INITIAL COMMENTS
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This report is a result of an onsite follow-up inspection regarding the plans of correction for the Jefferson Outreach Drug and Alcohol Program Central January 10, 2013 licensure renewal inspection. The follow-up inspection was conducted on July 31, 2013 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the onsite follow-up inspection, Jefferson Outreach Drug and Alcohol Program Central 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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711.14(b)(4) LICENSURE Subchapter B.Approval Procedures.Restrictions
711.14. Restrictions on certificate of compliance.
(b) Utilizing appropriate Department forms, the holder of a certificate shall notify the Department within 90 days of the occurrence of any of the following conditions:
(4) Change in activity.
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Observations
Based on a review of client records and a discussion with one of the directors and one of the counselors, the facility failed to notify the Department of a change in activity.
The findings include:
On July 31, 2013, eleven client records were reviewed for compliance with licensure regulations. The facility documented that they were providing Suboxone treatment services, an activity for which they do not have Departmental authorization, in five of eleven records reviewed, specifically, client records # 7, 8, 9, 10, and 11.
Client # 7 was admitted September 5, 2012. Client record # 7 included documented medical records and physician's notes which indicated that client # 7 was receiving Suboxone treatment.
Client # 8 was admitted February 2, 2009. Client record # 8 included documented medical records and physician's notes which indicated that client # 8 was receiving Suboxone treatment.
Client # 9 was admitted February 9, 2009. Client record # 9 included documented medical records and physician's notes which indicated that client # 9 was receiving Suboxone treatment.
Client # 10 was admitted September 12, 2012. Client record # 10 included documented medical records and physician's notes which indicated that client # 10 was receiving Suboxone treatment.
Client # 11 was admitted March 20, 2007. Client record # 11 included documented medical records and physician's notes which indicated that client # 11 was receiving Suboxone treatment.
The findings were confirmed during an interview with one of the counselors and one of the directors at approximately 12:10 P.M.
This is a repeat citation. The facility was cited on January 10, 2013 for noncompliance with this standard.
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Plan of Correction
A detailed request for a non-residential outpatient program to prescribe suboxone was submitted to DDAP on 8/21/13.In the event that the request is rejected, it will be the responsibility of the program's Medical Director, working closely with the patient and his/her counselor to either; a)locate a certified provider to continue medication, or, b)work closely with the patient to arrange a 30 day detoxification schedule.
No new patients will be accepted into suboxone treatment until the request for approval for a non-residential outpatient treatment program has been approved and this issue is resolved.. |
711.93(a)(6) LICENSURE Aftercare Plans
711.93. Client records.
(a) Record requirements. There shall be a complete client record on an individual which includes information relative to the client's involvement with the project. In addition to the requirements in 115.32 (relating to contents), the client record shall include the following:
(6) Aftercare plans, if applicable.
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Observations
Based on a review of client records, the facility failed to document an aftercare plan in one of one record reviewed.
The findings include:
The facility policy states "Aftercare plans are plans patients develop to establish future goals and objectives for a period of time after completion of treatment. The patient and counselor work out the aftercare plan during the last treatment sessions. The aftercare plan defines the aftercare program, follow-up activities and re-entry criteria for a patient."
On July 31, 2013, one client record requiring documentation of an aftercare plan was reviewed. The facility did not document an aftercare plan in one of one record reviewed, specifically, client record # 6.
Client # 6 was admitted January 7, 2013 and discharged April 1, 2013. An aftercare plan was due at the time of discharge during the last treatment session. However, client record # 6 did not include documentation of an aftercare plan as of July 31, 2013.
The findings were confirmed during an interview with one of the counselors and one of the directors at approximately 12:10 P.M.
This is a repeat citation. The facility was cited on January 10, 2013 for noncompliance with this standard.
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Plan of Correction
It will be the reponsibilityof the Facility Director to ensure that patients who successfully complete a course of treatment have a signed/dated Aftercare Plan in their clinical record.
The Facility Director will communicate the need for Aftercare Plans to program personneland will ensure compliance by routine chart audits.
Revised POC:
As noted above, the Facility Director will be responsible for ensuring that Aftercare Plans are in place via ongoing chart reviews for all discharged patients. |