INITIAL COMMENTS
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This report is a result of an onsite licensure renewal and methadone monitoring inspection. The inspection was conducted on September 26 - 27, 2017 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the onsite inspection, Alliance Medical 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 the inspection:
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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
The facility failed to obtain an informed and voluntary consent in three of nine patient records reviewed during the inspection on September 26 - 27, 2017.
Patient # 2- Release of information forms signed on 2-3-2017, 2-23-2017 and 7-14-2017, failed to include the specific information to be disclosed.
Patient #3 - A release of information form signed on 6-2-2017 failed to include the specific information to be disclosed.
Patient #8 - A release of information form signed on 6-28-2017 failed to include the specific information to be disclosed.
These findings were discussed with the facility staff during the licensing process.
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Plan of Correction
The Facility Director and Clinical Supervisor conducted a training review of the releases of information with all staff on 10/3/17. Information permitted to be released with a signed consent for various entities (medical, legal, treatment providers,etc) was reviewed. All counselors were given a reference guide on the information. To prevent reoccurance, all releases will be reviewed during both intake chart audits and on-going weekly chart audits that are conducted by the Clinical Superviosrs and Facility Director. Individual supervision sessions will address the issue on-going as needed as well. |
715.15(b) LICENSURE Medication dosage
(b) The narcotic treatment physician shall determine the proper dosage level for a patient, except as otherwise provided in this section. If the narcotic treatment physician determining the initial dose is not the narcotic treatment physician who conducted the patient examination, the narcotic treatment physician shall consult with the narcotic treatment physician who performed the examination before determining the patient 's initial dose and schedule.
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Observations
The narcotic treatment program failed to document the consultation between the narcotic treatment physician determining the initial dose and the narcotic treatment physician performing the examination in two of two patient records reviewed on September 26 & 27, 2017.
Record #2 - Patient was admitted on 1-30-2017. The Physican Assistant (PA) completed the physical examination on 1-30-2017. The narcotic treatment physician determined the initial dose on 1-30-2017, but failed to document the consultation with the Physican Assistant who completed the physical examination.
Record #5 - Patient was admitted on 7-5-2017. The Physican Assistant (PA) completed the physical examination on 7-5-2017. The narcotic treatment physician determined the initial dose on 7-5-2017, but failed to document the consultation with the Physican Assistant who completed the physical examination.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
This regulation and deficiency was reviewed with both the Medical Director and Physician's Asst. on 10/2/17. It was agreed upon that the Medical Director will document the consultation between himself and the PA following the PA's completion of the History and Physical at intake on the Determination of Addiciton form prior to writing the first medication order. To ensure compliance, this documentation will be reviewed during the Intake Chart audit completed by either a Clinical Supervisor or Facility Director beginning the week of 10/9/17. |
715.17(c)(1)(i-vi)) LICENSURE Medication control
(c) A narcotic treatment program shall develop and implement written policies and procedures regarding the medications used by patients which shall include, at a minimum:
(1) Administration of medication.
(i) A narcotic treatment physician shall determine the patient 's initial and subsequent dose and schedule. The physician shall communicate the initial and subsequent dose and schedule to the person responsible for the administration of medication. Each medication order and dosage change shall be written and signed by the narcotic treatment physician.
(ii) An agent shall be administered or dispensed only by a practitioner licensed under the appropriate Federal and State laws to dispense agents to patients.
(iii) Only authorized staff and patients who are receiving medication shall be permitted in the dispensing area.
(iv) There shall be only one patient permitted at a dispensing station at any given time.
(v) Each patient shall be observed when ingesting the agent.
(vi) Administering and dispensing shall be conducted in a manner that protects the patient from disruption or annoyance from other individuals.
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Observations
The facility failed to document each medication order was written and signed by the narcotic treatment physician in three of eight patient records reviewed on September 26 & 27, 2017.
Patient records # 2, 3, and 6 had documented verbal orders which were not signed by the nurse or signed by the physician.
Patient #2 - Verbal order dated 2-23-2017 was not signed.
Patient #3 - Verbal order dated 10-13-2016 and 11-29-2016 was not signed.
Patient #6 - Verbal order dated 2-11-2017 was not signed.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
After investigating this issue in early 2017, it was determined that there was a setting/access issue for the Physician Asst. within the new EMR which did not allow her to select the proper doctor for verbal order documentation and prevented her signature. This setting was corrected and the problem was eliminated. To ensure on-going compliance, the Physician's Asst. will review at least 10 verbal orders per month for proper documentation in the EMR beginning October 2017. |
715.20(4) LICENSURE Patient transfers
A narcotic treatment program shall develop written transfer policies and procedures which shall require that the narcotic treatment program transfer a patient to another narcotic treatment program for continued maintenance, detoxification or another treatment activity within 7 days of the request of the patient.
(4) The receiving narcotic treatment program shall document in writing that it notified the transferring narcotic treatment program of the admission of the patient and the date of the initial dose given to the patient by the receiving narcotic treatment program.
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Observations
The facility failed to document the written notification of the admission and initial dosing of the patient to the referring facility in three of three patient records reviewed on September 26 & 27, 2017.
Patient records # 4, 5, and 6 were referred by another narcotic treatment program. There was no documentation of the referral being notified of the admission and initial dosing of the patients.
Patient #4 was admitted 7-14-2017.
Patient #5 was admitted 7-5-2017.
Patient #6 was admitted 2-1-2017.
These findings were reviewed with the facility staff during the licensing process.
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Plan of Correction
Proper Transfer In processes were reviewed with all counselors at the 10/3/17 staff meeting, including the completion of a Transfer Letter notification to the sending facility and proper documentation that the letter was sent to the facility. This will be documented on the Transfer In checklist for each transfer intake and scanned into the EMR. To ensure compliance, The Facility Director and Clinical Supervisors will review each Transfer In record during the Intake Chart Audit for proper documentation beginning 10/9/17. |
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
The facility failed to complete an annual evaluation in one of three patient records reviewed on September 26 & 27, 2017.
Patient # 3 was admitted May 16, 2016 and discharged June 26, 2017. An annual evaluation was due to be completed by May 16, 2017, and was not documented.
These findings were reviewed with the facility staff during the licensing process.
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Plan of Correction
Requirements for completion of the Annual Review for patients was reviewed at the 10/3/17 staff meeting. To ensure compliance, all counselors will review the Services Due report for their case load each month for any Annual Review due dates. Facility Director and Clinical Supervisors will review the overall Services Due report weekly for each supervisee to ensure completion. In addition, the Facility Director and Clinical Supervisors will review at least one chart per supervisee weekly for on-going compliance effective immediately. |