INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on August 3, 2023 by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, Addiction and Behavioral Counseling Associates, LLC dba Matrix Treatment Center 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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709.32 (b) LICENSURE Medication control
§ 709.32. Medication control.
(b) Verbal orders for medication can be given only by a physician or other medical professional authorized by State and Federal law to prescribe medication and verbal orders may be received only by another physician or medical professional authorized by State and Federal law to receive verbal orders. When a verbal or telephone order is given, it has to be authenticated in writing by a physician or other medical professional authorized by State and Federal law to prescribe medication. In detoxification levels of care, written authentication shall occur no later than 24 hours from the time the order was given. Otherwise, written authentication shall occur within 3 business days from the time the order was given.
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Observations
Based on a review of client records, the facility failed to document a physician signature for verbal medication orders within the required timeframes in seven of seven client records.
Client #1 was admitted on June 20, 2023 and is currently an active client. Client #1 was in the detox and rehabilitation levels of care. None of the verbal medication orders documented in client record #1 were signed by a physician.
Client #2 was admitted on June 20, 2023 and is currently an active client. Client #2 was in the rehabilitation level of care. None of the verbal medication orders documented in client record #2 were sign by a physician.
Client #3 was admitted on July 7, 2023 and is currently an active client. Client #3 was in the rehabilitation level of care. None of the verbal medication orders documented in client record #3 were sign by a physician.
Client #4 was admitted on February 10, 2023 and discharged on April 10, 2023. Client #4 was in the detox and rehabilitation levels of care. None of the verbal medication orders documented in client record #4 were signed by a physician.
Client #5 was admitted on January 12, 2023 and discharged on February 1, 2023. Client #5 was in the detox and rehabilitation levels of care. None of the verbal medication orders documented in client record #5 were signed by a physician.
Client #6 was admitted on February 9, 2023 and discharged on February 25, 2023. Client #6 was in the detox and rehabilitation levels of care. None of the verbal medication orders documented in client record #6 were signed by a physician.
Client #7 was admitted on February 28, 2023 and discharged on March 30, 2023. Client #7 was in the detox and rehabilitation levels of care. None of the verbal medication orders documented in client record #7 were signed by a physician.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Immediately and moving forward Facility Director will ensure all verbal orders will be authenticated in writing by a physician or other medical professional authorized by the State and Federal law to prescribe medication. In detoxification levels of care written authentications will occur within less than 24 hours from the time the order was given. For inpatient level of care authentication will occur within 3 business days from the time the order was given. This will be monitored by routine chart audits . |
709.53(a)(12) LICENSURE Work as treatment
709.53. Client records.
(a) There shall be a complete client record on an individual which includes information relative to the client's involvement with the project. This shall include, but not be limited to, the following:
(12) Verification that work done by the client at the project is an integral part of his treatment and rehabilitation plan.
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Observations
Based on a review of client records, the facility failed to include work therapy tasks as part of the client's treatment and rehabilitation plan in seven of seven client records.
All rehabilitation clients are assigned tasks as part of the treatment process. These work therapy tasks were not included on the treatment and rehabilitation plans in client records #1, 2, 3, 4, 5, 6 and 7.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Immediately and moving forward assigned client tasks will be implemented into the treatment plan as work therapy. This will be monitored by routine chart audits. Facility Director will conduct chart audits on a routine basis. |