INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection, as well as an on-site inspection conducted for the approval to use a narcotic agent, specifically methadone, in the treatment of narcotic addiction. This inspection was conducted on March 8, 2016 through March 9, 2016 by staff from the Department of Drug and Alcohol Programs, Bureau of Quality Assurance for Prevention and Treatment, Program Licensure Division. Based on the findings of the on-site inspection, Williamsport Family Medical Center was found not to be in compliance with the applicable chapters of 4 PA Code and 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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715.23(b)(5) LICENSURE Patient records
(b) Each patient file shall include the following information:
(5) The results of all annual physical examinations given by the narcotic treatment program which includes an annual reevaluation by the narcotic treatment physician.
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Observations
Based on a review of client records, the facility failed to document the results of the annual physical examinations/physician reevaluations in three of eleven client records reviewed.The findings include:Eleven client records were reviewed on March 8, 2016 through March 9, 2016. Five client records required documentation of annual physical examinations. The facility failed to document annual physical examinations/physician reevaluations in client record #'s 2, 8, and 12.Client #2 was admitted into treatment on October 8, 2014 and was still an active client as of the date of the on-site inspection. The client's initial physical examination was completed on 10/08/2014 and the annual physical examination/physician reevaluation was due by 10/08/2015. However, there was no annual physical examination/physician reevaluation documented in the client record as of the date of this inspection.Client #8 was admitted into treatment on August 14, 2014 and was discharged on October 30, 2015. The client's initial physical examination was completed on 8/14/2014 and the annual physical examination/physician reevaluation was due by 8/14/2015. However, there was no annual physical examination/physician reevaluation documented in the client record as of the date of this inspection.Client #12 was admitted into treatment on June 19, 2014 and was discharged on January 31, 2016. The client's initial physical examination was completed on 6/19/2014 and the annual physical examination/physician reevaluation was due by 6/19/2015. However, there was no annual physical examination/physician reevaluation documented in the client record as of the date of this inspection.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
An adjustment to WFMC's monitoring system will occur by Facility Director and PA-C utilizing the electronic medical recording system, which identifies admission date, to ensure that all annual physical examinations occur prior to due date. PA-C will ensure all annual physicals are completed by random record reviews and checks system monthly. Facility Director will complete a record review of the identified deficiencies for active charts to ensure that corrections were made by 4/8/16, notation will occur on record review tool. |
715.23(b)(24) LICENSURE Patient records
(b) Each patient file shall include the following information:
(24) Follow-up information regarding the patient.
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Observations
Based on a review of client records, the facility failed to document a complete client record on an individual, which is to include follow-up information in two of eleven client records reviewed.The findings include:Eleven client records were reviewed on March 8, 2016 through March 9, 2016. Six client records required documentation of follow-up information. The facility did not provide documentation of follow-up information in client record #'s 8 and 10.Client #8 was admitted into treatment on August 14, 2014 and was discharged on October 30, 2015. The facility failed to include documentation of any follow-up information in the client's record as of the date of the on-site inspection.Client #10 was admitted into treatment on March 12, 2015 and was discharged on July 16, 2015. The facility failed to include documentation of any follow-up information in the client's record as of the date of the on-site inspection.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Facility and Director and Clinical Supervisor will review/re-educate clinical staff on appropriate discharge procedures. Upon discharge, all discharge charts will be review by either Facility Director or Clinical Supervisor to ensure all documentation is completed including follow-up. Record review tool will be placed within the individuals record. Facility Director will complete discharge follow up for #10 and the assigned counselor will document her follow up in the record of #8. Facility Director will make notation of follow up on record review tool. |
709.92(a) 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:
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Observations
Based on a review of client records, the facility failed to provide documentation that an individual treatment and rehabilitation plan was developed with the client in one of one Outpatient Drug-Free client record reviewed.The findings include:Twelve client records requiring the documentation of a client-involved development of the individual treatment and rehabilitation plan were reviewed on March 8, 2016 through March 9, 2016. The facility failed to document a comprehensive treatment plan developed with the client in client record #6.Client #6 was admitted into outpatient drug-free treatment on February 7, 2016 and was still an active client as of the date of the on-site inspection. There was no documentation in the client record of a comprehensive treatment plan being developed.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
All individuals being admitted into the Drug-Free program will comply with regulatory timeframes for documentation to address the completion of comprehensive treatment plan. Facility Director or Clinical Supervisor will provide re-education to all clinicians providing drug-free services. All individuals will complete a new intake regardless if he/she transitions from MMT to drug-free. All drug-free intakes will be reviewed by either Facility Director or Clinical Supervisor within first 30 days of treatment to ensure the completion of comprehensive treatment plan is completed. Supervisor will sign off on comprehensive treatment plan in addition to Medical Director. Facility Director will complete a record review for #6 to ensure that comprehensive treatment plan has been completed where deficient by 4/8/16 and make notation on record review tool. |