INITIAL COMMENTS
|
This report is a result of an on-site licensure renewal inspection conducted on October 31 through November 02, 2007 by staff from the Division of Drug and Alcohol 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 and a plan of correction is due on December 6, 2007.
|
Plan of Correction
|
705.22 (1) LICENSURE Building exterior and grounds.
705.22. Building exterior and grounds.
The nonresidential facility shall:
(1) Maintain all structures, fences and playground equipment, when applicable, on the grounds of the facility so as to be free from any danger to health and safety.
|
Observations
Based upon observation on October 31, 2007 through November 02, 2007 the facility failed to maintain structures to be free of danger. There was a section of the exterior sidewalk located in front of the newly acquired lot, adjacent to the facility, that is in disrepair and presents a tripping hazard. There was a section of the building foundation wall, located on the side of the building adjacent to the convenience store, that had separated and was pulling away from the remainder of the building.
|
Plan of Correction
At the time of the licensing visit, the NATP was under the impression that the property adjacent to the facility had been transferred to UPMC ownership. That property transfer has not yet been finalized and is not currently the property of UPMC. At such time that the transfer is finalized, the exterior sidewalk will be repaired.
The section of the building foundation wall, located on the side of the building adjacent to the convenience store, which had separated and was pulling away from the remainder of the building has been repaired by the WPIC facilities department and no longer presents as a fault in the foundation wall.
To ensure this deficiency does not recur, $400,000 has been allocated for the repairs and ongoing improvments to the structure. NATP leadership will work closely with WPIC facilities management in identifying areas of potential concern and develop a preventative maintenance schedule for the structural concerns.
|
705.28 (d) (4) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(4) Maintain a written fire drill record including the date, time, the amount of time it took for evacuation, the exit route used, the number of persons in the facility at the time of the drill, problems encountered and whether the fire alarm or smoke detector was operative.
|
Observations
Based on a review of the facility's written fire drill log on November 02, 2007 it was determined that the facility failed to document the number of persons in the facility at the time of the drill. A review of the facility's fire drill log indicated that the facility failed to account for the clients participating in the fire drill.
|
Plan of Correction
The Facility Director shall meet with the Safety Officer for the building in which the program is housed. They shall review the licensing standards to ensure understanding and compliance regarding the data required on the fire drill report form. The form shall be adapted for use for the WPIC CPCDS programs and will include the date, time, the amount of time it took for evacuation, the exit route used, the number of persons in the facility at the time of the drill, problems encountered and whether the fire alarm or smoke detector was operative. The Facility Director and shall provide ongoing follow-up to ensure the information and report form is maintained correctly. Use of the complete report form will begin immediately.
|
711.91(b)(3)(i) LICENSURE Medical History
711.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(3) Histories, which include the following:
(i) Medical history.
|
Observations
Based on a review of the facility's policy manual and client records on November 1- 2, 2007 it was determined that the facility failed to document medical histories in a timely manner. A review of ten client records revealed that in four of those records, specifically #1, 2, 3 and 4, the medical history was late in accordance with the facility's policy. Client record #18 was missing the medical history.
|
Plan of Correction
The Facility Director and Clinical Supervisor will ensure, through supervision and quality assurance chart review, that the aspects of the medical history comprises a history documenting the client's personal medical history, family medical history, and history of illness and symptoms. The information will be gathered and recorded within the required time frame as identified by policy, which is by the end of the 3rd outpatient session. The Facility Director and/or the Clinical Supervisor will convey the necessity of inclusion of this information during a staff meeting by 1/1/07. The reviews and supervision will begin immediately.
|
711.91(b)(3(ii) LICENSURE D & A History
711.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(3) Histories, which include the following:
(ii) Drug or alcohol history, or both.
|
Observations
Based on a review of the facility's policy manual and client records on November 1- 2, 2007 it was determined that the facility failed to document drug and alcohol histories in a timely manner. A review of ten client records revealed that in four of those records, specifically #1, 2, 3 and 4, the drug and alcohol history was late in accordance with the facility's policy. Client record #18 was missing the drug and alcohol history.
