INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection and buprenorphine monitoring conducted on December 2, 2014 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Nuestra Clinica of SACA 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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709.33(a) LICENSURE Notification of Termination
709.33. Notification of termination.
(a) Project staff shall notify the client, in writing, of a decision to involuntarily terminate the client's treatment at the project. The notice shall include the reason for termination.
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Observations
Based on a review of client records, the facility failed to notify the client, in writing, of a decision to involuntarily terminate the client's treatment at the project in two of two client records.
The findings include:
Two client records requiring written notification to the client of facility's decision to involuntarily terminate the client's treatment were reviewed on 12/2/2014. The facility failed to notify the client, in writing, of a decision to involuntarily terminate the client's treatment at the facility in client records # 4 and 5.
Client # 4 was admitted into treatment on 6/18/2014 and was involuntarily terminated from the facility on 9/5/2014. There was no documentation of written notification of the facility's decision to involuntarily terminate the client's treatment as of the date of the on-site inspection.
Client # 5 was admitted into treatment on 7/17/2014 and was involuntarily terminated from the facility on 9/5/2014. There was no documentation of written notification of the facility's decision to involuntarily terminate the client's treatment as of the date of the on-site inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The program director changed the policy to include 2 written notices to be mailed priorto involuntary terminations. First notice will allow 10 days for client to contact facility and 2nd notice will explain the termination. Copies of each will be placed in the file by the counselor when mailed. The clinical supervisor will audit charts weekly for 6 months then biweekly going forward to ensure compliance. The two clients refered to in the citation were notified as part of the immediate plan of correction on Tuesday, December 16, 2014 via mail. |
715.6(a)(1)(i)-(iii) LICENSURE Physician staffing
(a) A narcotic treatment program shall designate a medical director to assume responsibility for administering all medical services performed by the narcotic treatment program
(1) A medical director shall be a physician and shall have obtained one of the following:
(i) Three years documented experience in the provision of services to persons who are addicted to alcohol or other drugs, including at least 1 year of experience in the treatment of narcotic addiction with a narcotic drug.
(ii) Certification in addiction medicine by the American Society of Addiction Medicine.
(iii) A certificate of added qualifications in addiction psychiatry by the American Board of Psychiatry and Neurology, Inc.
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Observations
Based on a review of the medical director's personnel record, the facility failed to verify that the medical director met the experiential qualifications for the position.
The findings include:
Medical director #1's personnel record was reviewed during the renewal inspection on 12/2/2014 for the purpose of measuring compliance with the facility's wavier dated 9/22/2014 that authorizes the use of the narcotic agent Buprenorphine for the purpose of outpatient maintenance.
Medical director #1 does not meet any of the experiential qualifications specified in for the position of medical director.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The program will NOT make use of the waiver to offer buprenorphine until the doctor meets licensing requirments. The program director will them submit the certifiaction ifnormation to licensing for approval. This will take place within the next 6 months. |
715.28(a)(1-10) LICENSURE Unusual incidents
(a) A narcotic treatment program shall develop and implement policies and procedures to respond to the following unusual incidents:
(1) Physical assault by a patient.
(2) Inappropriate behavior by a patient causing disruption to the narcotic treatment program.
(3) Selling of drugs on the premises.
(4) Complaints of patient abuse (physical, verbal, sexual and emotional).
(5) Death or serious injury due to trauma, suicide, medication error or unusual circumstances.
(6) Significant disruption of services due to disaster such as fire, storm, flood or other occurrence.
(7) Incident with potential for negative community reaction or which the facility director believes may lead to community concern.
(8) Theft, burglary, break-in or similar incident at the facility.
(9) Drug related hospitalization of a patient.
(10) Other unusual incidents the narcotic treatment program believes should be documented.
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Observations
Based on the review of administrative documentation, the facility failed to provide a complete policy and procedure addressing unusual incidents.
The findings include:
Administrative documentation regarding the facility's policies and procedures was reviewed on 12/2/2014. The policy addressing unusual incidents failed to address procedures for responding to all of the unusual incidents specified in findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The program director reviewed the new regulAtion and updated the unusual incident reporting policy to match the new licensing requirment. Policy book updated 12/3/14. The program director will be responsible for monthly reviews and updates to policy if alerts have been sent out. |
709.93(a)(9) LICENSURE Client records
709.93. 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:
(9) Aftercare plan, if applicable.
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Observations
Based on the review of client records, the facility failed to ensure that a complete record was documented in five of ten client records reviewed.
The findings include:
Ten client records were reviewed for documentation of a complete client record during the renewal inspection on 12/2/2014. The facility failed to document a complete record of service in client records # 6, 7, 8, 9, and 10.
Client # 6 was admitted on 7/21/2014 and discharged on 9/22/2014 for successfully completing treatment. An aftercare plan was not documented in the client's record.
Client # 7 was admitted on 1/27/2014 and discharged on 9/23/2014 for successfully completing treatment. An aftercare plan was not documented in the client's record.
Client # 8 was admitted on 7/3/2014 and discharged on 9/23/2014 for successfully completing treatment. An aftercare plan was not documented in the client's record.
Client # 9 was admitted on 7/14/2014 and discharged on 9/15/2014 for successfully completing treatment. An aftercare plan was not documented in the client's record.
Client # 10 was admitted on 7/22/2014 and discharged on 9/23/2014 for successfully completing treatment. An aftercare plan was not documented in the client's record.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The program director met with staff and clincial supervisor to discuss defieciency. The clinical supervisor will audit charts weekly for the next 6 months and then bi-weely to ensure comlplaince. The primary counselor and the cleint will develop the aftercare plan together. The afterfcare plan for clients successfully completing treatment will be fully developed by the completion of the treatment episode, but will begin at the admission of treatment. |
709.94(b) LICENSURE Project management services
709.94. Project management services.
(b) The hours of project operation shall be displayed conspicuously to the general public.
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Observations
Based on a physical plant inspection, the facility failed to display the hours of project operation that can be accessed by the general public.
The findings include:
A physical plant inspection was conducted on 12/2/2014. The facility did not display a complete listing of the facility's hours of operation.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The lobby was being painted and the sign was removed. The program director re-hung the sign displaying the hours of operation and will check daily to ensure the sign remains in tact. |
709.94(c) LICENSURE Project management services
709.94. Project management services.
(c) A telephone number shall be displayed conspicuously to the general public for emergency purposes.
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Observations
Based on a physical plant inspection, the facility failed to display a telephone number that can be accessed by the general public in case of an emergency.
The findings include:
A physical plant inspection was conducted on 12/2/2014. A telephone number that is conspicuously displayed to the general public is required at all outpatient treatment programs. The facility did not display an emergency telephone number.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The lobby was being painted and the sign was removed. The program director re-hung the sign displaying the telephone number and will check daily to ensure the sign remains in tact. |