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 March 16-17, 2011 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, 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 and a plan of correction is due on April 6, 2011.
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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 on the review of patient records, the oral swab exception and an interview with the lead counselor, the facility failed to document a monthly urinalysis in three of thirteen patient records. The findings include:Twenty three patient records were reviewed on March 16-17, 2011. Thirteen records were reviewed for monthly random urinalysis. An exception was granted to the facility on September 26, 2005, for the use of oral fluid testing for patient who had difficulty in providing urine samples. There was no documentation of the patient's difficulty in providing a urine sample in patient records 7, 13 and 23. Patient # 7 was admitted on February 11, 2010. The use of oral fluid testing was documented for the patient's February 25, 2011 drug and alcohol screening test. There was no documentation of the patient's difficulty in providing a urine sample. Patient # 13 was admitted on September 4, 2008. The use of oral fluid testing was documented for the patient's November 17 and December 27, 2010 drug and alcohol screening test and the January 24 and February 15, 2011 drug and alcohol screening test There was no documentation of the patient's difficulty in providing a urine sample. Patient # 23 was admitted on November 10, 2010. The use of oral fluid testing was documented for the patient's November 17 and December 27, 2010 drug and alcohol screening test and the January 24 and February 15, 2011 drug and alcohol screening test There was no documentation of the patient's difficulty in providing a urine sample.
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Plan of Correction
The facility failed to document a monthly urinalysis for all patients.
It is the responsibility of the facility to document a minimum of one uds per patient in treatment. Although the facility utilized an oral swab as approved through an exception, the swabs were not given with attached medical documentation indicating their legitimacy.
If an oral swab is to be utilized for any patient there must be accompanying medical documentation as justification.
The Facility Director will train staff in this area and will inform any affected patient of the regulation.
The Facility Director will be responsible for monitoring this procedure in conjunction with input from the facility Medical Director.
Ongoing compliance will be the responsibility of the Facility Director through review of monthly urinalysis reports. |
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 patient records and an interview with the lead counselor, the facility failed to notify the patient, in writing, of a decision to involuntarily terminate the patient's treatment at the project, in one of one patient record.The findings include:Twenty two patient records were reviewed on March 16-17, 2011. One patient record was required to notify the patient, in writing, of a decision to involuntarily terminate the patient's treatment at the project. The facility failed to notify the patient, in writing, of a decision to involuntarily terminate the patient's treatment at the project, in patient record # 18.Patient # 18 was admitted into treatment and was involuntarily terminated from the project on February 11, 2011. There was no documentation that the patient had been provided written notification of the decision to involuntarily terminate the patient's treatment. The lead counselor was interviewed on March 17, 2011 and verified that an involuntary termination notice was not included in patient record # 18.
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Plan of Correction
The facility failed to provide written notice to a patient related to an involuntary termination.
It is the responsibility of the facility to provide any patient facing involuntary termination with timely written notice of discharge.
In the event that one or more of the conditions for involuntary termination are met, the counselor notifies the Project Director and/or Facility Director and the Medical Director who is responsible for the determination for involuntary termination. The counselor will make notation in the patient case file indicating the action taken, when it was taken, and what the results of the action are The patient is notified, both verbally and in writing, within three days of the decision to involuntary terminate. A copy of the written notification is retained in the client file.
The Facility Director will provide training to all staff regarding this regulation and the required documentation.
The Clinical Supervisor is responsible for ongoing compliance with this policy through supervision and regular chart review.
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709.33(b) LICENSURE Notification of Termination
709.33. Notification of termination.
(b) The client shall have an opportunity to request reconsideration of a decision terminating treatment.
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Observations
Based on a review of patient records and an interview with the lead counselor, the facility failed to document the patient was given the opportunity to request reconsideration of a decision terminating treatment in one of one patient record. The findings include:Twenty two patient records were reviewed on March 16-17, 2011. One patient record was required to provide the patient with the opportunity to request reconsideration of a decision terminating treatment. The facility failed to document the patient was provided the opportunity to request reconsideration of a decision terminating treatment in patient record # 18.Patient # 18 was admitted into treatment and was involuntarily terminated from the project on February 11, 2011. There was no documentation that the patient had been provided the opportunity to request reconsideration of a decision terminating treatment. The lead counselor was interviewed on March 17, 2011 and verified that there was no documentation provided in patient record # 18 to show the patient been provided the opportunity to request reconsideration of a decision terminating treatment.
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Plan of Correction
The facility failed to document that the patient was given the opportunity to request reconsideration of a decision to involuntarily terminate treatment.
Alliance Medical Services maintains an appeal procedure to assure that clients have the opportunity to have a staff decision to terminate participation in the program reviewed. Alliance patients have the right to submit grievances concerning any aspect of their treatment
It is the responsibility of the Facility Director to train staff related to this policy. It is the responsibility of the Clinical Supervisor to monitor ongoing compliance through supervision, regular record review and to provide further training as necessary. |