|
Plan of Correction
The Facility Director and Clinical Supervisors will ensure through supervision and quality assurance chart review, that the aspects of a drug and/or alcohol history shall be compiled to include, at a minimum, the substances most frequently abused, the length and patterns of use and prior treatment episodes. The history shall include the client's perception of their effect on his/her social, physical and mental state. Any available substance abuse history of the family, or that of significant others will also be noted. The Facility Director and/or the Clinical Supervisor will convey the necessity of inclusion of this information during a staff meeting by 1/1/07. The reviews and supervision will begin immediately.
|
711.91(b)(3)(iii) LICENSURE Personal History
711.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(3) Histories, which include the following:
(iii) Personal history.
|
Observations
Based on a review of the facility ' s policy manual and client records on November 1- 2, 2007 it was determined that the facility failed to document personal histories in a timely manner. A review of ten client records revealed that in four of those records, specifically #1, 2, 3 and 4, the personal history was late in accordance with the facility's policy. Client record #18 was missing the personal history
|
Plan of Correction
The Facility Director and Clinical Supervisor will ensure, through supervision and quality assurance chart review, that the aspects of personal history comprises a history documenting the client's historical and pertinent personal data including: family, legal, employment/vocational, educational, military, recreational, sexual and others where appropriate. The information will be gathered and recorded within the required time frame as identified by policy, which is by the end of the 3rd outpatient session, and by the end of the first week of partial services. The Facility Director and/or the Clinical Supervisor will convey the necessity of inclusion of this information during a staff meeting by 1/1/07. The reviews and supervision will begin immediately.
|
711.91(b)(5) LICENSURE Physical Examination
711.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(5) Physical examination, if applicable.
|
Observations
Based on a review of the facility's policy manual and client records on November 1- 2, 2007 it was determined that the facility failed to conduct a physical examination in a timely manner. A review of one of eleven client records reviewed, specifically #12, revealed that the clients admitted for " drug dispensing " on May 14, 2007 did not receive a physical examination until September 25, 2007. The facility's policy manual indicated that physical examinations would be conducted by the second session and prior to the client's first dosing.
|
Plan of Correction
The Medical Director, Facility Director, Nurse Coordinator, and Clinical Supervisor will ensure, through supervision and quality assurance chart review that physical examinations occur within the appropriate time frames as evidenced by both chapter 711 and 715 of the licensing standards require. The physical examination shall be conducted upon admission to treatment, by the end of the 2nd intake session, and prior to the patient being dosed with methadone. The Medical Director and/or designee will meet with all physicians and convey the necessity of inclusion of this information to all attending physicians by 1/1/07. The reviews and supervision will begin immediately.
|
711.91(b)(6) LICENSURE Psychosocial Evaluation
711.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(6) Psychosocial evaluation.
|
Observations
Based on a review of the facility's policy manual and client records on November 1- 2, 2007 it was determined that the facility failed to document psychosocial evaluations in a timely manner. A review of eight client records revealed that in four of those records, specifically #1, 3, 4 and 6, the psychosocial evaluations was late in accordance with the facility's policy. Client record #18 was missing the psychosocial evaluations. In addition, client records #1, 2, 4 and 6 contained psychosocial evaluations that were based on client stated comments and failed to include the clinicians' analysis of the clients' past and present circumstances.
