INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on October 17, 2016 through October 19, 2016 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, ARS of Lancaster, LP was found not to be in compliance with the applicable chapters of 28 PA Code which pertain to the facility.
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Plan of Correction
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709.28 (c) 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.
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Observations
Eighteen client records were reviewed from October 17-19, 2016. The facility failed to obtain a consent to release information form for information released to a pharmacy in one of eighteen client records reviewed, specifically client record # 9.
Client #9 was admitted into treatment on June 27, 2016 and was still an active client at the time of the inspection. The client record contained documentation indicating that the facility released patient identifying information to a pharmacy and failed to obtain an informed and voluntary consent.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The clinical supervisors will provide a training to all staff on confidentiality on November 22nd reviewing 255.5. The counselor met with the patient in record 9 on 10/19/16 and completed a consent for the pharmacy to prevent any further information from being released. After the training, the clinical supervisor/designee will audit 10% of all active charts for 3 months until 100% compliance is achieved. Continued compliance will be monitored through regular random chart audits by Clinical Supervisors and Peer Reviews. |
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 physician ' s hours, the facility failed to ensure that one-third of all required narcotic treatment physician time was provided by a narcotic treatment physician.
Three weeks of schedules were reviewed. During the week of September 4-10, 2016, the facility reported a census of 628 patients with a total of 65.25 hours of physician services. However the physician was required to provide 21 of those hours. There were only 8 physician hours documented for that week.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Medical Director was trained that he needs to provide 1/3 of the medical hours based on the census regardless of his personal commitments. The facility currently has substitute physician that can provide coverage when the Medical Director has a conflict. Additionally, the facility has a contract with a staffing agency that can also provide coverage when the Medical Director has a conflict. The Executive Director and Director of Nursing will continue to monitor medical hours on a weekly basis to ensure that correct ratios are maintained for medical hours. |
715.23(b)(6) LICENSURE Patient records
(b) Each patient file shall include the following information:
(6) Results of laboratory tests or other special examinations given by the narcotic treatment program.
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Observations
Eight client records requiring documentation of serological test results were reviewed on October 17, 2016. Client #2 was admitted on June 22, 2016 and was still a client at the time of the inspection. There was no documentation of the results of the serological test in client record #2 as of the date of the inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Client #2 was stopped by medical on 10/19/16 to have her serological test completed. Client #2 received her results for this test on 10/21/16. Medical documented this information in the client's record. The Director of Nursing will complete a training with her nursing staff on November 15th on the proper procedure for completing laboratory tests and the appropriate documentation. After the training, the DON/designee will audit 10% of all active charts for 3 months until 100% compliance is achieved. Continued compliance will be monitored through regular random chart audits by the DON. |