INITIAL COMMENTS
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This report is a result of an on-site plan of correction follow up inspection conducted on June 20, 2007 by staff from the Division of Drug and Alcohol Program Licensure. The following deficiencies were identified during this inspection and a plan of correction is due on July 27, 2007.
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Plan of Correction
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715.6(d) LICENSURE Physician Staffing
(d) A narcotic treatment program shall provide narcotic treatment physician services at least 1 hour per week onsite for every ten patients
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Observations
The facility failed to provide for the required 20.9 hours of narcotic treatment physician services for the 209 patient census during the week of May 28, 2007. Time sheets available for review documented only 12.75 hours of narcotic treatment physician services during that week.
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Plan of Correction
Licensee acknowledges that it failed to provide the required 20.9 hours. A scheduled vacation during the week of May 28, 2007 was overlooked. Licensee could easily have rearranged its schedule to arrive at the 20.9 hours.
Due to vacation scheduling, Licensee also failed to rearrange its schedule during the week of June 16, 2007 resulting in insufficient Medical Doctor hours. The CRNP had in excess of 20.9 hours during the week of June16, 2007
Licensee shall compensate for the vacation scheduling to provide the required 20.9 hours in the future.
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715.9(c) LICENSURE Intake
(c) If a patient was previously discharged from treatment at another narcotic treatment program, the admitting narcotic treatment program, with patient consent, shall contact the previous facility for the treatment history.
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Observations
The facility failed to document any attempt to contact the previous narcotic treatment agency for the client represented by client record # 2.
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Plan of Correction
Licensee acknowledges that it failed to contact the referring facility of record #2. The Facility Director has now assumed the responsibility of transfers and will be contacting the referring facility and the receiving facility in transfer cases. |
715.11 LICENSURE Confidentiality of patient records
A narcotic treatment program shall physically secure and maintain the confidentiality of all patient records in accordance with 42 CFR 2.22 (relating to notice to patients of Federal confidentiality requirements) and § 709.28 (relating to confidentiality).
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Observations
The facility failed to comply with the requirements at 28 Pa. Code Subsection 709.28(c) by allowing clients to sign consent to release information forms where the sections identifying the intended recipient of the information, the specific information that was to be released and the purpose for the release of information were left blank in client records # 2, 3, 5 and 6.
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Plan of Correction
715.11.1 Licensee acknowledges that patients have signed consent forms in blank. The Facility Director has met with all staff concerning this issue. All staff have been instructed that under no circumstance shall a patient sign any form in blank. Staff will be reminded of this standing operating procedure periodically. |
715.23(b)(5) LICENSURE Patient records
(b) Each patient file shall include the following information:
(5) The results of all annual physical examinations given by the narcotic treatment program which includes an annual reevaluation by the narcotic treatment physician.
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Observations
The facility failed to ensure that the physical exam document in client record # 5 was dated, making it impossible to determine if the physical exam was completed within the timeframe written by the facility and approved by the Department.
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Plan of Correction
Licensee acknowledges that the physical exam document of record #5 was
Inadvertently not dated. The Facility Director has met with all staff reinforcing
the standing operating procedure that all documents are to be dated and signed.
Staff will be reminded of this standing operating procedure periodically.
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715.23(c)(1-7) LICENSURE Patient records
(c) An annual evaluation of each patient 's status shall be completed by the patient 's counselor and shall be reviewed, dated and signed by the medical director. The annual evaluation period shall start on the date of the patient 's admission to a narcotic treatment program and shall address the following areas:
(1) Employment, education and training.
(2) Legal standing.
(3) Substance abuse.
(4) Financial management abilities.
(5) Physical and emotional health.
(6) Fulfillment of treatment objectives.
(7) Family and community supports.
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Observations
The facility failed to document an annual evaluation of the patient's status in client record # 3. The facility medical director failed to sign the annual evaluations documented in client records #5 and 6.
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Plan of Correction
Licensee acknowledges its failure to document an annual evaluation of
record #3. In addition, it's failure to sign the annual evaluations of client records
#5 and 6. An annual inservice will be conducted by the IT department instructing
the staff how to use the software to identify patients that need an annual
evaluation. In addition the staff has been instructed that all documents must be
signed and dated. Staff will be reminded of this standing operating procedure
Periodically.
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