INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection and methadone monitoring conducted on October 22, 2018 through October 24, 2018 by staff from the Department of Drug and Alcohol Programs, Bureau of Quality Assurance for Prevention and Treatment, Program Licensure Division. Based on the findings of the on-site inspection, New Directions Treatment Services, 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 a valid consent to release information form for one of fourteen client records reviewed. Client # 13 was admitted on admitted March 13, 2017 and discharged July 2, 2018. A release of information form signed and dated by the client on March 1, 2017 failed to contain the clients name and specific information to be released.The findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
The Program Director met with all of the counselors during group supervision, on October 30,2018 and discussed the correct way to complete releases of information. Specifically, counselors were informed that releases of information cannot be left blank with a client's signature and date missing on the form. Counselors were informed that all information on a release of information needs to be specified in terms of what is being released to other agencies and individuals. The Program Director also met with the individual counselor overseeing Client #13 to review which signature was left blank on a release of information. The Program Director will continue to complete chart audits to ensure that releases of information are completed correctly.
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715.6(d) LICENSURE Physician Staffing
(d) A narcotic treatment program shall provide narcotic treatment physician services at least 1 hour per week onsite for every ten patients
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Observations
The facility failed to provide narcotic treatment physician services of at least one hour per week onsite for every ten patients during four of the previous twelve weeks reviewed. 1.The first week of July 2018, the client census was documented at 597 and there were 38 physician hours documented.2.The second week of July 2018, the client census was documented at 597 and there were 56.5 physician hours documented. 3.The last week of August 2018, the client census was documented at 597 and there were 56.5 physician hours documented.4.The first week of September 2018, the client census was documented at 597 and there were 54.5 physician hours documented.The findings were discussed with facility staff during the licensing process.
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Plan of Correction
The Executive Director, since the licensing inspection, has hired a nurse practitioner to provide narcotic treatment services onsite at least one hour per week for every ten patients. The nurse practitioner will be working 37.5 hours per week. |
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
The facility failed to document the annual physical examinations in two of fourteen client records reviewed.Client #4 was admitted on February 6, 2017 and was discharged on May 15, 2018. The annual physical exam was due no later than February 7, 2018. However, there was no documented annual physical in the client's record.Client #13 was admitted on March 13, 2017 and was discharged on July 2, 2018. The annual physical exam was due no later than March 13, 2018. However, there was no documented annual physical in the client's record.The findings were discussed with facility staff during the licensing process.
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Plan of Correction
With regard to clients #4 and #13, the history and physical exams that were not found in the charts were, in fact, there. The date on patient #4 was 2/22/18 and the date for patient #13 was 3/12/18. It is observed that the area where the date is noted on the form is quite small making the handwritten date difficult to read. Our corrective action for this will be to change the form in order to have a better visualization of the date of the exams. The Program Director will meet with the Narcotic Treatment Physician and Executive Director, by 1/2/2019, to discuss changing the form to have a better visualization of the date of the exams. The Program Director will be responsible for making sure that the new form is used correctly. |