INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection and methadone monitoring inspection conducted on August 29-30, 2022 by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, WPIC Narcotic Addiction Treatment Program 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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705.26 (2) LICENSURE Heating and cooling.
705.26. Heating and cooling.
The nonresidential facility:
(2) May not permit in the facility heaters that are not permanently mounted or installed.
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Observations
Based on a physical plant inspection, the facility failed to prohibit the use of heaters that are not permanently mounted or installed.
The physical plant inspection was conducted on August 30, 2022. At the time of the inspection, the facility director's office was observed to have a portable heater.
These findings were reviewed with facility staff throughout the licensing process.
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Plan of Correction
Under the direction of the Facility Director or designee:
A. Free standing space heaters will not be permitted in the clinic. Staff were informed on 9/1/22 at Team Meeting that free standing space heaters are prohibited.
B. Director will work with East End Behavioral Health Building Management to adjust temperatures in offices to better accommodate patients and staff.
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715.6(d) LICENSURE Physician Staffing
(d) A narcotic treatment program shall provide narcotic treatment physician services at least 1 hour per week onsite for every ten patients
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Observations
Based on the review of time sheets and census reports, the facility failed to provide at least one hour of physician time per week on site for every ten patients in five of seventeen weeks reviewed.
During the week of April 11 -15, 2022, the patient census was 382 patients which required 38.2 physician hours; however, there were only 32 physician hours documented.
During the week of May 9 -13, 2022, the patient census was 380 patients which required 38.0 physician hours; however, there were only 36 physician hours documented.
During the week of May 30 - June 3, 2022, the patient census was 386 patients which required 38.6 physician hours; however, there were only 31.5 physician hours documented.
During the week of July 4 - July 8, 2022, the patient census was 388 patients which required 38.8 physician hours; however, there were only 33.5 physician hours documented.
During the week of July 11- 15, 2022, the patient census was 389 patients which required 38.9 physician hours; however, there were only 33 physician hours documented.
These findings were reviewed with facility staff throughout the licensing process.
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Plan of Correction
Under the direction of the Facility Director or designee:
A.MD schedules will be documented weekly and reviewed by nurse manager to ensure we have sufficient MD coverage to meet regulations regarding our patient census.
B.MD hours will be reviewed by Facility Director monthly to ensure that we are meeting regulations.
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715.20(1) 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.
(1) The transferring narcotic treatment program shall transfer patient files which include admission date, medical and psychosocial summaries, dosage level, urinalysis reports or summary, exception requests, and current status of the patient, and shall contain the written consent of the patient.
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Observations
Based on a review of patient records, the facility failed to transfer patient files within seven days of the request of the patient in one of one patient records.
Patient #5 was the only patient reviewed that transferred out to another narcotic treatment program. Patient #5 signed a release of information for the transfer of the patient file; however, there was no documentation that any information from the patient record was sent to the receiving program.
These findings were reviewed with facility staff throughout the licensing process.
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Plan of Correction
Under the direction of the Facility Director or designee:
A. Transfer paperwork will be documented in the record within the discharge summary when patients transfer to another clinic .
B. Supervisors reviewed this requirement with staff on 9/6/22.
C. Supervisors will monitor patient discharges monthly to ensure transfer paperwork has been documented in the record.
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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 client records.
Client #8 was the only successful discharge reviewed. Client #8 was admitted on March 15, 2018 and successfully discharged on August 22, 2022. There was no aftercare plan documented in client record #8.
These findings were reviewed with facility staff throughout the licensing process.
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Plan of Correction
Under the direction of the Facility Director or designee:
A. Aftercare plans will be developed for all patients who successfully complete treatment.
B. Supervisors reviewed this requirement with staff on 9/6/22.
C. Supervisors will monitor patient discharges monthly to ensure that aftercare plans have been completed with patients who have successfully completed treatment.
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