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 September 24-26, 2013 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, John F. Kennedy Behavioral Health Center 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.
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Plan of Correction
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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
Based on the review of patient records, the facility failed to restrict the release of information to the legal justice system according to 4 PA Code 255.5 in one patient record reviewed.
The findings include:
Twelve patient records were reviewed September 24-26, 2013. Four patient records were reviewed specifically for confidentiality in accordance with 42 CFR 2.22 and 709.28.
Patient # 8 was admitted January 7, 2013. The patient record included a consent to the patient's probation officer releasing therapy notes, treatment plans, urine drug screens and progress. Another consent for transportation assistance did not specify what information was to be released, but rather stated the purpose for the release. A third consent to release information for emergency contact did not include the specific information that was being released in the event of an emergency, but rather stated the purpose of the release.
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Plan of Correction
On October 2, 2013 the Clinical Supervisor will provide staff training on Pa. 255.5 to improve staff's understanding of the strict limitations required by this code. In addition, the release of information forms for transportation assistance and emergency contact have been revised to comply with State regulation. Staff have been trained on the proper completion of these forms. The Clinical Supervisor will monitor these releases to ensure compliance. |
715.23(b)(14) LICENSURE Patient records
(b) Each patient file shall include the following information:
(14) Case consultation notes regarding the patient.
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Observations
Based on the review of patient records, the facility failed to complete case consultations as required in three of nine patient records reviewed.
The findings include:
Twelve patient records were reviewed September 24-26, 2013. Nine patient records were reviewed for case consultations.
Patient # 1 was admitted May 8, 2013. There should have been at least one quarterly case consultation at the time of the inspection. There was no case consultation found in the patient record.
Patient # 3 was admitted June 4, 2009. An annual case consultation was due by June 4, 2013. There was no annual case consultation.
Patient # 8 was admitted January 7, 2013. Quarterly case consultations are due the first year of treatment and at least annually thereafter. The first case consultation was due by April 2013, but was not completed until June 13, 2013.
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Plan of Correction
On October 9, 2013 the Clinical Supervisor will conduct a training to improve staff's compliance with the completion of case consultations. The Clinical Supervisor will meet with staff weekly for the sole purpose of reviewing and completing case consultations in a timely manner. The Clinical Supervisor is reponsible for ensuring staff compliance. |
715.23(b)(24) LICENSURE Patient records
(b) Each patient file shall include the following information:
(24) Follow-up information regarding the patient.
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Observations
Based on a review of patient records, the facility failed to complete a follow up as required in one of two patient records reviewed.
The findings include:
Twelve patient records were reviewed September 24-26, 2013. Two patient records reviewed required documentation of the follow up information.
Patient # 11 was admitted March 18, 2011. The patient was transferred to another narcotic treatment program October 8, 2013. A follow up contact was required within seven days of the scheduled appointment, or October 15, 2013. The follow up was not completed until November 6, 2013.
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Plan of Correction
Effective October 1, 2013 the Clinical Supervisor is responsible for agency follow-up within 7 days when a client is transferred to another methadone clinic or other agency. The Clinical Supervisor will clearly and consistently document timely agency follow-up in client records.The Clinical Supervisor is also responsible for ongoing monitoring of compliance. The Clinical Supervisor will review each record at discharge to ensure timely follow-up. |