INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on March 31-April 1, 2016 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Deerfield Center for Addictions Treatment 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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709.28 (c) 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.
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Observations
Based on a review of the client records, the facility failed to obtain an informed and voluntary consent from the client prior to the disclosure of information in one of nine client records.
The findings include:
On March 31 - April 1, 2016, nine client records were reviewed for informed and voluntary consent to release information forms.
Client #3 was admitted to treatment on 7-10-2015, and discharged on 1-11-2016. A release of information was completed for an attorney, but failed to include an expiration date, a dated client signature, and a dated witness signature. A letter to the attorney dated 8-12-2015, included documentation it was given to the client for the attorney.
The findings were reviewed with the facility staff during the licensing process.
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Plan of Correction
During the staff meeting on 4/5/16 the clinical Supervisor remind staff that all sections of the Consent form need to be completed before information can be disseminated. In addition, if information is being given to the client for a third person, staff were instructed to obtain a consent from the client that received the information and a consent for the person intended to receive the information. A support staff person has also been instructed to review consent forms that are completed at the time of intake. The Clinical Supervisor will review 5 random charts over the next 2 months to ensure that consent forms are being completed accurately. |
709.28 (d) LICENSURE Confidentiality
§ 709.28. Confidentiality.
(d) A copy of a client consent shall be offered to the client and a copy maintained in the client record.
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Observations
Based on a review of the client records, the facility failed to offer the client a copy of the client consent in three of nine client records.
The findings include:
On March 31 - April 1, 2016, nine client records were reviewed for offering the client a copy of the consent, and three records, #3, #4, and #8, were missing.
Client #3 was admitted to treatment on 7-10-2015 and discharged on 1-11-2016. Release of information forms were completed, but failed to indicate a copy was accepted/declined by the client.
Client #4 was admitted to treatment on 9-8-2015 and discharged on 12-17-2015. Release of information forms were completed, but failed to indicate a copy was accepted/declined by the client.
Client #8 was admitted to treatment on 11-11-2015. Release of information forms were completed, but failed to indicate a copy was accepted/declined by the client.
The findings were reviewed with the facility staff during the licensing process.
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Plan of Correction
On 4/5/16 a staff meeting was held and the Clinical Supervisor instructed staff that client's needed to complete the section indicating whether the client accepted/declined a copy of the consent form. The Clinical Supervisor will review consent forms over the next month to ensure they are being completed accurately |
715.10(f) LICENSURE Pregnant patients
(f) The narcotic treatment program shall ensure that each female patient is fully informed of the possible risk to her or her unborn child from continued use of illicit drugs and from use of, or withdrawal from a narcotic drug administered or dispensed by the program in comprehensive maintenance or detoxification treatment.
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Observations
Based on a review of patient records, the facility failed to fully inform each female patient of the possible risk to her and her unborn child of continued use of illicit drugs and from the use of, or withdrawal from a narcotic drug administered or dispensed by the program for comprehensive maintenance or detoxification treatment in two of two patient records.
The findings include:
Nine patient records were reviewed on March 31 - April 1, 2016. Two patient records were applicable and were reviewed for documentation of informing female patients of possible risks. Patient #1 and #2 are female and did not include the above mentioned information pertaining to female patients.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Clinical Supervisor will add a statement to the client Consent to Treatment form that will address for female clients the possible risks that may occur to her and her unborn child if use of illicit drugs continued and from the use of, or withdrawal from a narcotic drug administered or dispensed by the program for comprehensive maintenance or detoxification treatment. This change to the Consent to Treatment form will be made by 4/15/2016. The Clinical Supervisor will review new buprenorphine client charts for the next two months to ensure that the Consent to treatment form is signed by the client. |
715.14(a) LICENSURE Urine testing
(a) A narcotic treatment program shall complete an initial drug-screening urinalysis for each prospective patient and a random urinalysis at least monthly thereafter.
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Observations
Based on a review of patient records, the facility failed to complete a random drug screening urinalysis at least monthly in two of two patient records. A complete drug screen includes receiving the results from the CLIA and Department of Health approved laboratory.
The findings include:
Nine patient records were reviewed on March 31 - April 1, 2016. Two patient records were applicable and were reviewed for random urinalysis at least monthly.
Patient #1 was admitted to treatment on 11-17-2015 and was discharged on 2-29-2016. Documentation of a drug screening urinalysis was missing for December 2015 and January 2016.
