INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection and methadone monitoring inspection conducted on March 7 - 9, 2018 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Fayette Treatment Center, LLC d/b/a 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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704.11(c)(1) LICENSURE Mandatory Communicable Disease Training
704.11. Staff development program.
(c) General training requirements.
(1) Staff persons and volunteers shall receive a minimum of 6 hours of HIV/AIDS and at least 4 hours of tuberculosis, sexually transmitted diseases and other health related topics training using a Department approved curriculum. Counselors and counselor assistants shall complete the training within the first year of employment. All other staff shall complete the training within the first 2 years of employment.
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Observations
The facility failed to document 6 hours of HIV/AIDS and at least 4 hours of TB/STD training within the first year of employment in two of three personnel records reviewed on March 7, 2018.Counselor # 2 was hired on July 11, 2016.Counselor # 4 was hired on August 15, 2016.The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Narcotic Treatment Program failed to document 6 hours of HIV/AIDS and 4 hours of TB/STD training within the first year of employment in two of three counselor personnel records reviewed.
MD/CRNP will conduct the mandatory 6 hours of HIV/AIDS and the 4 hours of TB/STD training using the DDAP curriculum for the counselors at GTC by: 6/30/18. Clinical Supervisor will ensure new counselors receive the mandatory training by collaborating with MD/CRNP to schedule the trainings for the new counselors.
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704.11(f)(2) LICENSURE Trng Hours Req-Coun
704.11. Staff development program.
(f) Training requirements for counselors.
(2) Each counselor shall complete at least 25 clock hours of training annually in areas such as:
(i) Client recordkeeping.
(ii) Confidentiality.
(iii) Pharmacology.
(iv) Treatment planning.
(v) Counseling techniques.
(vi) Drug and alcohol assessment.
(vii) Codependency.
(viii) Adult Children of Alcoholics (ACOA) issues.
(ix) Disease of addiction.
(x) Aftercare planning.
(xi) Principles of Alcoholics Anonymous and Narcotics Anonymous.
(xii) Ethics.
(xiii) Substance abuse trends.
(xiv) Interaction of addiction and mental illness.
(xv) Cultural awareness.
(xvi) Sexual harassment.
(xvii) Developmental psychology.
(xviii) Relapse prevention.
(3) If a counselor has been designated as lead counselor supervising other counselors, the training shall include courses appropriate to the functions of this position and a Department approved core curriculum or comparable training in supervision.
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Observations
The facility failed to document 25 clock hours of annual training for counselors during the January 1 - January 31, 2017 training year in two of three personnel records reviewed on March 7, 2018.Counselor # 2 was hired on July 11, 2016 and only had 21 clock hours of annual training documented for the the 2017 training year.Counselor # 3 was hired on November 21, 2016 and only had 5 clock hours of annual training documented for the the 2017 training year.The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Narcotic Treatment Program failed to meet the training requirements for counselors for 2 out of 3 counselors; completing 25 clock hours of training annually. The Clinical Supervisor will be responsible for ensuring 25 clock hours of training are completed by counselors annually in areas such as Client recordkeeping, confidentiality, pharmacology, counseling techniques, drug and alcohol assessment, codependency, adult children of alcoholics issues, disease of addiction, aftercare planning, principles of alcoholics anonymous and narcotics anonymous, ethics, substance abuse trends, interaction of addiction and mental illness, cultural awareness, sexual harassment, developmental psychology, and relapse prevention. The Clinical Supervisor will conduct quarterly audits on counselor's training records to ensure compliance with obtained required hours. |
705.28 (d) (4) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(4) Maintain a written fire drill record including the date, time, the amount of time it took for evacuation, the exit route used, the number of persons in the facility at the time of the drill, problems encountered and whether the fire alarm or smoke detector was operative.
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Observations
The facility failed to document a fire drill record including the exit route used, problems encountered and whether the fire alarm or smoke detector was operative based on a review of the February 2017 - February 2018 fire drill records on March 7, 2018.The findings were reviewed with facilty staff during the licensing process.This is a repeat citation from the February 15 - 16, 2017 licensing inspection.
