INITIAL COMMENTS
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This report is a result of a complaint investigation conducted on April 15, 2008, by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings, A.R.S. of Lancaster, LP, 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 and a plan of correction is due May 16, 2008.
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Plan of Correction
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715.21 LICENSURE Patient termination
A narcotic treatment program shall develop and implement policies and procedures regarding involuntary terminations. Involuntary terminations shall be initiated only when all other efforts to retain the patient in the program have failed.
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Observations
Based on review of patient records, the facility failed to ensure all efforts had been initiated to retain the patient prior to the involuntary termination. Patient # 1 was admitted on September 25, 2007 and involuntarily discharged March 18, 2008 for non-compliance with financial obligations; the issue of financial issues was briefly addressed in a treatment update, however, the patient had no specific treatment goals or objectives to address his financial issues. Patient # 4 was admitted to the facility on July 10, 2006; he received a treatment plan on February 26, 2008 that addressed arrears totaling $1700. The patient was discharged April 10, 2008 for financial noncompliance. He never received written notification of an involuntary discharge. Six weeks is insufficient time for the patient to implement a plan to address financial responsibilities. Patient # 14 was discharged on March 31, 2008, with arrears totaling over $950. At the time of his discharge the patient was in the process of applying for medical assistance as he was no longer able to pay the weekly fee. The patient applied for medical assistance on his own and was not referred by ARS. This patient was not afforded the opportunity to satisfactorily address his financial responsibilities.
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Plan of Correction
Policies and detailed procedures have been written and implemented to guide counselors in assisting patients in the management of financial affairs and training is planned for all personnel in this critical area by May 23, 2008 by the ARS Director of Clinical Services. The Executive Director will document the completion of training by all team members.
Patients who present with any evidence or degree of financial difficulty receive documented financial interventions and appropriate referrals for assistance. Documented follow-up will be routine with patients being given adequate time to demonstrate conformance. Financial issues will be immediately incorporated into the individualized treatment plan with specific steps towards resolution. Progress notes will document completion of these actions or the failure of the patient to follow through with them and the efforts made to engage the patient in being compliant so that each patient is afforded an adequate opportunity to satisfactorily address his or her financial responsibilities. Additionally, the Clinical Supervisor or Executive Director will ensure that no patient is discharged without proper written notification being given to the patient and a copy being placed in the treatment file.
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715.21(1)(i-iv) LICENSURE Patient termination
A narcotic treatment program shall develop and implement policies and procedures regarding involuntary terminations. Involuntary terminations shall be initiated only when all other efforts to retain the patient in the program have failed.
(1) A narcotic treatment program may involuntarily terminate a patient from the narcotic treatment program if it deems that the termination would be in the best interests of the health or safety of the patient and others, or the program finds any of the following conditions to exist:
(i) The patient has committed or threatened to commit acts of physical violence in or around the narcotic treatment program premises.
(ii) The patient possessed a controlled substance without a prescription or sold or distributed a controlled substance, in or around the narcotic treatment program premises.
(iii) The patient has been absent from the narcotic treatment program for 3 consecutive days or longer without cause.
(iv) The patient has failed to follow treatment plan objectives.
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Observations
Following a review of eleven patient records and staff interviews, the facility developed policies and procedures that exceeded the permitted reasons to involuntary terminate a patient. Specifically, the facility had developed a policy and procedure to address financial noncompliance as a reason for an involuntary termination from treatment. Further, the involuntary termination of patients #1, 4, and 14 identified the primary reason for their terminations as financial noncompliance.
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Plan of Correction
ARS policies and procedures governing involuntary terminations will be corrected by the ARS Vice President of Operations and ARS Director of Clinical Services to meet the requirements of the regulation. The policy shall specifically restrict involuntary terminations to those cases when all other efforts to retain the patient have failed. Involuntary termination will be limited to those cases when ARS deems the discharge would be in the best interest of the health and/or safety of the patient and/or others or when and/or if the program finds that: (1) the patient has committed or threatened to commit an act of violence in or around the program; (2) the patient has sold or distributed a controlled substance in or around the program; (3) the patient has been absent from the program for three or more days; and/or (4) the patient has failed to follow treatment plan objectives. |
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
Following a review of two patient records who were in treatment for longer than one year, the facility failed to address the current status of patient # 14's financial situation in the annual evaluation.
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Plan of Correction
A form will be developed to guide the annual review process to ensure that all annual reviews minimally address each of the areas required by the regulations. This form will be immediately implemented to ensure that the program is in full compliance with this regulation from this point forward for all patients. The Clinical Supervisor will be responsible to develop the form with the approval of the Executive Director and the ARS Director of Clinical Services. The Clinical Supervisor will be responsible to monitor for ongoing compliance. |
715.23(d)(2) LICENSURE Patient records
(d) A narcotic treatment program shall prepare a treatment plan that outlines realistic short and long-term treatment goals which are mutually acceptable to the patient and the narcotic treatment program.
(2) The narcotic treatment physician or the patient 's counselor shall review, reevaluate, modify and update each patient 's treatment plan as required by Chapters 157, 709 and 711 (relating to drug and alcohol services general provisions; standards for licensure of freestanding treatment activities; and standards for certification of treatment activities which are a part of a health care facility).
