INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on February 9, 2021 by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, Treatment Trends, Inc.-Half-Way Home of the Lehigh Valley 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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709.28 (c) (5) LICENSURE Confidentiality
§ 709.28. Confidentiality.
(c) The project shall obtain an informed and voluntary consent from the client for the disclosure of information contained in the client record. The consent must be in writing and include, but not be limited to:
(5) Dated signature of witness.
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Observations
Based on a review of seven client records on February 9, 2021, the facility failed to provide a consent to release form that included the witness signature and date. Client # 6 was admitted on July 6, 2020 and was discharged on November 28, 2020. A consent form dated August 27, 2020 to a pharmacy was missing a dated signature of a witness. These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The QA Coordinator monthly chart audit includes a check for comprehensiveness of the Releases of Information. This documentation standard was reinforced with staff. Bi-weekly Clinical Supervision includes a review of charts.
Completion Date: 3/31/2021
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709.30 (2) LICENSURE Client rights
§ 709.30. Client rights.
The project shall develop written policies and procedures on client rights and document written acknowledgement by clients that they have been notified of those rights.
(2) The project may not discriminate in the provision of services on the basis of age, race, creed, sex, ethnicity, color, national origin, marital status, sexual orientation, handicap or religion.
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Observations
Based on review of seven client records on February 9, 2021, the project failed to include documentation of the clients being notified that the project may not discriminate in the provision of services based on ethnicity and creed. These findings were reviewed with project staff during the licensing process.This was a repeat citation from a licensing inspection that took place on January 30, 2020.
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Plan of Correction
The QA Coordinator has updated the Client Rights form to ensure that it mirrors the DDAP standard regarding discrimination in the provision of services. This form was sent to program staff. New clients admitted from 3/8/2021 on will be signing the new form and all current clients will sign the new form by 3/31/2021.
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715.9(a)(4) LICENSURE Intake
(a) Prior to administration of an agent, a narcotic treatment program shall screen each individual to determine eligibility for admission. The narcotic treatment program shall:
(4) Have a narcotic treatment physician make a face-to-face determination of whether an individual is currently physiologically dependent upon a narcotic drug and has been physiologically dependent for at least 1 year prior to admission for maintenance treatment. The narcotic treatment physician shall document in the patient 's record the basis for the determination of current dependency and evidence of a 1 year history of addiction.
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Observations
Based on a review of records on February 9, 2021, the program failed to have a narcotic treatment physician make a face-to-face determination of whether an individual is currently physiologically dependent upon a narcotic drug and has been physiologically dependent for at least one year prior to admission for maintenance treatment. The narcotic treatment physician shall document in the patient's record the basis for the determination of current dependency and evidence of a one year history of addiction in one out of three patient files. Patient #7 was admitted on October 12, 2020 and did not have a narcotic treatment physician make a face-to-face determination of whether they were currently physiologically dependent upon a narcotic drug and had been physiologically dependent for at least one year prior to admission for maintenance treatment. There was no documentation by a narcotic treatment physician in the patient's record the basis for the determination of current dependency and evidence of a one year history of addiction. These findings were reviewed with program staff during the licensing process.
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Plan of Correction
Medical Director is responsible for ensuring that notation in the chart reflects the medical necessity and evaluation for Medication-Assisted Treatment (MAT). QA Coordinator monthly audit includes a check for necessary documentation related to MAT. This expectation was reviewed with staff and Medical Director.
Completion Date: 3/31/2021
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715.23(b)(4) LICENSURE Patient records
(b) Each patient file shall include the following information:
(4) The results of an initial intake physical examination.
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Observations
Based on a review of patient records on February 9, 2021, the results of an initial intake physical examination was missing in one out of three patient files. Patient #7 was admitted on October 12, 2020. Patient #7 had no intake physical examination in their patient file. These findings were reviewed with program staff during the licensing process.
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Plan of Correction
The Medical Director is responsible for the initial intake physical examination. The Service Coordinator submits the completed form to the counselor, who is responsible for filing the document in the client chart. QA Coordinator monthly audit includes a check for the presence and comprehensiveness of this form. This process was reinforced with staff.
Completion Date: 3/31/2021
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