|
Plan of Correction
The Facility Director and Clinical Supervisors will ensure through supervision and quality assurance chart review that the aspects of the psychosocial summary will be in compliance with licensing standards. The evaluation will provide a composite picture of the individual in relationship to the collected historical information in order to identify possible relationships, conditions, and causes leading to the patient's current situation. The evaluation shall also include: A clear description of the client's presenting and underlying problems; Client needs or problems that can or cannot be resolved through treatment or that might inhibit treatment; Client assets, strengths or other factors that can contribute to the resolution of identified problems; The potential or available client support systems; Negative factors that might affect treatment; The client's preferred coping mechanisms; Conclusions regarding the client's appearance, behavior and reactions during the intake process; Conclusions regarding the client's attitude toward and ability to participate in the treatment process. Particular attention will be focused upon the synthesis of the collected historical information allowing each clinician to generate their own clinical perspective regarding the treatment needs of the assessed individual. The information will be gathered and recorded within the required time frame as identified by policy, which is by the end of the 3rd outpatient session, and by the end of the first week of partial services. The Facility Director and/or the Clinical Supervisor will convey the necessity of inclusion of this information during a staff meeting by 1/1/07. The reviews and supervision will begin immediately.
|
711.91(b)(7) LICENSURE Preliminary Treatment Plan
711.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(7) Preliminary treatment and rehabilitation plan.
|
Observations
Based on a review of the facility's policy manual and client records on November 1- 2, 2007 it was determined that the facility failed to document preliminary treatment plans in a timely fashion. A review of seven client records revealed that in four of those records, specifically #1, 3, 4 and 6, the preliminary treatment plan was completed late in accordance with the facility's policy. Client record #18 was missing the preliminary treatment plan.
|
Plan of Correction
The Facility Director and Clinical Supervisor will ensure through supervision and quality assurance chart review that the aspects of the preliminary treatment plan will be in compliance with licensing standards. The Preliminary Treatment Plan shall be based upon information derived from the initial interview, psychosocial and other evaluations. This plan should also identify critical client problems and strategies for their resolution. The information will be gathered and recorded within the required time frame as identified by policy, which is by the end of the 3rd outpatient session, and by the end of the first week of partial services. The Facility Director and/or the Clinical Supervisor will convey the necessity of inclusion of this information during a staff meeting by 1/1/07. The reviews and supervision will begin immediately.
|
711.92(c) LICENSURE Individual TX Plan
711.92. Treatment and rehabilitation services.
(c) An individual treatment and rehabilitation plan shall be developed with a client. This plan shall include, but not be limited to, written documentation of:
|
Observations
Based on a review of client records on November 1- 2, 2007 it was determined that the facility failed to document individual treatment plans. A review of seven client records revealed that in two of those records, specifically #3 and 18, the individual treatment plan was missing.
|
Plan of Correction
Compliance to developing individualized treatment plans in timely fashion will be evidenced by periodic quality reviews by the Facility Director combined with monitoring and sharing of feedback about particular cases reviewed in supervision with the Therapists. Training about the regulations and completion of treatment plans will occur as a group in treatment team meeting by the Facility Director. The Facility Director and/or the Clinical Supervisor will convey the necessity of inclusion of this information during a staff meeting by 1/1/07. The reviews and supervision will begin immediately.
|
711.92(c)(1) LICENSURE TX Plan Goals
711.92. Treatment and rehabilitation services.
(c) An individual treatment and rehabilitation plan shall be developed with a client. This plan shall include, but not be limited to, written documentation of:
(1) Short and long-term goals for treatment, as formulated by both staff and client.
|
Observations
Based on a review of client records on November 1- 2, 2007 it was determined that the facility failed to document short and long-term goals formulated by both staff and client in the individual treatment plans. A review of seven client records revealed that in two of those records, specifically #1 and 12, the short and long-term goals documented on the individual treatment plan were completed prior to the completion of the clients' histories and psychosocial evaluation.
|
Plan of Correction
Compliance to developing individualized treatment plans in timely fashion will be evidenced by periodic quality reviews by the Facility Director combined with monitoring and sharing of feedback about particular cases reviewed in supervision with the Therapists. Particular attention will be paid to the development of realistic and measurable short and long-term goals. Training about the regulations and completion of treatment plans will occur as a group in treatment team meeting by the Facility Director. The Facility Director and/or the Clinical Supervisor will convey the necessity of inclusion of this information during a staff meeting by 1/1/07. The reviews and supervision will begin immediately.
|
711.92(c)(3) LICENSURE Support Service
711.92. Treatment and rehabilitation services.
(c) 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.
