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 27, 2019 through August 29, 2019 by staff from the Department of Drug and Alcohol Programs, Bureau of Quality Assurance for Prevention and Treatment. Based on the findings of the on-site inspection, Addiction Medicine and Health Advocate Inc. 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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705.28 (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.
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Observations
A review of the fire drill logs was conducted during the onsite inspection. The facility failed to document in the log whether the smoke detectors were operative in 12 of 12 fire drills reviewed.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The fire drill documentation form will be revised to include a question related to whether the smoke detectors were operable during a fire drill. The Program Director will make the edit to the form. The Health and Safety Committee Chairperson will monitor completion of the forms monthly to make sure all areas of the form, including the new question, are completed. |
709.28 (b) LICENSURE Confidentiality
§ 709.28. Confidentiality.
(b) The project shall secure hard copy client records within locked storage containers. Electronic records must be stored on secure, password protected data bases.
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Observations
Based on a physical plant inspection conducted on August 30, 2019, it was determined that the facility failed to secure hard copies of client records within locked storage containers as two client records were found to be unsecured inside a staff member's office. The office was unattended, and the door was unlocked. The two unsecured client records were found sitting on top of a filing cabinet.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
An interoffice e-mail has already been sent to all staff regarding appropriate storage of patient records. Additionally, a staff meeting is being held on 9/26/19 to review the findings of the inspection. We will again review regulations related to appropriate storage of patient records. If needed, we will order additional file cabinets for counselors' offices. The Clinical Program Manager will be responsible for conducting the staff meeting and for monitoring appropriate storage of patient records on an ongoing basis. |
709.32 (c) (3) (i) - (v) LICENSURE Medication control
§ 709.32. Medication control.
(3) Inspection of storage areas that ensures compliance with State and Federal laws and program policy. The policy must include, but not be limited to:
(i) What is to be verified through the inspection, who inspects, how often, but not less than quarterly, and in what manner it is to be recorded.
(ii) Disinfectants and drugs for external use are stored separately from oral and injectable drugs.
(iii) Drugs requiring special conditions for storage to insure stability are properly stored.
(iv) Outdated drugs are removed.
(v) Copies of drug-related regulations are available in appropriate areas.
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Observations
During the review of the facility's policy and procedure manual, it was determined that the facility's written policies failed to address making copies of drug-related regulations available in appropriate areas.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
This particular policy (#1006) has already been revised to include the language that was noted as missing during the inspection. Copies of drug-related regulations are available in the medication dispensing room. The updated version has been shared with staff. The Program Director was responsible for revising the policy and sharing with staff. |
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 client records, the facility failed to provide patient number one with 2.5 hours of psychotherapy per month during the patient's first 2 years of treatment.
Patient # 1 was admitted on June 29, 2018 and was a current patient at the time of the inspection. In February 2019, the patient had 1.5 hours of psychotherapy. In March 2019, the patient had 2 hours of psychotherapy. In April 2019, the patient had 1.5 hours of psychotherapy. In May 2019, the patient had 1.5 hours of psychotherapy and in June 2019, the patient had 1 hour of psychotherapy. There is no contact documented with the patient between November 13, 2018 and December 18, 2018.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
During a staff meeting to be conducted on 9/26/19 in which the findings from this inspection will be reviewed, we will review and discuss regulations related to minimum psychotherapy contact hours. The Clinical Program Manager will conduct this staff meeting. During individual supervision sessions, clinical supervisors will monitor therapy attendance and discuss strategies for engaging patients who may be at risk of not meeting minimum contact hours. Additionally, minimum contact hours will be monitored by clinical supervisors through submitted billing and monthly chart reviews conducted as part of the Quality Assurance program. |