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Plan of Correction
Regulations 705.28(d)(4) shall be observed. The Fire Drill record will be modified to include the exit route used, problems encountered, and whether the fire alarm and/or smoke detector is operative. The Project Director or his designee shall ensure that the modified Fire Drill procedure is followed. GTC Project Director or designee will reveiw the fire drill records monthly to ensure the required categories are documented.
Completion Date: Corrective Action Date shall be on or before 5/15/18.
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709.28 (c) 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.
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Observations
The facility failed to document an informed and voluntary consent from the client for the disclosure of information contained in the client record in twelve of twelve client records reviewed on March 7 - 9, 2018.The facility failed to obtain written consent from the client or a Qualified Service Organization Agreement (QSOA) prior to releasing client names and urine samples to an outside agency for drug testing in the following client records.Client # 1 was admitted on March 9, 2017 and discharged on November 14, 2017.Client # 2 was admitted on April 28, 2017 and discharged on July 19, 2017.Client # 3 was admitted on August 15, 2017 and discharged on January 16, 2018.Client # 4 was admitted on March 15, 2017 and discharged on November 6, 2017.Client # 5 was admitted on September 18, 2017 and discharged on November 20, 2017.Client # 6 was admitted on February 27, 2017 and discharged on April 20, 2017.Client # 7 was admitted on December 8, 2017.Client # 8 was admitted on November 20, 2017.Client # 9 was admitted on October 25, 2017.Client # 10 was admitted on February 21, 2017.Client # 11 was admitted on February 22, 2017.Client # 12 was admitted on March 21, 2017.The facility failed to obtain written consent from the client prior to obtaining authorization from the funding entity for treatment services. Funding authorization was obtained by the facility during the intake process. Written consents for the funding entity were not obtained until December 20 - 22, 2017 in client records # 1, 3, 4, 7, 8, 9, 10 and 11. Client records # 5 and 6 did not contain any consents for the funding entity.In addition, the consent to release information form utilized for the funding entity exceeded the limits imposed at 4 Pa. Code 255.5 in client records # 1, 3, 4, 7, 8, 9, 10 and 11. The consent allowed for the release of the following information: "summary of treatment, psychosocial evaluation, medical evaluation, length of prescription data, prescription modality, last methadone/Suboxone dose, prescription verification, lab work/results, discharge summary, and the complete client record including progress notes and evaluation ". The consent to release information form included the following statement: "If I revoke this authorization, I need to do so in writing and mail or hand deliver it to the HIPAA Privacy Officer of the Provider Entity named above, at the address set forth above." The facility failed to adhere to the requirements in the federal confidentiality regulations by requiring the client to revoke the consent in writing in client records # 1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11 and 12.The findings were reviewed with and confirmed by facility staff during the licensing process.
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Plan of Correction
The Narcotic Treatment Program failed to obtain written consent from the client or a Qualified Service Agreement prior to releasing client names and urine samples to an outside agency for drug testing in 12 patient records. Project Director completed Qualified Service Agreement with outside agency for drug testing on March 8, 2018. The Narcotic Treatment Program failed to obtain written consent from client prior to obtaining authorization from the funding entity for treatment services until December 20-22, 2017 in 8 out of 10 charts, and two charts failed to have any written consent from client. The Project Director will be responsible for ensuring that written consent from the patient will be completed prior to obtaining authorization from the funding entity for treatment services. The program utilized a consent to release information form for the funding entity that exceeded the limits imposed at 4 Pa Code 255.5 in 8 out of 11 records. The consent allowed for the release of the following information: summary of treatment, psychosocial evaluation, medical evaluation, length of prescription data, prescription modality, last methadone/suboxone dose, prescription verification, lab work/results, discharge summary, and the complete client record including progress notes and evaluation. Effective 3/19/18, the form utilized to consent to release information for funding entity was changed to items allowable per 4 Pa. Code 255.5, which are: whether the client is or is not in treatment, client's prognosis, nature of project, brief description of the client's progress, and short statement as to whether the client has relapsed into drug or alcohol abuse and the frequency of such relapse. The Project Director will ensure that all consents to release information to funding entity are updated by 4/19/18.
