INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection and methadone monitoring inspection conducted on October 20 - 21, 2015 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Addiction Medicine and Health Advocates, Inc. 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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705.23 (3) LICENSURE Counseling or activity areas and office space
705.23. Counseling or activity areas and office space.
The nonresidential facility shall:
(3) Ensure privacy so that counseling sessions cannot be seen or heard outside the counseling room. Counseling room walls shall extend from the floor to the ceiling.
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Observations
Based on observations made by the licensing specialists, the facility failed to ensure that counseling sessions could not be heard outside of the counseling room.
The findings include:
The annual licensing inspection was conducted from October 20 - 21, 2015. The facility failed to ensure that counseling sessions could not be heard outside of the counseling room.
During the inspection, the licensing specialists utilized an office which was situated between numerous counseling rooms, group counseling sessions in these rooms could be clearly heard throughout the inspection.
The findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
The organization will buy "white noise" machines for all clinical offices and group rooms to be utilized during clinical business hours to ensure that patient sessions cannot be heard outside of the counseling room/group room. All clinical staff will be required to utilize the white noise machines during clinic business hours.
The Clinical Program Manager will be responsible for ensuring staff compliance with the purchase and use of the machines.
The white noise machines will be purchased and in use no later than 11/6/15. |
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. The consent shall be in writing and include, but not be limited to:
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Observations
Based on a review of client records, the facility failed to obtain an informed and voluntary consent from the client for the disclosure of information in four of twelve records reviewed.
The findings include:
Twelve client records were reviewed on October 20 - 21, 2015, to ensure that the facility obtained an informed and voluntary consent from the client for the disclosure of information. The facility failed to obtain an informed and voluntary consent in client records, # 3, 4, 5 and 8.
Client # 3 was admitted to the facility on November 10, 2014. The facility obtained a consent to release from client # 3 on February 9, 2015 that did not comply with 4 Pa. Code 255.5. The facility documented the disclosure of client # 3's urinalysis results to a contract governmental agency. In addition, per faxed documentation, the facility released client # 3's urinalysis and medications for the following months; November, December, January and February.
Client # 4 was admitted to the facility on April 30, 2015. The facility obtained a consent to release from client # 4 on April 30, 2015 that did not comply with 4 Pa. Code 255.5. The facility documented the disclosure of client # 4's urinalysis results to a governmental agency.
Client # 5 was admitted to the facility on December 8, 2014. The facility obtained a consent to release from client # 5 on December 8, 2014 that did not comply with 4 Pa. Code 255.5. The facility documented the disclosure of client # 5's physical exam including blood work, urinalysis results, progress notes, discharge summary and bio-psychosocial history to two governmental agencies.
Client # 8 was admitted to the facility on December 17, 2014. The facility obtained a consent to release from client # 8 on December 17, 2014 that did not comply with 4 Pa. Code 255.5. The facility documented the disclosure of client # 8's physical exam including blood work, urinalysis results, progress notes, discharge summary and bio-psychosocial history to two governmental agencies.
The findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
The Program Director and Clinical Program Manager will conduct an in-house training on PA 255.5 to review and discuss informed patient consent and limitations for information disclosure from a patient record to governmental agencies, the criminal justice system and third party payers. This training will take place prior to 11/13/15.
For charts identified as being deficient during this inspection, we will have the patients sign new release forms allowing for only that information which can be released under PA 255.5 to governmental agencies. The previous release forms, which did not comply with PA 255.5, will revoked at the same time.
Additionally, compliance with PA 255.5 will be monitored via the monthly quality record review with results being presented to and discussed in the agency's Performance Improvement Committee meeting.
The Clinical Program Manager will be responsible for ensuring the training takes place. The Program Director will be responsible for ensuring compliance with the record reviews and discussion in the Performance Improvement Committee meetings. |
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
Based on a review of patient records, the facility failed to document in writing notification of admission and the initial dose given to the patient to the transferring narcotic treatment program in one of five patient records reviewed.
The findings include:
Five patient transfer-in records were reviewed for transfer documentation on October 20 - 21, 2015. The facility failed to document notification of admission and the initial dose to the referring facility in one of five patient records reviewed, specifically patient record # 1.
The findings were reviewed with facility staff during the methadone monitoring inspection.
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Plan of Correction
The Clinical Program Manger has met with the Intake Counselor on 10/22/15 and reviewed the regulatory requirements for transfer admission confirmation and initial dose documentation to a referring agency. Beginning 10/23/15, the Clinical Program Manager will review all intake charts upon completion to ensure that all required documentation, including transfer admission and first dose confirmation, have been completed and sent to the referring agency.
Additionally, as part of the monthly quality record review, the Clinical Supervisor will monitor compliance with documentation requirements. The Clinical Program Manager will be responsible for implementation and ongoing monitoring for overall compliance effective 10/23/15. |