INITIAL COMMENTS
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This report is a result of an on-site licensure renewal and Methadone/Buprenorphine inspection conducted on November 27-29, 2017, by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, ARS of Pennsylvania LLC was found not to be in compliance with the applicable chapters of 28 PA Code which pertain to the facility.
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Plan of Correction
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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
Based on a review of facility records submitted as part of the presubmission process, and staff interviews conducted during the on-site inspection, the facility failed to ensure that all of the staff received the required training in communicable diseases. Staff Person #6 was hired as a counselor on 09/27/2016, but the facility did not have documentation that the staff person received the required 4 hours of TB/STD training at the time of the on-site inspection. These findings were reviewed with facility staff as part of the inspection process.
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Plan of Correction
Staff person number 6 attended the required 4 hours of TB/STD/HEP training on November 28th, 2017. Program Director met with Clinical Supervisor to review training plans and to ensure all trainings are completed within the required time frame. Clinical Supervisor will review training plans for all new hires during orientation. In addition, ED and Clinical Supervisor will continue utilizing the annual training forms and will continue to review compliance on a quarterly basis. |
715.20(4) LICENSURE Patient transfers
A narcotic treatment program shall develop written transfer policies and procedures which shall require that the narcotic treatment program transfer a patient to another narcotic treatment program for continued maintenance, detoxification or another treatment activity within 7 days of the request of the patient.
(4) The receiving narcotic treatment program shall document in writing that it notified the transferring narcotic treatment program of the admission of the patient and the date of the initial dose given to the patient by the receiving narcotic treatment program.
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Observations
Based on a review of facility records conducted during the on-site inspection, the facility failed to give the required notifications to the narcotic treatment facility that it was receing a narcotic treatment patient from. Patient #2 was transferred into the facility on 11/09/.2017, but the receiving facility did not notify the sending facility of the date of the patient's initial dose. These findings were reviewed with facility staff as part of the inspection process.
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Plan of Correction
Transfer acknowledgement form was modified to include the amount dose received by patient on day one. In order to differentiate between programs, a separate transfer acknowledgment form was created for buprenorphine patients. Clinical Director met with all staff on November 29th, 2017 to inform clinical staff of this change and the form was implemented on the same day. Clinical admission assessor will complete the form and will submit to medical for signature and approval prior to sending back to the narcotic treatment facility. |
715.23(b)(5) LICENSURE Patient records
(b) Each patient file shall include the following information:
(5) The results of all annual physical examinations given by the narcotic treatment program which includes an annual reevaluation by the narcotic treatment physician.
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Observations
Based on a review of facility records conducted during the on-site inspection, the facility failed to perform the annual physical examination with the required annual reevaluation within one year in one of four applicable patient records. Patient #6 had a physical exam performed on 02/16/2016, but the patient's next physical exam was not performed until 03/28/2017. These findings were reviewed with facility staff as part of the inspection process.
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Plan of Correction
Program Director met with Director of Nursing on December 7th 2017 and developed a new protocol to schedule patient a minimum of 30 days prior to their annual physical examination. It is expected for patients to comply with these treatment requirements, therefore, Medical Director and DON, will continue to monitor patient's records to ensure annual physical examinations are completed on time. |