INITIAL COMMENTS
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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 April 18 through 19, 2011 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, PA Associates, LLC D/B/A Mount Pocono Medical 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 May 18, 2011.
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Plan of Correction
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715.13(b) LICENSURE Patient identification
(b) A narcotic treatment program shall maintain onsite a photograph of each patient which includes the patient 's name and birth date. The narcotic treatment program shall update the photograph every 3 years.
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Observations
Based on the review of patient information, review of administrative documentation and discussion with the facility director and administrative staff, the facility failed to demonstrate the patient's photograph was updated every three years.
The findings include:
Per regulation, a narcotic treatment program shall maintain onsite a photograph of each patient which includes the patient's name and birth date. The narcotic treatment program shall update the photograph every three years.
Facility policy states "at admission Pinnacle Treatment Centers, Inc. provides each patient with a clear unalterable photo identification which includes the patient's name, addresses and telephone number. All identification cards contain both an issuance and expiration date. ID cards must be presented daily to the medical staff for identity verification prior to the administration of any medications.
The medication dispensing room was observed April 19, 2011 at approximately 9:30 AM. Patients presented their identification cards to the nursing staff for identification. A review of the photo identification determined that the identification card contained the issuance date but did not contain the expiration date in accordance with facility policy.
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Plan of Correction
The facility failed to demonstrate the patient's photograph was updated every three years by not including an expiration date on the required identification card.
It is the responsibility of the facility to include an expiration date on the facility issued id card.
The Facility Director will contact TOWER in order to add an expiration date to all identification cards made by that system. In addition, the Facility Director will coordinate efforts to complete new identification cards for all active patients. Finally, the Facility Director will monitor compliance related to new patients, assuring that all new admissions are receiving the appropriately documented identification cards.
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715.23(b)(13) LICENSURE Patient records
(b) Each patient file shall include the following information:
(13) Patient record of services.
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Observations
Based on the review of patient records, the facility failed to document a patient record of services in seven of seven patient records reviewed .
The findings include:
Thirteen patient records were reviewed April 18 through 19, 2011. Seven patient records were reviewed for documented record of services. Patient records # 1, 2, 4, 6, 7, 8, and 13. did not contain documentation of a record of services to include various specific services provided to the individual patient.
The patient record contained a form titled Encounter Form. This form does not include the various specific services provided to the patient.
This was discussed with the facility director and administrative staff at the time of the exit interview and it was confirmed that the form does not include specific services provided.
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Plan of Correction
The facility failed to provide or document a "patient record of services" in the patient file.
It is the responsibility of the facility to include a completed record of service in each patient file.
The Facility Director will provide training in this area for all staff. The Facility Director will be responsible to provide ongoing oversite regarding the record of service through regular record review and additional supervision/training as necessary. |
715.23(d)(1) LICENSURE Patient records
(d) A narcotic treatment program shall prepare a treatment plan that outlines realistic short and long-term treatment goals which are mutually acceptable to the patient and the narcotic treatment program.
(1) The treatment plan shall identify the behavioral tasks a patient shall perform to complete each short-term goal.
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Observations
Based on a review of patient records, and a discussion with the facility director, the facility failed to provide written documentation of the proposed type of support service, in the individual treatment and rehabilitation plans, in three patient records.
The findings include:
Thirteen client records were reviewed on April 18 and 19, 2011. The individual treatment and rehabilitation plans were required to document proposed type of support services in three patient records. The facility did not document proposed type of support services in patient records # 7, 10, and 12.
Patient # 7 was admitted on February 17, 2011. The individual treatment and rehabilitation plan was completed on March 18, 2011. There was no documentation of support services in the treatment plan.
Patient # 10 was admitted on March 3, 2011. The individual treatment and rehabilitation plan was completed on April 7, 2011. There was no documentation of support services in the treatment plan.
Patient # 12 was admitted on February 9, 2011. The individual treatment and rehabilitation plan was completed on March 15, 2011. There was no documentation of support services in the treatment plan.
In a discussion with the facility director and administrative staff at the exit interview, it was confirmed that supportive services were not being documented on the comprehensive treatment plans. Although the documentation is on the initial treatment plans, supportive services are not included in the comprehensive treatment plans.
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Plan of Correction
The facility failed to provide for referrals to supportive services in the comprehensive treatment plan.
It is the responsibility of the facility to include recommendations for supportive services in the plan.
The Facility Director will provide training for all counseling staff related to referrals and documentation of referral to supportive services in the comprehensive plan.
The Facility Director will monitor ongoing compliance through regular record review and additional supervision/training as indicated. |