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Observations
Following a review of seven patient records, the facility failed to include financial issues in the treatment plan updates for patients # 1, 4, 6, and 14, to include financial status. Additionally, financial issues as were not added to the treatment plan until shortly prior to patients 1, 4, and 14's involuntary termination.
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Plan of Correction
Treatment plan training will be conducted with the entire treatment team on the development of long and short term goals that specifically address financial issues. The importance of fully and adequately addressing financial issues as an early and continuing intervention until resolution will be presented along with other general financial concerns. Training will be comprehensive to ensure competency development and program refinement in addition to regulatory compliance. Supervision is provided by the Clinical Supervisor and is routine, continuous and ongoing. Comprehensive training addressing this and other issues is scheduled to be conducted during the week beginning May 19th and will be completed by May 20rd, 2008. This training is being conducted by the ARS Director of Clinical Services. |
709.23(a) LICENSURE Project Director
709.23. Project director.
(a) The project director shall prepare and annually update a written manual delineating project policies and procedures.
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Observations
The policies and procedures presented during the narcotic treatment inspection of March 4, 5, and 6, 2008 did not include the ARS policy and procedure to patient's relating financial obligations and involuntary detoxification. The policies and procedures manual needs to be complete.
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Plan of Correction
The newly created and revised policies and procedures created by the ARS Vice President of Operations and Director of Clinical Services, as a product of this corrective action plan and all other policies and procedures, will be immediately placed in the policy manual upon approval by the Executive Director from this point forward so that the manual is accurate, up-to-date, thorough and complete at all times. |
709.28(c)(2) 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:
(2) Specific information disclosed.
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Observations
Based on a review of patient records, the facility released information in one of seven records reviewed, specifically # 13, that exceeded the parameters of 4 Pa. Code 255.5. The facility released the results of the patient's urine drug tests to a probation office.
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Plan of Correction
ARS has purchased training videos from the Legal Action Center of New York City. This group is generally considered to be the experts in confidentiality issues for many decades. All ARS employees are now required to watch these videos and completion of this training is documented. Routine and regular record reviews by the Clinical Supervisor are monitoring for this issue on an ongoing basis. In addition, supervisory sessions by the Clinical Supervisor are being provided to counselors and include this topic. Training is being provided by the Executive Director, Clinical Supervisor, and ARS Director of Clinical Services. The Executive Director is responsible to ensure that this corrective action is fully implemented. |
709.33(a) LICENSURE Notification of Termination
709.33. Notification of termination.
(a) Project staff shall notify the client, in writing, of a decision to involuntarily terminate the client's treatment at the project. The notice shall include the reason for termination.
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Observations
Following a review of seven patient records, the facility failed to provide three of three patients with written documentation that identified involuntary termination and the reasons for termination; for patients # 1, 4, and 14. Patient records provided documentation of financial non-compliance but the records did not include letters that notified patients # 1, 4, and 14 of their involuntary termination and the reason(s) for termination.
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Plan of Correction
Non-compliant patients who have exhausted all resources and supports afforded them or who have failed to follow through with recommended treatment objectives within a reasonable period will be notified in writing of a decision to involuntary terminate his or her treatment with ARS. This notice shall include the reason for termination and a copy shall be immediately placed in the patient's treatment record. The Executive Director and Clinical Supervisor will monitor for conformance with this requirement and will be the only ARS authorized personnel to present the notices of pending involuntary termination. |
709.91(a)(1) LICENSURE Intake and admission
709.91. Intake and admission.
(a) The project director shall develop a written plan providing for intake and admission which includes, but not be limited to:
(1) Criteria for admission.
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Observations
Following a review of seven patient records, the facility failed to follow it's procedure to assess the potential patient's ability to pay for treatment in one of seven records reviewed. Patient #1 was admitted to treatment even though he had acknowledged during intake that he had financial difficulties. Patient # 1 was admitted to ARS with the expectation that he would pay for treatment through his own financial resources.
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Plan of Correction
The Executive Director, Clinical Supervisor and entire treatment team have received extensive training in financial compliance as of 05/20/08. Close supervision in this area continues on a daily basis. The treatment team is closely reviewing each applicant for services financial status at the time of screening to determine if s/he can meet the financial obligations required for admission and treatment. If the individual does not have the funds required for intake or to continue to pay for treatment, s/he is immediately referred for assistance. The responsibility for full compliance rests with the program's Executive Director. |
709.92(a)(3) LICENSURE Treatment and rehabilitation services
709.92. Treatment and rehabilitation services.
(a) An individual treatment and rehabilitation plan shall be developed with a client. This plan shall include, but not be limited to, written documentation of:
(3) Proposed type of support service.
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Observations
Following a review of seven patient records, the facility failed to include support services on the individual treatment and rehabilitation plan. Specifically, there were no financial support services identified in treatment plans patients # 1, 3, 4, 6, and 14.
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Plan of Correction
Training is being provided to counselors in treatment planning and specifically in identifying financial support services. The Clinical Supervisor will review for this element and ensure its presence. The Clinical Supervisor and Executive Director will develop a written guide to assist counselors in the preparation of the treatment plan outlining financial supports that can be used in treatment planning. |