23, 2018. The patient was prescribed Suboxone on May 2, 2018. In addition, the facility failed to document verification of the identity of patient # 9 including their name, address and date of birth.The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
All clients within the drug and alcohol program will be asked for emergency contact information. This information will be entered in the client's Profile Page of the Electronic Medical Record. Drug and alcohol therapist and RN assigned to the program were provided with training on this requirement on 6/26/18 by the Program Director.
Additionally, the Program Director developed a checklist for new client requirements which was given to drug and alcohol staff on 6/26/18.
Program Director will review each MAT client's record to ensure that emergency contact is noted.
RN assigned to the MAT program will also review with client that an emergency contact has been noted prior to scheduling with psychiatrist.
This process was implemented on 6/26/18.
For MAT clients without emergency contacts noted, all clients were contacted via phone or asked when they came in for their scheduled appointment. Records were updated by 7/02/18 |
715.10(f) LICENSURE Pregnant patients
(f) The narcotic treatment program shall ensure that each female patient is fully informed of the possible risk to her or her unborn child from continued use of illicit drugs and from use of, or withdrawal from a narcotic drug administered or dispensed by the program in comprehensive maintenance or detoxification treatment.
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Observations
The facility failed to document that each female patient was fully informed of the possible risk to her or her unborn child from continued use of illicit drugs and from use of, or withdrawal from a narcotic drug administered by the program in two of two patient records reviewed on June 12 - 13, 2018.Patient # 1 was admitted on April 20, 2018. The patient was prescribed Suboxone on April 28, 2018.Patient # 8 was admitted on March 1, 2018. The patient was prescribed Suboxone on April 24, 2018.The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Information regarding the risk of Subxone for pregnant females was added to the Suboxone Client Handbook on 6/15/18.
This handbook is reviewed with clients by the RN assigned to the program prior to admission into Medication Assisted Treatment. All individuals sign a consent verifying that they were provided with education.
Clients 1 and 8 noted in the deficiency were given new copies of the handbook.
Program Director updated handbooks available for use and will maintain the updates. |
715.13(b) LICENSURE Patient identification
(b) A narcotic treatment program shall maintain onsite a photograph of each patient which includes the patient 's name and birth date. The narcotic treatment program shall update the photograph every 3 years.
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Observations
The facility failed to maintain onsite a photograph of each patient which included the patient's name and birth date in one of three patient records reviewed on June 12 - 13, 2018.Patient # 9 was admitted on April 23, 2018. The patient was prescribed Suboxone on May 2, 2018.The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Upon intake, receptionist copy and scan photo identification into the Profile Page of the Electronic Health Record for each client. If this information is not available, the individual is asked to bring in the necessary documentation.
Receptionist staff will be re-trained on this procedure on 7/11/18 by the Program Director.
The RN assigned to the Medication Assisted Treatment program and prescribing psychiatrist were provided training on 6/26/18 on the necessity for having verification of an individual's identity prior to providing treatment. A checklist for required documentation on clients was developed and given to Drug and Alcohol program staff on 6/26/18 during group supervision.
Program Director will complete chart audits monthly to ensure that identification is in place.
For patient 9 who did not have a photo id in place, this deficiency was corrected at his appointment on 7/02/18.
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709.92(a) LICENSURE Treatment and rehabilitation services
709.92. 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
The facility failed to document an individual treatment plan that included the type and frequency of treatment services in seven of thirteen client records reviewed on June 12 - 13, 2018.Client # 7 was admitted on December 27, 2017 and discharged on March 8, 2018. The treatment plan was completed on January 3, 2018.Client # 8 was admitted on March 1, 2018. The treatment plan was completed on March 18, 2018.Client # 9 was admitted on April 23, 2018. The treatment plan was completed on May 2, 2018 and did not include the frequency of treatment services.Client # 10 was admitted on October 23, 2017 and discharged on January 22, 2018. The treatment plan was completed on November 2, 2017.Client # 11 was admitted on November 28, 2017 and was discharged April 25, 2018. The treatment plan was completed on December 8, 2017.Client # 12 was admitted on January 29, 2018 and was discharged April 18, 2018. The treatment plan was completed on February 14, 2018.Client # 13 was admitted on October 27, 2017. The treatment plan was completed on December 7, 2017The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
On 6/26/18, drug and alcohol therapists were provided with training by the Program Director on the requirements for treatment planning and necessity to add frequency and type of treatment.
This training will be offered by the Program Director again on 7/10/18 as a refresher during group supervision meeting.
Program Director will complete monthly audits of client records to ensure that staff are following through with this requirement. Additionally, prior to treatment plan approval, the Program Director will review treatment plans and provide feedback.
For clients whereby the frequency and type were not noted, monthly updates will be completed by therapists and information added.
Categories listing type and frequency will also be added to the treatment plan document location within the electronic health record.
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709.93(a) LICENSURE Client records
709.93. 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:
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Observations
The facility failed to document a complete client record including follow-up information in four of thirteen client records reviewed on June 12 - 13, 2018.The facility's policy specifies a follow-up will occur within seven days of discharge. No follow-up information was documented in the following client records.Client # 7 was admitted on December 27, 2017 and discharged on March 8, 2018.Client # 10 was admitted on October 23, 2017 and discharged on January 22, 2018.Client # 11 was admitted on November 28, 2017 and discharged on April 25, 2018.Client # 12 was admitted on January 29, 2018 and discharged on April 18, 2018.The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
A follow up note and corresponding survey was developed by the Program Director on 7/01/18. This note will be built within the electronic medical record.
The Guidance Center policy on follow up will be updated to state that after 30 days post discharge, a survey will be completed either via mail or telephone with the client. This survey will be documented on the follow up progress note by the therapist or assigned program staff.
Discharged clients will be reviewed at weekly group supervision meetings with therapists and Program Directors.
The Program Director will be responsible for ensuring that all follow up are completed. This process was implemented 7/01/18.
The new form build is targeted to be completed by 8/30/18.
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