|
Observations
Based on a review of client records on November 1- 2, 2007 it was determined that the facility failed to document support services in the individual treatment plans. A review of seven client records revealed that in two of those records, specifically #5 and 12, the proposed support services were missing from the individual treatment plan.
|
Plan of Correction
The Facility Director and Clinical Supervisor will ensure, through supervision and quality assurance chart review, that individual treatment plans include documentation of access to support services.The information will be gathered and recorded within the required time frame as identified by policy. The Facility Director and/or the Clinical Supervisor at a staff meeting will convey the necessity of inclusion of this information to staff by 1/1/07. The reviews and supervision will begin immediately.
|
711.92(d) LICENSURE Tx Plan Update
711.92. Treatment and rehabilitation services.
(d) Treatment and rehabilitation plans shall be reviewed and updated at least every 60 days.
|
Observations
Based on a review of the facility's policy manual and client records on November 1- 2, 2007 it was determined that the facility failed to document individual treatment plan updates in a timely manner. A review of nine client records revealed that in four of those records, specifically #4, 7, 12 and 16, the treatment plan update was completed more than 60 days after the previous treatment plan. In addition, three of nine client records, specifically #1, 2 and 5, were missing treatment plan updates.
|
Plan of Correction
Compliance to developing individualized treatment plan updates in timely fashion will be evidenced by periodic quality reviews by the Facility Director and Clinical Supervisor combined with monitoring and sharing of feedback about particular cases reviewed in supervision with the Therapists. Training about the regulations and completion of treatment plan updates will occur as a group in treatment team meeting by the Facility Director and Clinical Supervisor by 1/1/07. The reviews and supervision will begin immediately.
|
711.92(e) LICENSURE Provision of TX RE: TX Plan
711.92. Treatment and rehabilitation services.
(e) The project shall assure that counseling services are provided according to the individual treatment and rehabilitation plan.
|
Observations
Based on a review of client records on November 1- 2, 2007 it was determined that the facility failed to assure that counseling services were provided according to the individual treatment plan. A review of eleven client records demonstrated that in six of those records, specifically #2, 5, 6, 8, 16 and 18, the clients were not receiving counseling sessions in accordance with the individual treatment plan.
|
Plan of Correction
The Facility Director and Clinical Supervisors will ensure through supervision and quality assurance chart review, that counseling sessions are provided in accordance with the goals identified in the treatment plan. When sessions are not held, documentation will be provided indicating variance in the schedule of counseling agreed upon in the treatment plan. All patients within the first year of program participation will attend a minimum of 2.5 hours of group or individual programming monthly, while individuals in years two and three will attend a minimum of 1 hour monthly. The necessity of this documentation will be conveyed to staff by the Facility Director; and by the Clinical Supervisors at a staff meeting by 1/1/08. The reviews and supervision will begin immediately.
|
711.92(f) LICENSURE Couns. Prov.- Reg & Sched.
711.92. Treatment and rehabilitation services.
(f) Counseling shall be provided to a client on a regular and scheduled basis.
|
Observations
Based on a review of client records on November 1- 2, 2007 it was determined that the facility failed to provide regular and scheduled counseling services. A review of eleven client records revealed that in six of those records, specifically #2, 5, 6, 8, 16 and 18, the clients were not receiving counseling sessions on a regular and scheduled basis.
|
Plan of Correction
The Facility Director and Clinical Supervisor will ensure through supervision and quality assurance chart review, that counseling sessions are provided in accordance with the goals identified in the treatment plan. When sessions are not held, documentation will be provided indicating variance in the schedule of counseling agreed upon in the treatment plan. All patients within the first year of program participation will attend a minimum of 2.5 hours of group or individual programming monthly, while individuals in years two and three will attend a minimum of 1 hour monthly. The necessity of this documentation will be conveyed to staff by the Facility Director; and by the Clinical Supervisors at a staff meeting by 1/1/08. The reviews and supervision will begin immediately.