The Narcotic Treatment Program failed to adhere to the requirements in the federal confidentiality regulations by requiring the client to revoke the consent in writing in records #1, 2, 3, 4, 5, 6, 7, 8, 9. 10, 11, and 12.
The consent to release form was corrected by CRNP with the following words: " This authorization may be revoked by me at any time in writing and/or verbally (such action verified in writing), except to the extent the above-named Greene Treatment Center has already acted in reliance on this authorization." The LPN staff will have all the patients sign the corrected forms by: 6/30/18. The CRNP will make sure the corrected consent to release form is in the SMART software system and is available to use. The LPN supervisor will ensure that the corrected consent to release forms required by the medical department are completed by all future patients.
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709.32 (c) LICENSURE Medication control
§ 709.32. Medication control.
(c) The project shall have and implement a written policy and procedures regarding all medications used by clients which shall include, but not be limited to:
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Observations
The facility failed to document a written policy and procedure for the administration of Vivitrol based on a review of medication policies on March 7, 2018.The Department granted permission to the facility to administer Vivitrol medication beginning on August 11, 2017.The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Narcotic Treatment Program failed to document a written policy and procedure for the administration of Vivitrol based on a review of medication policies. GTC will conduct appropriate preadmission screenings on each patient. Diagnostic screenings may include pregnancy test, CMP, CBC with Diff, Coag. Studies, urine drug screens, and any others deemed appropriate by the Medical Director. Patients will be asked during the intake process about any current or past hepatic, renal, or hematological disorders. A history and physical will be performed. Patients will also be screened for depression, suicide, and alcohol use (CAGE questionnaire). Patients who were on methadone, buprenorphine, or any long acting opioid will wait 14 days after discontinuing opioid use before the naloxone challenge is administered to minimize precipitated withdrawal. Patients using short acting opioids must wait 7-10 days after discontinuation before taking the naloxone challenge. GTC will administer the Vivitrol according to pharmaceutical recommendations. Documentation will be completed in GTC's SMART software system. The Vivitrol will be stored in a locked refrigerator set at a temperature recommended by the pharmaceutical manufacturer. 28Pa.code 709.83 (a)(5) and 709.93 (a)(2) regulations of medication records will be observed. Medication records: 28Pa.code 709.32 (c)(1)-(7) or711.87(a)(1)-(7) and or 711.97(a)(1)-(7) regulations shall be observed dealing with medication control. The project shall continue to maintain the appropriate client to counselor ratio as outlined in the staffing regulations and comply with all licensing regulations. GTC Project Director and Medical Director will write the policy and procedures for the use of Vivitrol Treatment. Completion date will be on or before 6/15/18 |
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
The facility failed to document the client was notified in writing of a decision to involuntarily terminate the client's treatment at the project in one of one records reviewed on March 7 - 9, 2018.Client # 4 was admitted into treatment on March 15, 2017 and involuntarily terminated from treatment on November 6, 2017.The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Narcotic Treatment Program failed to document the client was notified in writing of a decision to involuntarily terminate the client's treatment at the project in one of one records reviewed.
GTC physician will have patients who are involuntarily terminated sign an "Administrative Withdrawal Notification" a minimum of 7 days prior to termination. If the patient refuses to sign or cooperate, it will be documented in the patient's record that the patient refuses to sign the notification and that the notification was offered to the patient. This correction will be implemented on the next involuntary termination that occurs. The Medical Director will ensure that patients are notified in writing of an involuntary termination by conducting chart audits.
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709.34 (c) (4) LICENSURE Reporting of unusual incidents
§ 709.34. Reporting of unusual incidents.
(c) To the extent permitted by State and Federal confidentiality laws, the project shall file a written unusual incident report with the Department within 3 business days following an unusual incident involving:
(4) Event at the facility requiring the presence of police, fire or ambulance personnel.