Patient #2 was admitted to treatment on 6-9-2015. Documentation of a drug screening urinalysis was missing for June 2015 through March 2016.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Clinical Supervisor and Program Director will work to develop a policy that addresses random urine drug screens to be completed monthly on all clients' who are participating in a buprenorphine maintenance program. A policy will be created and implemented by 4/30/2016. The Clinical Supervisor will monitor buprenorphine client charts on an ongoing basis to ensure clients are being tested monthly. |
715.15(b) LICENSURE Medication dosage
(b) The narcotic treatment physician shall determine the proper dosage level for a patient, except as otherwise provided in this section. If the narcotic treatment physician determining the initial dose is not the narcotic treatment physician who conducted the patient examination, the narcotic treatment physician shall consult with the narcotic treatment physician who performed the examination before determining the patient 's initial dose and schedule.
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Observations
Based on a review of patient records, the facility physician failed to adhere to the dosing protocol listed on the medication by ordering that single dose Suboxone be halved/quartered in two of two patient records. The medication packaging identifies this as a single dose medication.
The findings include:
Nine patient records were reviewed on March 31 - April 1, 2016. Two patient records were applicable and reviewed for the use of buprenorphine.
Patient #1 was admitted to treatment on 11-17-2015 and was discharged on 2-29-2016. Prescriptions dated for 11-17-2015, 12-29-2015, and 1-14-2016 documented directions as "1/2 SL TID". Prescriptions dated for 11-30-2015, and 12-15-2015 documented directions as "1/4 SL TID". Prescription dated 1-19-2016 documented directions as "1/2 SL TID x7, and 1/4 SL TID x7".
Patient #2 was admitted to treatment on 6-9-2015. Prescriptions dated for 12-1-2015, and 12-29-2015 documented directions as "1/2 SL Q 7p". Prescriptions dated for
2-2-2016, and 3-2-2016 documented directions as "1 SL Qam and 1/2 SL qhs".
Suboxone is not formulated to be cut into smaller doses. Prescriptions need to be for the manufactured quantities of 12 mg/3 mg, 8 mg/2 mg, 4 mg/1 mg or 2 mg/.5 mg doses.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Clinical Supervisor met with the program physician to report that patients could not be instructed to split a buprenorphine dose and that all doses need to be taken whole. This issue was addressed on 4/5/2016 during the staff meeting. The clinical supervisor will review all new prescriptions over the next month to ensure that the scheduled dosage does not instruct clients' to split the dose. |
715.19(1) LICENSURE Psychotherapy services
A narcotic treatment program shall provide individualized psychotherapy services and shall meet the following requirements:
(1) A narcotic treatment program shall provide each patient an average of 2.5 hours of psychotherapy per month during the patient 's first 2 years, 1 hour of which shall be individual psychotherapy. Additional psychotherapy shall be provided as dictated by ongoing assessment of the patient.
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Observations
Based on a review of patient records, the facility failed to provide each patient an average of 2.5 hours of psychotherapy per month during the patient's first 2 years of treatment in two of two patient records.
The findings include:
Nine patient records were reviewed on March 31 - April 1, 2016. Two patient records were applicable and were reviewed for psychotherapy hours during the first year of treatment.
Patient #1 was admitted to treatment on 11-17-2015 and was discharged on 2-29-2016. An average of 2.5 hours of psychotherapy per month was required, but was not documented for December 2015 and January 2016.
Patient #2 was admitted to treatment on 6-9-2015. An average of 2.5 hours of psychotherapy per month was required, but was not documented for December 2015, January 2016, February 2016 and March 2016.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Clinical Supervisor will begin seeing clients' receiving buprenorphine a minimum of 2 times a month individually and in a group once a month to ensure they receive 2.5 hours of psychotherapy per month during their first 2 years of treatment. This process will be initiated by the Clinical Supervisor by 4/30/2016. The clinical Supervisor will review buprenorphine client charts over the next three months to ensure clients are being seen for 2.5 hours of psychotherapy a month. |
709.94(g) LICENSURE Project management services
709.94. Project management services.
(g) Outpatient projects which receive reimbursement under the medical assistance program shall have a current, signed provider agreement with the Department of Public Welfare and comply with 55 Pa. Code Part III (relating to Medical Assistance Manual).
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Observations
Based on a review of the client records, the facility failed to provide a physician signature on treatment plans and treatment plan updates in three of three client records.
The findings include:
Nine client records were reviewed on March 31 - April 1, 2016. Three of the nine client records were required to have a physician signature on the treatment plans and treatment plan updates. This documentation was missing in records #2, #4, and #7.
These findings were reviewed with the facility staff during the licensing process.
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Plan of Correction
The Clinical Supervisor, during the staff meeting on 4/5/16, informed the staff and the program physician that MA funded clients need to have their treatment plans and treatment plan update forms reviewed and signed by the program physician. The Clinical Supervisor will identify clients that are funded through MA and work with the program physician to see that treatment plans and treatment plan updates are signed. The clinical Supervisor will review 6 MA client charts monthly for the next 3 months to ensure that client Treatment Plans and Treatment Plan Updates are being signed by the program physician. |