INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection and methadone monitoring inspection conducted on September 30 to October 2, 2014 by staff from the Division of Drug and Alcohol Program Licensure. 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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705.28 (c) (3) LICENSURE Fire safety.
705.28. Fire safety.
(c) Fire extinguishers. The nonresidential facility shall:
(3) Ensure fire extinguishers are inspected and approved annually by the local fire department or fire extinguisher company. The date of the inspection shall be indicated on the extinguisher or inspection tag. If a fire extinguisher is found to be inoperable, it shall be replaced or repaired within 48 hours of the time it was found to be inoperable.
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Observations
Based on a physical plant inspection, the facility failed to ensure all of the fire extinguishers located within the facility were inspected and approved annually by the local fire department or fire extinguisher company.The findings include:A physical plant inspection was conducted October 2, 2014 at approximately 11:00 AM. The facility had four fire extinguishers located at strategic points around the facility. The fire extinguisher located nearest the female employee's bathroom was last inspected in November 2012. The results were discussed with facility staff throughout the inspection.
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Plan of Correction
The fire extinguisher in violation was inspected on 10/3/14 at 3 pm. Going forward, the Safety Officer or her designee will accompany the local fire department officials during their inspections to ensure that no extinguishers are missed. |
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 the review of patient records, the facility failed to complete the annual physical with a re-evaluation by the physician in two of three patient records reviewed. The findings include:Eleven patient records were reviewed from September 30, 2014 to October 2, 2014.Patient # 3 was admitted March 2, 2011. The annual physical exam was completed on March 24, 2014 by the Certified Nurse Practitioner (CRNP) but did not include a re-evaluation by the physician. Patient # 8 was admitted April 21, 1977. The annual physical exam was completed on May 14, 2014 by the physician but did not include a re-evaluation by the physician. This was discussed with facility during the inspection.
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Plan of Correction
All physical examinations,(admission and yearly) will be reviewed by the Nursing supervisor or her designee to ensure that re-evaluations and sign offs arecompleted and in order by the physicians. After each evaluation or re-evaluation, the chart is to be forwarded to the nursing supervisor within 7 days of the evaluation or re-evaluation. The files will then be filed with all of the medical parts of the charts. The physicians received an e-mail explaining the re-evaluation process for the yearly annual physicals. They will now be sure to complete the entire package which documents continued physical dependence and the need for continued methadone maintenance. |
715.23(c)(1-7) LICENSURE Patient records
(c) An annual evaluation of each patient 's status shall be completed by the patient 's counselor and shall be reviewed, dated and signed by the medical director. The annual evaluation period shall start on the date of the patient 's admission to a narcotic treatment program and shall address the following areas:
(1) Employment, education and training.
(2) Legal standing.
(3) Substance abuse.
(4) Financial management abilities.
(5) Physical and emotional health.
(6) Fulfillment of treatment objectives.
(7) Family and community supports.
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Observations
Based on a review of the patient records, the facility failed to complete the annual evaluation as required in two of the three patient records reviewed.The findings include:Eleven patient records were reviewed September 30-October 2, 2014. Three of the patient records were required to include an annual evaluation by the patient's counselor. Patient # 3 was admitted March 2, 2011. The annual evaluation was to be completed in March 2014. However, the annual evaluation was not completed until July 24, 2014. Patient # 8 was admitted to treatment In April 2004. The annual evaluation was documented as being completed April 22, 2014. However, there was no signature of the counselor who completed the document, or the medical director.This was discussed with facility during the inspection.
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Plan of Correction
In order to ensure that all signatures are completed on the annual evaluations, the Clinical Supervisor will be the last person to sign off on the document. If a signature is missing, he/she will obtain the signature and return it to the counselor for filing. Each clinical supervisor will have a monthly list of annual reviews which are due and will discuss the due dates with each counselor to ensure timely completion of the document. THE COUNSELORS WILL ALL BE RE-TRAINED TO COMPLETE THE ANNUAL EVAUATION OF THE CLIENT IN THEIR WEEKLY GROUP SUPERVISION ON 11/4/14. |