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Observations
The project failed to provide documentation that the Department was notified within 3 business days following an unusual incident involving an event at the facility requiring the presence of police, fire or ambulance personnel based on a review of unusual incident reports on March 7, 2018.An ambulance responded to the facility on the following dates:March 21, 2017July 20, 2017August 16, 2017.The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
: GTC documented each of the unusual incidents dated March 21, July 20, and August 16, 2017 on the date the incident occurred. However, Project Director failed to provide documentation to the department per 709.34 (c). These three (3) unusual incidents shall be provided to DDAP and any future unusual incident per 709.34 shall be reported to DDAP within the regulatory time frame.
Completion Date: GTC Project Director will forward past unusual incident reports (3) on or before April 10, 2018. All future unusual incidents per 709.34 shall be reported within regulatory time frames.
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715.9(a)(2) 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:
(2) Verify the individual 's identity, including name, address, date of birth, emergency contact and other identifying data.
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Observations
The facility failed to document verification of the individual's emergency contact in twelve of twelve patient records reviewed on March 7 - 9, 2018.Patient # 1 was admitted on March 9, 2017 and discharged on November 14, 2017.Patient # 2 was admitted on April 28, 2017 and discharged on July 19, 2017.Patient # 3 was admitted on August 15, 2017 and discharged on January 16, 2018.Patient # 4 was admitted on March 15, 2017 and discharged on November 6, 2017.Patient # 5 was admitted on September 18, 2017 and discharged on November 20, 2017.Patient # 6 was admitted on February 27, 2017 and discharged on April 20, 2017.Patient # 7 was admitted on December 8, 2017.Patient # 8 was admitted on November 20, 2017.Patient # 9 was admitted on October 25, 2017.Patient # 10 was admitted on February 21, 2017.Patient # 11 was admitted on February 22, 2017.Patient # 12 was admitted on March 21, 2017.The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Narcotic Treatment Program failed to document verification of the individual's emergency contact in 12 out of 12 patient records. The Project Director will ensure that all patients have documented verification of the individual's emergency contact in records by 4/30/18 and the clinical supervisor will monitor ongoing completion through chart reviews beginning 4/30/18. |
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
The narcotic treatment physician failed to document a face-to-face determination of whether an individual was currently physiologically dependent upon a narcotic drug and had been physiologically dependent for at least 1 year prior to admission for maintenance treatment in nine of twelve patient records reviewed on March 7 - 9, 2018.Patient # 1 was admitted on March 9, 2017 and discharged on November 14, 2017. The patient received their first dose of methadone on March 13, 2017.Patient # 2 was admitted on April 28, 2017 and discharged on July 19,2017. The patient received their first dose of methadone on April 29, 2017. The face to face determination was not documented until May 4, 2017.Patient # 4 was admitted on March 15, 2017 and discharged on November 6, 2017. The patient received their first dose of methadone on March 15, 2017.Patient # 6 was admitted on February 27, 2017 and discharged on May 3, 2017. The patient received their first dose of methadone on March 2, 2017.Patient # 8 was admitted on November 20, 2017. The patient received their first dose of methadone on November 21, 2017. The face to face determination was not documented until November 27, 2017.Patient # 9 was admitted on October 25, 2017. The patient received their first dose of methadone on October 25, 2017. The face to face determination was not documented until October 26, 2017.Patient # 10 was admitted on February 21, 2017. The patient received their first dose of methadone on February 27, 2017.Patient # 11 was admitted on February 22, 2017. The patient received their first dose of methadone on February 23, 2017.Patient # 12 was admitted on March 21, 2017. The patient received their first dose of methadone on March 21, 2017.The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Narcotic Treatment Physician failed to document a face-to-face determination of whether an individual was currently physiologically dependent for at least 1 year prior to admission for maintenance treatment in nine of twelve patient records.