|
711.93(a)(4) LICENSURE Progress Notes
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:
(4) Progress notes.
|
Observations
Based on a review of the facility's policy manual and client records on November 1- 2, 2007 it was determined that the facility failed to provide progress notes in the format of data, assessment and plan. A review of six of eleven client records, specifically #2, 6, 8, 12, 16 and 18, revealed that the progress notes did not include data, assessment and plan in accordance with the facility's policy. In addition, the progress notes failed to include continuity and did not relate to the goals established in the individual treatment plan.
|
Plan of Correction
The Facility Director and Clinical Supervisor will ensure through supervision and quality assurance chart review, that progress notes of counseling and group sessions are counseling sessions are documented in the DAP format according to program policy. The necessity of this style of documentation will be conveyed to staff by the Facility Director and by the Clinical Supervisor at a staff meeting by 1/1/08. The reviews and supervision will begin immediately.
|
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.
|
Observations
Based on a review of the facility's policy manual and client records on November 1- 2, 2007 it was determined that the facility failed to complete aftercare plans. A review of eight client records revealed that in three of those records, specifically #11, 16 and 18, the aftercare plan was missing in accordance with the facility's policy that indicated aftercare plans would be developed upon the client's admission.
|
Plan of Correction
Compliance will be evidenced by reviews of all files pending discharge for thoroughly completed Aftercare Plans when applicable during individual supervision by the Facility Director and Clinical Supervisors. Reentry guidelines and contact procedures will be documented consistently when an Aftercare Plan is completed. Staff training about completion of Aftercare Plans will be provided by the Facility Director and Clinical Supervisors. Particular focus shall be placed upon ensuring that goals and timeframes are reasonable and measurable. This will be conveyed to staff by the Facility Director and by the Clinical Supervisors at a staff meeting by 1/1/08. The reviews and supervision will begin immediately.
|
711.93(a)(7) LICENSURE Follow-up Information
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:
(7) Follow-up information.
|
Observations
Based on a review of the facility's policy manual and client records on November 1- 2, 2007 it was determined that the facility failed to conduct follow up on clients discharged from treatment. A review of eight client records showed that in four client records, specifically #2, 9, 10 and 18, no follow up was conducted on discharged clients in accordance with the facility's own policy.
|
Plan of Correction
The Facility Director and Clinical Supervisor shall ensure that each clinician pursues the act of follow-up contacts on each patient who is discharged from services. Staff training about completion of Aftercare Plans will be provided by the Facility Director and Clinical Supervisor. This will be conveyed to staff by the Facility Director; and by the Clinical Supervisor at a staff meeting by 1/1/08. The reviews and supervision will begin immediately.
|
711.93(c)(1)(ii) LICENSURE Confidentiality-Staff Access to Records
711.93. Client records.
(c) Confidentiality.
(1) A written procedure shall be developed by the project director which complies with 4 Pa. Code 255.5 (relating to projects and coordinating bodies: disclosure of client-oriented information). The procedure shall include, but not be limited to:
(ii) Staff access to client records.
|
Observations
Based on a review of the project's written policies and procedures on October 30, 2007 it was determined that the facility failed to provide for a system that ensures security of drug and alcohol treatment records in accordance with state law and federal regulations. Refer to 71 P. S. and 42 CFR Part 2, Subpart C, subsection 2.32. A review of four client records, specifically #1, 2, 3 and 4, demonstrated that client records documented in the project's electronic record system, "PsychConsult", were accessible by all WPIC staff and not just those involved in the provision of substance abuse treatment services when client's presented for non drug and alcohol treatment services.
|
Plan of Correction
WPIC Addiction Medicine Services has met with the Division of Drug and Alcohol Program Licensure on 2/29/08 in regard to the WPIC electronic medical records system which is used in five of the WPIC AMS programs licensed by the Division. WPIC AMS continues to work through a process pursuant to the outcome of this meeting in collaboration the Division. |
711.93(c)(2) LICENSURE Consent to Release-Informed & Voluntary
711.93. Client records.
(c) Confidentiality.
