INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on June 21, 2017 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Allied Addiction Recovery, LLC 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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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 obtain a complete drug screen urinalysis prior to the administration of Suboxone, a narcotic agent, in seven of seven patient records reviewed on June 21, 2017. A complete drug screen includes results from a CLIA and Department of Health approved laboratory. Seven records were reviewed. Patient records # 1, 2, 3, 4, 5, 6 and 7 did not document a complete drug screen urinalysis prior to the administration of Suboxone.Patient # 1 received their initial dose on September 30, 2016. The results of the initial drug screen were received on October 4, 2016. Patient # 2 received their initial dose on November 12, 2016. The results of the initial drug screen were received on November 17, 2016. Patient # 3 received their initial dose on October 14, 2016. The results of the initial drug screen were received on October 18, 2016. Patient # 4 received their initial dose on July 30, 2016. The results of the initial drug screen were received on August 4, 2016. Patient # 5 received their initial dose on August 20, 2016. The results of the initial drug screen were received on August 23, 2016.Patient # 6 received their initial dose on July 15, 2016. The results of the initial drug screen were received on July 25, 2016. Patient # 7 received their initial dose on December 24, 2016. The results of the initial drug screen were received on December 30, 2016. These findings were reviewed with facility staff during the licensing process..
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Plan of Correction
Clinical Supervisor and Office Manager reviewed results of pending application with DOH and Clia. The office manager will correct the deficiency by making sure that the process is updated with multiple site wavers. The Clinical Supervisor and the Office Manger will track the application and any updates needed for all sites. While the application is pending the clinical supervisor will implement policy that the clients will submit to a UA at intake but will not be given a prescription until the lab test is received the next week. The client will then be seen by the Doctor after he has reviewed the lab results and will then receive a prescription of Suboxone. Quality assurance of this process will be over seen by the clinical supervisor.
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715.19(1) LICENSURE Psychotherapy services
A narcotic treatment program shall provide individualized psychotherapy services and shall meet the following requirements:
(1) A narcotic treatment program shall provide each patient an average of 2.5 hours of psychotherapy per month during the patient 's first 2 years, 1 hour of which shall be individual psychotherapy. Additional psychotherapy shall be provided as dictated by ongoing assessment of the patient.
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Observations
The facility failed to ensure that patients received 1 hour of individual psychotherapy per month during the patient 's first 2 years in six of seven patient records reviewed on June 21, 2017.Seven records were reviewed. Patient records # 1, 2, 3, 4, 5 and 6 did not document 1 hour of individual psychotherapy per month during the patient 's first 2 years.Patient # 1- there were no individual sessions documented from October, 3, 2016 to June 21, 2017.Patient # 2 - there were no individual sessions documented from December, 2016 to June 21, 2017. Patient # 3 - there were no individual sessions documented from November, 2016 to June 21, 2017.Patient # 4 - there were no individual sessions documented from August, 2016 to February, 2017.Patient # 5 - there were no individual sessions documented from September to December, 2016 and January, 2017.Patient # 6 - there were no individual sessions documented from August to December, 2016. These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The clinical supervisor will review the results of the survey with the clinical team on 7/11/2017 at a staff meeting. The clinical supervisor will conduct training on the regulation with the clinical staff at that meeting. Documentation of at least one hour of individual clinical services will be provided monthly for the clients first two years in treatment along with 1.5 hours of group. The implementation of this will be monitored by the clinical supervisor reviewing chart documentation weekly during chart audits and case consults. |