GTC physician will document face to face determination prior to patient receiving 1st dose. Implementation will begin: 4/2/18. GTC is in process of applying for face to face waiver. Medical Director will ensure GTC physician and/or CRNP (if waiver is approved) documents face to face determination by conducting weekly audits of the face to face determination.
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715.15(b) LICENSURE Medication dosage
(b) The narcotic treatment physician shall determine the proper dosage level for a patient, except as otherwise provided in this section. If the narcotic treatment physician determining the initial dose is not the narcotic treatment physician who conducted the patient examination, the narcotic treatment physician shall consult with the narcotic treatment physician who performed the examination before determining the patient 's initial dose and schedule.
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Observations
The narcotic treatment physician failed to document a consult with the CRNP (Certified Registered Nurse Practitioner) who completed the patient examination prior to determining the patient's initial dose and schedule in ten of twelve patient records reviewed on March 7 - 9, 2018.Patient # 1 was admitted on March 9, 2017 and discharged on November 14, 2017.Patient # 2 was admitted on April 28, 2017 and discharged on July 19, 2017.Patient # 3 was admitted on August 15, 2017 and discharged on January 16, 2018.Patient # 4 was admitted on March 15, 2017 and discharged on November 6, 2017.Patient # 6 was admitted on February 27, 2017 and discharged on April 20, 2017.Patient # 8 was admitted on November 20, 2017.Patient # 9 was admitted on October 25, 2017.Patient # 10 was admitted on February 21, 2017.Patient # 11 was admitted on February 22, 2017.Patient # 12 was admitted on March 21, 2017.The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Narcotic Treatment Physician failed to document a consult with the CRNP who completed the patient examination prior to determining the patient's initial dose and schedule in ten of 12 patient records reviewed.
The GTC physician will document consultation with the provider who conducted initial physical exam. The correction has already been implemented by GTC physician and CRNP. Both are documenting the mandatory consultation with new intakes. The Medical Director will ensure consultations are completed by conducting weekly audits of new intake charts.
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715.16(a)(3) LICENSURE Take-home privileges
(a) A narcotic treatment program shall determine whether a patient may be provided take-home medications.
(3) The narcotic treatment physician shall document in the patient record the rationale for permitting take-home medication.
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Observations
The narcotic treatment physician failed to document the rationale for permitting take home medication in three of three patient records reviewed on March 7 - 9, 2018.Patient # 6 was admitted on February 27, 2017 and discharged on May 3, 2017 and was granted take home medication on March 2, 2017.Patient # 11 was admitted on February 22, 2017 and granted take home medication on June 28, 2017.Patient # 12 was admitted on March 21, 2017 and granted take home medications on July 3, 2017, August 9, 2017 and November 25, 2017.The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Narcotic Treatment Physician failed to document the rationale for permitting take home medication in 3 of 3 patient records reviewed.
The GTC physician will document rationale on case conference notes that involve take home medications and on request for take out bottles form. CRNP has made changes in the case conference template form and take out request form to reflect the correction. Implementation of correction has begun on 4/2/18. The Medical Director will ensure rationales are documented on the case conference and take out request forms by conducting weekly audits.
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715.19(1) LICENSURE Psychotherapy services
A narcotic treatment program shall provide individualized psychotherapy services and shall meet the following requirements:
(1) A narcotic treatment program shall provide each patient an average of 2.5 hours of psychotherapy per month during the patient 's first 2 years, 1 hour of which shall be individual psychotherapy. Additional psychotherapy shall be provided as dictated by ongoing assessment of the patient.
