INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on March 9-11, 2020 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, Greene Treatment Center 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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715.16(c)(3)(i-viii) LICENSURE Take-home privileges
(c) A narcotic treatment program shall require a patient to come to the narcotic treatment program for observation daily or at least 6 days a week for comprehensive maintenance treatment, unless a patient is permitted to receive take-home medication as follows:
(3) A narcotic treatment program may permit a patient to reduce attendance at the narcotic treatment program for observation to one time weekly and receive no more than a 6-day take-home supply of medication when in the reasonable clinical judgment of the narcotic treatment physician, which is documented in the patient record:
(i) A patient demonstrates satisfactory adherence to narcotic treatment program rules for at least 3 years.
(ii) A patient demonstrates substantial progress in rehabilitation.
(iii) A patient demonstrates responsibility in handling narcotic drugs.
(iv) A patient demonstrates that rehabilitation progress would improve by decreasing the frequency of attendance for observation.
(v) A patient demonstrates no major behavioral problems.
(vi) A patient is employed, is actively seeking employment, attends school, is a homemaker or is considered unemployable for mental or physical reasons.
(vii) A patient is not known to have abused alcohol or other drugs within the previous year.
(viii) A patient is not known to have engaged in any criminal activity within the previous year.
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Observations
The facility failed to follow their policy relating to the reinstatement of 6-day take-home privileges.
Patient records were reviewed March 9-11, 2020. Patient #7 was admitted as a transfer patient on February 23, 2017 and is a current patient. Patient #7 had a 6-day take home privileges as of February 23, 2017 up until July 18, 2019. Patient #7 had positive urine screens for the months of June, July, August, September, October and November 2019.
The facility policy states that 45 days after the revocation privilege status will be assessed for reinstatement. Patient #7 continued to have positive urine screens for 4 months after revocation. After the patient provided 3 negative urine screens, patient #7 was reinstated to 6-day take-home status, even though the policy states that he would start over with privilege status.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Take home policy will be revised by the medical director and facility director by 4/30/20 and then shared with staff. As suspended privileged patients meet the criteria for reinstatment, they will be presented at our weekly treatment team for approval. Facility director and medical director will sign off on approval during treatment team. Facility director will maintain a record of the treatment team sheets. |
715.20(1) LICENSURE Patient transfers
A narcotic treatment program shall develop written transfer policies and procedures which shall require that the narcotic treatment program transfer a patient to another narcotic treatment program for continued maintenance, detoxification or another treatment activity within 7 days of the request of the patient.
(1) The transferring narcotic treatment program shall transfer patient files which include admission date, medical and psychosocial summaries, dosage level, urinalysis reports or summary, exception requests, and current status of the patient, and shall contain the written consent of the patient.
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Observations
The facility failed to transfer patient files which include admission date, medical and psychosocial summaries, doseage level, urinalysis report or summary, exception request and current status of the patient.
Patient records were reviewed on March 9-11, 2020. Patient #8 was admitted on September 9, 2019 transferred on 2/25/20. There was no documentation that information was transferred to the receiving clinic.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Counselors will be trained on GTC patient transfer policy and appropriate record keeping protocol by 4/9/2020 by clinical supervisor, as they will be the staff responsible for the transfer process and patient files.
Clinical supervisor will review all new transfer client charts within 7 days to verify information is correctly entered. Clinical supervisor will review all discharge transfer clients within 7 days to verify information has been transferred and correctly recorded by their counselor. |