INITIAL COMMENTS
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This report is a result of a complaint investigation conducted on April 11, 2016, 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 complaint investigation, the allegations made against New Directions Treatment Services were partially substantiated and 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 complaint investigation:
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Plan of Correction
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715.15(a) LICENSURE Medication Dosage
(a) The narcotic treatment physician shall review the dosage levels at least twice a year, with each review occurring at least 2 months apart, to determine a patient 's therapeutic dosage.
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Observations
Based on a thorough review of patient #1's record, including the medication record, on April 11, 2016, it was found that there was no documentation of the narcotic treatment physician's required bi-annual review to determine the patient's therapeutic dose, since the patient was admitted on November 23, 2011 to the time of discharge on October 31, 2015.The findings were reviewed with facility staff during the complaint investigation process.
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Plan of Correction
Action/ Plan: Clinic Supervisor will create a tracking system with patients' semiannual review due dates. This list will be kept up to date weekly. Clinic Supervisor will notify Medical Director when semiannual review is due. Medical Director will complete semiannual review of dosage level and document in the patient record. Ongoing Compliance will be monitored through random medication record review by the clinic supervisor.
Person(s) Responsible: Clinic Supervisor, Medical Director
Date of full compliance: May 15, 2016
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715.23(b)(13) LICENSURE Patient records
(b) Each patient file shall include the following information:
(13) Patient record of services.
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Observations
Based on a thorough review of patient #1's record, including the medication record, on April 11, 2016, it was found that the patient record of service only had two sessions recorded during the patient's entire episode of treatment. The patient was admitted on November 23, 2011 and was discharged on October 31, 2015.The findings were reviewed with facility staff during the complaint investigation process.
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Plan of Correction
Action/ Plan: Clinical Director will remind staff during clinical team meeting that the record of service must be completed the day of service at the end of every session. Clinical Director will monitor compliance with the standard through random record reviews and during individual clinical supervision.
Person(s) Responsible: Clinical Director
Date of full compliance: May 3, 2016
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715.28(c)(1-5) LICENSURE Unusual incidents
(c) A narcotic treatment program shall file a written Unusual Incident Report with the Department within 48 hours following an unusual incident including the following:
(1) Complaints of patient abuse (physical, verbal, sexual and emotional).
(2) Death or serious injury due to trauma, suicide, medication error or unusual circumstances.
(3) Significant disruption of services due to a disaster such as a fire, storm, flood or other occurrence.
(4) Incidents with potential for negative community reaction or which the facility director believes may lead to community concern.
(5) Drug related hospitalization of a patient.
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Observations
Based on a review of administrative documentation on April 11, 2016, the facility failed to file a written Unusual Incident Report with the Department within 48 hours following an unusual incident including the death or serious injury due to trauma, suicide, medication error, or unusual circumstances.The findings were reviewed with facility staff during the complaint investigation process.
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Plan of Correction
Action/ Plan: Clinical Director will review the 715.28(c) (1-5) Licensure Unusual Incident reporting policy at the May 3rd, 2016 team meetings. Clinical Director will train and review how to complete an Unusual Incident form and the internal protocols. Clinical Director will direct all staff to notify any and all deaths to the Clinical Director for review and determine if the death meets the criteria of a reportable and unusual incident. All reportable deaths will be submitted to the department to comply with the standard. The Facility Director will be responsible for the compliance with the standard through monthly review of all incidents.
Person(s) Responsible: Clinical Director, Facility Director
Date of full compliance: May 3, 2016
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