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Observations
The facility failed to document an average of 2.5 hours of psychotherapy per month during the patient's first two years in eight of ten patient records reviewed on March 7 - 9, 2018.Patient # 1 was admitted on March 9, 2017 and discharged on November 14, 2017. Patient # 1 received the following psychotherapy hours: August 2017 - 1 hour, September 2017 - 0 hours and October 2017 - 0 hours.Patient # 2 was admitted on April 28, 2017 and discharged on July 19,2017. Patient # 2 received the following psychotherapy hours: May 2017 - .5 hours and June 2017 - 1 hour.Patient # 3 was admitted on August 15, 2017 and discharged on January 16, 2018. No psychotherapy hours were documented in October, November and December 2017.Patient # 4 was admitted on March 15, 2017 and discharged on November 6, 2017. Patient # 4 received the following psychotherapy hours: August 2017 - 2 hours, September 2017 - 1, October 2017 - .5 hours. Patient # 5 was admitted on September 18, 2017 and discharged on December 4, 2017. Patient # 5 received the following psychotherapy hours: September 2017 - 1.5 hours, October 2017 - 2.5 hours and November 2017 - .5 hours.Patient # 6 was admitted on February 27, 2017 and discharged on May 3, 2017. Patient # 6 received the following psychotherapy hours: March 2017 - 0 hours and April 2017 - 1 hour.Patient # 7 was admitted on December 8, 2017. No psychotherapy hours were documented since admission.Patient # 8 was admitted on November 20, 2017. Patient # 8 received the following psychotherapy hours: December 2017 - 1 hour, January 2018 - 2.5 hours and February 2018 - 2 hours.The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Narcotic Treatment Program failed to meet the required 2.5 hours of psychotherapy per month during patient's first two years of participation in program for 8 out of 10 patients. The Clinical Supervisor and counselors will complete chart audits monthly beginning 4/30/18 and weekly clinical supervision meetings to review the frequency of treatment and ensuring that patients are complying to program standards and fulfilling the required 2.5 hours of psychotherapy per month throughout the patient's first two years of participation in the program. |
715.19(2) LICENSURE Psychotherapy services
A narcotic treatment program shall provide individualized psychotherapy services and shall meet the following requirements:
(2) A narcotic treatment program shall provide each patient at least 1 hour per month of group or individual psychotherapy during the third and fourth year of treatment. Additional psychotherapy shall be provided as dictated by ongoing assessment of the patient.
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Observations
The facility failed to document at least one hour of psychotherapy per month during the third and fourth year of treatment in one of one patient record reviewed on March 7 - 9, 2018.Patient # 12 was admitted on March 21, 2017. Patient # 12 did not receive any psychotherapy hours in the following months: April 2017, June - September 2017 and February 2018.The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Narcotic Treatment Program failed to meet the required 1 hour of psychotherapy per month during patient's third and fourth year of participation in program for 1 out of 1 patients. The Clinical Supervisor and counselors will complete monthly chart audits beginning 4/30/18 and weekly clinical supervision meetings to review the frequency of treatment and ensuring that patients are complying to program standards and fulfilling the required 1 hour of psychotherapy per month throughout the patient's third and fourth years of participation in the program. |
715.20(4) 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.
(4) The receiving narcotic treatment program shall document in writing that it notified the transferring narcotic treatment program of the admission of the patient and the date of the initial dose given to the patient by the receiving narcotic treatment program.
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Observations
The facility failed to document in writing that it notified the transferring narcotic treatment program of the admission of the patient and date of initial dose given in five of seven patient records reviewed on March 7 - 9, 2018.Patient # 1 was admitted on March 9, 2017 and discharged on November 14, 2017.Patient # 6 was admitted on February 27, 2017 and discharged on May 3, 2017. Patient # 10 was admitted on February 21, 2017. Patient # 11 was admitted on February 22, 2017.Patient # 12 was admitted on March 21, 2017.The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Narcotic Treatment Program failed to document in writing that it notified the transferring narcotic treatment program of the admission of the patient and date of initial dose given in 5 of 7 patient records.
GTC LPN nurse will fill out and fax a transfer verification form containing the date of admission and the initial dose date to the transferring clinic. Implementation began prior to inspection date. LPN Supervisor will ensure transfer verification forms are completed and sent to transferring clinic by LPN staff after each transfer.
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715.23(b)(5) LICENSURE Patient records
(b) Each patient file shall include the following information:
(5) The results of all annual physical examinations given by the narcotic treatment program which includes an annual reevaluation by the narcotic treatment physician.
