This report is a result of 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 December 1-2, 2010 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Progressive Medical Specialists, Inc 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 and a plan of correction is due on December 23, 2010.
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Plan of Correction
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Observations
Based on the review of patient records, the facility failed to restrict the reasons for involuntary termination to those reasons allowed by regulation in one of two patient records.
The findings include:
Nineteen patient records were reviewed December 1-2, 2010. Two patient records were reviewed for involuntary, or therapeutic, discharge. Patient record #8 contained documentation of the patient being discharged for reasons other than those listed by regulation.
Patient # 8 was admitted on November 17, 2008 and involuntarily discharged on August 9, 2010. The reason documented for the involuntary discharge was illicit drug use.
An interview with the project/facility director on December 2, 2010 confirmed the involuntary discharge reason was documented as illicit drug use.
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Plan of Correction
As discussed, we believe we discharged these two clients for the correct reason as per regulation but our paperwork and terminology did not reflect this and needed to be updated to ensure compliance with state regulations.
All paperwork used in the disciplinary process has been updated, by the project director, to ensure that the reason for a client involuntary discharge is in compliance with regulations.
Terminology within the computer program used at the facility has been updated, by the project director, to ensure that the discharge reasons are in compliance with regulation regarding involuntary termination from the program.
The state regulations regarding involuntary termination from treatment were reviewed with all staff by the project director to ensure understanding of reasons for client termination.
The use of updated disciplinary paperwork was completed during training with staff on December 8, 2010, with special attention given to addressing the patient treatment plan and problem lists.
Clinical Supervisor and Project director will monitor the disciplinary process used by each clinical staff person to ensure compliance with regulations regarding involuntary termination from treatment by reviewing and signing all paperwork used as well as through chart audits.
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