INITIAL COMMENTS
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This report is a result of an off-site complaint investigation conducted on January 24 - 28, 2013, by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the off-site licensing inspection, Axiom Family Counseling Services, 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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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
Based on the review of the client record, the facility failed to inform the client, in writing, of a decision to involuntarily terminate the client's treatment in one of one client record reviewed. The findings include: Client # 1 was admitted on November 19, 2012 and administratively discharged on January 7, 2013. Client record # 1 was reviewed on January 24, 2013. This record was required to have written notification to the client informing her of the decision to terminate her treatment. The facility failed to document written notification in this client record. An interview with the facility director on January 25, 2013 confirmed there was no written notification of termination in the client record.
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Plan of Correction
Upon notification of non-compliance to program requirements, clinical director, treating physician, and main therapist assigned to case will conduct a treatment meeting to discuss plan of care.
If decision is reached to discharge patient, the clinical director and main therapist will complete the discharge summary detailing reasons for discharge and a termination of services letter will be composed for client.
The termination of services letter will detail reasons for termination, future treatment options with referrals, appeal options, and a signature line indicating that the patient has received these items and understands them to the best of their abilities.
The main therapist will meet with client to facilitate transition out of Axiom's drug and alcohol program and discuss referral options for a more appropriate level of care.
As part of our ongoing quality assurance process, the discharged client's chart will be given to the clinical director for audit and final review to determine that all requirements for discharge were met, including signed termination letter, appeal options, and referrals.
Through the quality assurance process,if clinical director deems any patient was discharged without following proper discharge procedures, the clinical director will address deficiencies with treatment team and contact client to address any deficiences in their discharge. |
709.33(b) LICENSURE Notification of Termination
709.33. Notification of termination.
(b) The client shall have an opportunity to request reconsideration of a decision terminating treatment.
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Observations
Based on the review of client records, the facility failed to give the client an opportunity to request reconsideration of a decision to terminate treatment in one of one record reviewed. The findings include:One client record was reviewed on January 24, 2012. The project was required to give the client an opportunity to request reconsideration of the decision to terminate treatment in one client record. The project did not document that the client was given an opportunity to request reconsideration in client record #1.
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Plan of Correction
The clinical director and main therapist will complete the discharge summary detailing reasons for discharge and a termination of services letter will be composed for client.
The termination of services letter will detail reasons for termination, future treatment options with referrals,appeal options and a signature line indicating that the patient has received these items and understands them to the best of their abilities.
The appeal option provides the client with direction on how to appeal and request for reconsideration of the decision to terminate treatment.
The main therapist will meet with client to facilitate transition out of Axiom's drug and alcohol program and discuss referral options for a more appropriate level of care.
As part of our ongoing quality assurance process, the discharged client's chart will be given to the clinical director for audit and final review to determine that all requirements for discharge were met, including signed termination letter, appeal options, and referrals.
Through the quality assurance process,if clinical director deems any patient was discharged without following proper discharge procedures, the clinical director will address deficiencies with treatment team and contact client to address any deficiences in their discharge.
This chart review process will be completed within two days of discharge. |
709.14(b)(4) LICENSURE Subchapter B.Licensing Procedures.Restriction
709.14. Restriction on license.
(b) The licensee, using Department forms, shall notify the Department within 90 days of the occurrence of any of the following conditions:
(4) Change in activity/discontinuance of an activity.
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Observations
Based on a review of a client record and an interview with the facility director, the facility failed to notify the Department of a change of activity. The findings include:One client record was reviewed on January 24, 2013 due to a complaint received by the client. The client record confirmed the client was receiving treatment from a physician who was providing medication management at the facility. This activity is an activity for which the facility did not receive Departmental approval to provide. Client # 1 was admitted on 11/19/2012. The record for client #1 contained documentation that the facility physician was prescribing Subutex for the patient. During an interview with the facility director, it was confirmed that the facility physician was prescribing buprenorphine to facility clients. The facility does not have Department approval to provide this service. When asked if the project was providing medically managed treatment services, the facility director acknowledged that the facility was.
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Plan of Correction
Axiom Family Counseling Services at this time is not accepting any new patients into the Drug and Alcohol program, specifically those needing medication management services.
All staff has been informed in writing of this decision by the project director.
The facility has responded by submitting all necessary forms for approval for the use of Buprenorphine in our facility to the
Department of Drug and Alcohol Programs, Bureau of Quality Assurance for Prevention and Treatment, Division of Program Licensure on January 26,2013.
In the future, the facility will not conduct new services they are not licensed to provide without prior approval from the Department.
As part of continuing quality assurance, the clinical director and project mananger will meet once a month to review all current and revised state program regulations to ensure Axiom Family Counseling Service is compliant.
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