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Observations
The narcotic treatment physician failed to document an annual physical examination which includes an annual reevaluation in two of two patient records reviewed on March 7 - 9, 2018.Patient # 10 was admitted on February 21, 2017. Patient # 11 was admitted on February 22, 2017.The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Narcotic Treatment Physician failed to document an annual physical examination which includes an annual reevaluation in 2 of 2 patient records reviewed.
GTC CRNP will conduct an annual physical exam on each patient. Implementation has begun and will be completed by: 7/30/18. The Medical Director will ensure annual physical exams are being completed by conducting monthly audits.
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715.23(c)(1-7) LICENSURE Patient records
(c) An annual evaluation of each patient 's status shall be completed by the patient 's counselor and shall be reviewed, dated and signed by the medical director. The annual evaluation period shall start on the date of the patient 's admission to a narcotic treatment program and shall address the following areas:
(1) Employment, education and training.
(2) Legal standing.
(3) Substance abuse.
(4) Financial management abilities.
(5) Physical and emotional health.
(6) Fulfillment of treatment objectives.
(7) Family and community supports.
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Observations
The patient's counselor failed to document an annual evaluation of each patient's status in two of two patient records reviewed on March 7 - 9, 2018.Patient # 10 was admitted on February 21, 2017. Patient # 11 was admitted on February 22, 2017.The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Narcotic Treatment Program failed to document an annual evaluation of patient's status in 2 out of 2 patient records. The Clinical Supervisor will complete a group supervision on 4/19/18 with all counselors regarding the required Annual Evaluation timeline and required content including: 1)Employment, education and training 2) Legal standing 3)Substance use 4)Financial management abilities 5)Physical and emotional health 6)Fulfillment of treatment objectives 7)Family and community supports. The Clinical Supervisor will complete chart audits on patient charts that meet annual status monthly beginning 4/16/18 to ensure completion of annual evaluations. Random monthly chart reviews of all charts will begin 4/30/18 to monitor completion of annual evaluations. |
709.91(b)(7) LICENSURE Intake and admission
709.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(7) Preliminary treatment and rehabilitation plan.
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Observations
The facility failed to document a preliminary treatment plan during the intake process in three of twelve client records reviewed on March 7 - 9, 2018.Client # 2 was admitted on April 28, 2017 and discharged on July 19, 2017.Client # 7 was admitted on December 8, 2017.Client # 11 was admitted on February 22, 2017.The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Narcotic Treatment Program failed to document a preliminary treatment plan during the intake process in 3 out of 12 patient records. The Clinical Supervisor will complete a group supervision with the clinical staff on 4/19/18 regarding required documentation during intake process including preliminary treatment plans and will continue to monitor completion in monthly chart audits beginning 4/30/18. |
709.92(b) LICENSURE Treatment and rehabilitation services
709.92. Treatment and rehabilitation services.
(b) Treatment and rehabilitation plans shall be reviewed and updated at least every 60 days.
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Observations
The facility failed to document treatment plan updates at least every 60 days in four of eight client records reviewed on March 7 - 9, 2018.Client #1 was admitted on March 9, 2017 and discharged on November 14, 2017. The comprehensive treatment plan was completed on April 19, 2017. No treatment plan update was documented for June 2017.Client # 3 was admitted on August 15, 2017 and discharged on January 16, 2018. The comprehensive treatment plan was completed on September 25, 2017. No treatment plan updates were documented.Client # 4 was admitted on March 15, 2017 and discharged on November 6, 2017. The comprehensive treatment plan was completed on June 20, 2017. Treatment plan updates were only documented for June 27 and July 16, 2017.Client # 11 was admitted on February 22, 2017. The comprehensive treatment plan was completed on June 12, 2017. Treatment plan updates were only documented for June 28, 2017 and January 28, 2018.The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Narcotic Treatment Program failed to document treatment plan updates at least every 60 days in 4 out of 8 patient records. The Clinical Supervisor will complete group supervision on documentation timelines with the clinical staff on 4/19/18 and will continue to monitor in monthly chart audits beginning 4/30/18. |