(2) 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:
|
Observations
Based on a review of client records on October 30, 2007 it was determined that the project failed to obtain informed and voluntary consent from the client for the disclosure of information contained in the client record. A review of four client records, specifically #1, 2, 3 and 4, revealed that it was possible for WPIC staff, not just those involved in provision of substance abuse treatment services, to identify patients as participants in those services without the client's written consent.
|
Plan of Correction
The Clinical Administrator for WPIC Addiction Medicine Services shall develop the required policy for inclusion into the policy manual. The President and CEO of WPIC shall send a letter of formal invitation to the Director of DAPL to meet in person and discuss resolution of the issues related to the sharing of information among the various users of the electronic record keeping system, PsychConsult, within WPIC. The letter shall be sent by 12/15/07 with a meeting to occur no later than 1/17/07 or as soon as can be coordinated among the 2 principles and their respective designees.
|
711.94(a) LICENSURE Hours of Operation
711.94. Project management services.
(a) Outpatient projects shall make an effort to adjust the hours of project operations to meet client needs, taking into account other client time commitments such as employment and school schedules.
|
Observations
Based on a review of the facility's policy manual and physical plant on October 31, 2007 it was determined that the facility failed to establish consistent hours of project operations to meet the client needs. A review of the facility's policy manual indicated that the facility's days and hours of operation were Monday through Friday from 5:45 AM to 2:00 PM and Saturday from 7:00 AM to 10:00 AM. A review of the physical plant indicated that the facility's days and hours of operation posted on the exterior of the front door were Monday through Friday from 5:30 AM to 4:00 PM for clinical and 5:45 AM to 1:00 PM for medication and Saturday from 7:00 AM to 11:00 AM for clinical and 7:00 AM to 10:00 AM for medication.
|
Plan of Correction
The Facility Director and Clinical Supervisor shall ensure that the hours of operation are established and posted for the benefit of program participants. Additionally, attention shall be paid to the hours identified in the operations manual being consistent with those posted throughout the program site. The policy will be written by the Facility and Medical Directors, and the Clinical Supervisor and Nurse Coordinator and presented to staff at a meeting by 1/1/08.
|
711.96(a) LICENSURE Written Termination Notice
711.96. Notification of termination.
(a) The project director 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.
|
Observations
Based on a review of client records on November 1- 2, 2007 it was determined that the facility failed to notify the client, in writing, of a decision to involuntarily terminate the client's treatment. A review of two of two client records, specifically #10 and 18, revealed that the facility's notice, in writing, to involuntarily discharge the client from treatment was missing.
|
Plan of Correction
The Facility Director will ensure that individuals who are terminated involuntarily from the program are notified in writing of this decision. This notification will include the reasons for termination and the individual will be provided the opportunity to request a review of this decision. The documentation shall also be maintained in the patient record. All patients are informed of this right during the intake and orientation process. Any patient request for reconsideration should be in writing and also maintained in the patient record. The Facility Director and Clinical Supervisor shall review this process with all staff by 1/1/08.
|
711.96(b) LICENSURE Appeal of Termination
711.96. Notification of termination.
(b) The client shall have the opportunity to request reconsideration of a decision terminating treatment.
|
Observations
Based on a review of client records on November 1- 2, 2007 it was determined that the facility failed to allow the client the opportunity to request reconsideration of a decision to terminate treatment. A review of two of two client records, specifically #10 and 18, revealed that the document was missing indicating that the facility allowed the client the opportunity to request reconsideration of a decision to terminate treatment.
|
Plan of Correction
The Facility Director will ensure that individuals who are terminated involuntarily from the program are notified in writing of this decision. This notification will include the reasons for termination and the individual will be provided the opportunity to request a review of this decision. The documentation shall also be maintained in the patient record. All patients are informed of this right during the intake and orientation process. Any patient request for reconsideration should be in writing and also maintained in the patient record. The Facility Director and Clinical Supervisor shall review this process with all staff by 1/1/08.
|