INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on April 16-17, 2019 by staff from the Department of Drug and Alcohol Programs, Bureau of Quality Assurance for Prevention and Treatment. Based on the findings of the on-site inspection, Clear Day Treatment of Westmoreland 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) (1) 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. The consent must be in writing and include, but not be limited to:
(1) Name of the person, agency or organization to whom disclosure is made.
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Observations
The facility failed to obtain an informed and voluntary consent from the client that included the name of the person, agency or organization to whom disclosure is made in two of seven client records.
Seven client records were reviewed on April 16-17, 2019. All seven were reviewed for consents.
In client records #1, a consent signed by the client on March 27, 2019, did not document the name of the person, agency or organization to whom disclosure was made.
In client record # 4, a consent signed by the client on February 19, 2019, did not document the name of the person, agency or organization to whom disclosure was made.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
On 5/1/19 a staff training was conducted by the Executive Director related informed and voluntary consent. At the 5/1/19 training Clear Day's counselors and intake personnel were given examples of a properly completed release form. Special attention was given on how to complete the name of the person, and the agency to whom the disclosure will be made. Additionally, instructions were added to the form regarding completion of the document.On 5/1/19 a staff training was conducted by the Executive Director related to informed and voluntary consent. At the 5/1/19 training Clear Day's counselors and intake personnel were given examples of a properly completed release form. Special attention was given on how to complete the name of the person, the agency to whom the disclosure will be made and name of the purpose. Additionally, on 5/1/19 instructions were added to the form regarding completion of the document. Special instruction were added to the consent document stating, "Do not sign this document until form this entirely completed. In the future all new staff members will be oriented on how to properly document the release of information forms. From this point on. The Clinical Director and the Lead Counselor are responsible for ensuring the release of information is filled out in a proper manor. In weekly supervision with the Executive Director the Clinical Director will report on their chart finding regarding the release of information form. |
709.28 (c) (2) 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. The consent must be in writing and include, but not be limited to:
(2) Specific information disclosed.
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Observations
The facility failed to obtain an informed and voluntary consent from the client that included the specific information to be disclosed in two of seven client records.
Seven client records were reviewed on April 16-17, 2019. All seven were reviewed for consents.
In client record #1, a consent signed by the client on March 27, 2019, did not document the specific information to be disclosed.
In client record #4, a consent signed by the client on February 19, 2019, did not document the name of the specific information to be disclosed.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
On 5/1/19 a staff training was conducted by the Executive Director related to informed and voluntary consent. At the 5/1/19 training Clear Day's counselors and intake personnel were given examples of a properly completed release form. Special attention was given on how to complete the name of the person, and the agency to whom the disclosure will be made Additionally on 5/1/19 instructions were added to the form regarding completion of the document. Special instruction were added to the consent document stating, "Do not sign this document until the form has been entirely completed".On 5/1/19 a staff training was conducted by the Executive Director related to informed and voluntary consent. At the 5/1/19 training Clear Day's counselors and intake personnel were given examples of a properly completed release form. Special attention was given on how to complete the name of the person, the agency to whom the disclosure will be made and name of the purpose. Additionally, on 5/1/19 instructions were added to the form regarding completion of the document. Special instruction were added to the consent document stating, "Do not sign this document until form this entirely completed. In the future all new staff member will be oriented on how to properly document the release of information forms. From this point on The Clinical Director and the Lead Counselor are responsible for ensuring the release of information is filled out in a proper manor. In weekly supervision with the Executive Director the Clinical Director will report on they chart finding regarding the release of information form.
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709.28 (c) (3) 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. The consent must be in writing and include, but not be limited to:
(3) Purpose of disclosure.
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Observations
The facility failed to obtain an informed and voluntary consent from the client that included the purpose in two of seven client records.
Seven client records were reviewed on April 16-17, 2019. All seven were reviewed for consents.
In client record #1, a consent signed by the client on March 27, 2019, did not document the purpose.
In client record #4, a consent signed by the client on February 19, 2019, did not document the name of the purpose.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
On 5/1/19 a staff training was conducted by the Executive Director related to informed and voluntary consent. At the 5/1/19 training Clear Day's counselors and intake personnel were given examples of a properly completed release form. Special attention was given on how to complete the name of the person, the agency to whom the disclosure will be made and name of the purpose. Additionally, on 5/1/19 instructions were added to the form regarding completion of the document. Special instruction were added to the consent document stating, "Do not sign this document until form this entirely completed. In the future all new staff member will be oriented on how to properly document the release of information forms. From this point on The Clinical Director and the Lead Counselor are responsible for ensuring the release of information is filled out in a proper manor. In weekly supervision with the Executive Director the Clinical Director will report on they chart finding regarding the release of information form. |
715.9(a)(4) 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:
(4) Have a narcotic treatment physician make a face-to-face determination of whether an individual is currently physiologically dependent upon a narcotic drug and has been physiologically dependent for at least 1 year prior to admission for maintenance treatment. The narcotic treatment physician shall document in the patient 's record the basis for the determination of current dependency and evidence of a 1 year history of addiction.
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Observations
The facility failed to have a narcotic treatment physician document their determination that the patient has been physiologically dependent for at least 1 year prior to admission for maintenance treatment in four of four patient records.
Seven records were reviewed on April 16-17, 2019. Four reviewed were receiving Suboxone and required documentation of the patient's dependency.
Patient records # 1, 2, 3 and 4 did not document that the physician determined that the patient has been physiologically dependent for at least 1 year prior to admission for maintenance treatment.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
On April 30, 2019 The executive director designed has implement a new document that the Narcotics Treatment Physicians will utilize to determine a one-year history of physiological Opioid dependence before prescribing Medically Assisted Treatment such as Suboxone/Subutex. The new Opioid dependence history form has now become a part of the physical exam documentation. Additional questions have been added to our intake documentation regarding the patient's history of opioid dependence. The new questions that have been added to the intake paperwork will assist the intake worker determining the patients opioid history. The Clinical Director of Nursing will review files weekly to ensure Opioid history is being documented on patients. |
715.14(a) LICENSURE Urine testing
(a) A narcotic treatment program shall complete an initial drug-screening urinalysis for each prospective patient and a random urinalysis at least monthly thereafter.
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Observations
The facility failed to complete an initial drug-screening urinalysis for each prospective patient in one of four patient records.
Seven records were reviewed on April 18, 2019. Four reviewed were receiving Suboxone and required initial drug-screening urinalysis.
Patient # 2 did not document a complete urinalysis. There was no documentation that the patient had provided an initial urinalysis.
These findings were reviewed with facilty staff during the licensing process.
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Plan of Correction
The Executive Director met with the nursing staff on 5/3/2019 for the purpose of clarifying Clear Day's drug screen urinalysis policy. In the meeting the drug screen policy for new patients was reiterated. It is the policy of Clear Day Treatment that all new patients receive a drug screen urine analysis in that the results are documented in the patient's medical record. All Clear Day's nurses were instructed on how to document urine drug screens results. The nurses were also given examples of proper documentation related to drug screen and analysis results. The examples included the patients name, wether the sample was positive or negative in the date the sample was tested. The Clinical Director and the Nursing Director are responsible for monitoring urinalysis proper documentation on weekly basis.
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