INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on February 25-27, 2020 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, Wilkes-Barre Treatment LLC dba Clearbrook Treatment Centers 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) (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
Based on the review of client records on February 25-27, 2020, the facility failed to document a completed informed and voluntary consent to release information in client #2, as the consent did not list a purpose for the consent. Client #2 was admitted on February 5, 2020 and was still active at the time of the inspection.The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
On February 26, 2020, QA PI Coordinator met with Clinical Director and Primary Counselor for Client #2 and informed them of the need to list a purpose for consent on the identified voluntary consent to release information in Client #2's chart. Primary counselor completed a new release of information noting the appropriate purpose, and had Client #2 sign the new release. As of 2/26/2020, Clinical Director, Clinical Supervisor, and QA PI Coordinator will ensure consents to release information are complete in all required sections as part of chart monitoring activities. |
715.6(e) LICENSURE Physician Staffing
(e) A physician assistant or certified registered nurse practitioner may perform functions of a narcotic treatment physician in a narcotic treatment program if authorized by Federal, State and local laws and regulations, and if these functions are delegated to the physician assistant or certified registered nurse practitioner by the medical director, and records are properly countersigned by the medical director or a narcotic treatment physician. One-third of all required narcotic treatment physician time shall be provided by a narcotic treatment physician. Time provided by a physician assistant or certified registered nurse practitioner may not exceed two-thirds of the required narcotic treatment physician time.
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Observations
Based on a review of client records on February 25-27, 2020, the facility failed to ensure that the medical director countersigned functions delegated to the physician ' s assistant in client #12.Client #12 was admitted on November 2, 2019 and discharged on November 4, 2019. A physical examination was conducted on November 3, 2019 by the physician ' s assistant. The medical director countersigned the physical examination on November 22, 2019.The findings were reviewed with facility staff during the licensing process. This is a repeat citation from the May 10, 2019 annual licensing inspection.
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Plan of Correction
Counter signature of Medical Director within required time frame is being monitored by quality assurance and compliance staff. Other principle plan of correction is the removal and replacement of medical director involved with signature non-compliance. Replacement Medical Director was effective January 6, 2020. |