INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on December 13 - 14, 2016 by staff from the Department of Drug and Alcohol Programs, Bureau of Quality Assurance for Prevention and Treatment, Program Licensure Division. Based on the findings of the on-site inspection, Jefferson Outreach Drug and Alcohol Program 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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715.14(a) LICENSURE Urine testing
(a) A narcotic treatment program shall complete an initial drug-screening urinalysis for each prospective patient and a random urinalysis at least monthly thereafter.
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Observations
Based upon a review of client records and an interview with the facility director, the facility failed to ensure that random urinalysis tests were completed and documented in two of two client records reviewed, specifically client records #3 & 4.
Client record #4 was missing documentation of random monthly urinalysis tests for the months of May, July, August, September and November of 2016.
Client records #3 & 4 contained documentation for lab results of urinalysis tests; however, there was no documentation of consent to release information forms for the lab in the client records, nor was there a copy of a Qualified Service Organization Agreement on file for the lab noted in the client records.
Following a discussion with the facility director, it was learned that the facility had been writing scripts for the clients to go to a lab for the urinalysis on their own.
The facility could not provide verification that the urinalysis was conclusively that of the client, that the urinalysis was not tampered with, and the facility director indicated that the clients sometimes would not bring back the results. In addition to the stated problems above, this hampers the facility's ability to ensure that there is no diversion of the Buprenorphine.
This was discussed with facility staff at the time of the inspection.
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Plan of Correction
Jefferson Outreach will sign a QSOA with Atlantic Diagnostic Laboratories and patients will submit urine drug screens once per month at the time of their appointment with the Medical Director. Randomly, urine drug screens will be observed by a medical student who is working with the Medical Director to ensure that the urine drug screens are unadulterated. A written policy and procedure will be added to the policies and procedures manual by March 23, 2017. Moving forward, all clients will receive random urine drug screens at our facility and specimens will be sent to Atlantic Diagnostic Laboratories to be analyzed per our QSOA. The QSOA will be signed and secured by March 23, 2017. Clients #3 and #4 will have urine drug screens completed no later than March 31, 2017. The Facility Director will be responsible for reviewing charts monthly and will review all charts for compliance by May 31, 2017. |
711.92(d) LICENSURE Tx Plan Update
711.92. Treatment and rehabilitation services.
(d) Treatment and rehabilitation plans shall be reviewed and updated at least every 60 days.
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Observations
Based on a review of client records, the facility failed to ensure that treatment plan updated were completed at least every 60 days in 3 of 7 records reviewed.
Seven client records were reviewed on December 13 & 14, 2016, six of which required treatment plan updates. The facilty failed to document treatment plan updates in client records # 2, 3 & 7.
Client #2 was admitted to treatment on 3/29/16 and was an active client at the time of the inspection. The comprehensive individualized treatment plan was completed on 4/18/16. Treatment plan updates were completed on 6/17/16 and 8/29/16. There were no treatment plan updates in the client record following the update completed on 8/29/16.
Client #3 was admitted to treatment on 12/7/15 and was an active client at the time of the inspection. Treatment plan updates were completed on 1/4/16, 3/1/16, 5/16/16, 6/21/16, 8/1/16, 9/26/16 7 12/6/16.
The treatment plan updates that were due for May and December were late. The May treatment plan update due on 5/1/16 was completed 15 days late on 5/16/16. The November treatment plan update due on 11/26/16 was completed 11 days late on 12/6/16.
Client #7 was admitted to treatment on 2/22/16 and was an active client at the time of the inspection. The comprehensive individualized treatment plan was completed on 7/28/16. A treatment plan update was completed on 9/29/16. A treatment plan update was due on 11/29/16. There was no documentation of treatment plan updates in the client record following the update completed on 9/29/16.
The findings were reviewed with the facility staff at the time of the inspection.
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Plan of Correction
Patient #2 has been discharged from treatment and patients #3, and #7 have had treatment plan updates since the exit date. In an effort to avoid this problem in the future, the facility director and counselor will meet before 3/17/17 to establish the following plan:
1) All treatment plans are to be initiated two weeks before the 60 day expiration date and completed one week before the 60 day expiration date.
2)The Facility Director will review a random sample of the census in 60 days to ensure compliance.
3) The Facility Director will ascertain during that review that treatment plan updates for all clients are on time.
4)This review process will continue indefinitely. |
711.93(c)(1)(i) LICENSURE Confidentiality - Client Identity/Records
711.93. Client records.
(c) Confidentiality.
(1) A written procedure shall be developed by the project director which complies with 4 Pa. Code 255.5 (relating to projects and coordinating bodies: disclosure of client-oriented information). The procedure shall include, but not be limited to:
(i) Confidentiality of client identity and records.
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Observations
Based on a review of client records the facility failed to document an informed and voluntary consent to release information in two of six records reviewed.
Client record #4 contained two consent to release information forms dated 10/16/15 that failed to identify a time frame for for which the consents were in effect. The first consent form, to a government agency, stated "This authorization is effective for the period from _______ until ______ ". No dates were provided, the lines were left blank. Additionally, the form indicated that revocation had to be written.
The second consent form, to a funding source, stated "This authorization is effective for the period from _______ until 30 days after my discharge." No start date was provided, the line was left blank.
Client record #6 contained two consent to release information forms that failed to identify a time frame for for which the consents were in effect. The first consent form, to a government agency, stated "This authorization is effective for the period from _______ until ______ ". No dates were provided, the lines were left blank. Additionally, the form indicated that revocation had to be written.
The second consent form, to a funding source, stated "This authorization is effective for the period from _______ until 30 days after my discharge." No start date was provided, the line was left blank.
The findings were reviewed with the facility staff at the time of the inspection.
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Plan of Correction
New consent forms with all required information, including start and end dates of the consent period, have been completed by patients #4 and #6 and the old consents have been voided. A review of all consent to release information forms will be conducted and any that are not in compliance will be voided and new consents will be obtained. Clinical and support staff will be trained on correctly completing the new, correct consent to release information forms by 3/24/2017. The Facility Director will be responsible for reviewing all consent to release information forms for two months and random reviews thereafter to ensure compliance. |