INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on May 26 - 27, 2015 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Freedom Healthcare, LLC 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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704.12(a)(6) LICENSURE OutPatient Caseload
704.12. Full-time equivalent (FTE) maximum client/staff and client/counselor ratios.
(a) General requirements. Projects shall be required to comply with the client/staff and client/counselor ratios in paragraphs (1)-(6) during primary care hours. These ratios refer to the total number of clients being treated including clients with diagnoses other than drug and alcohol addiction served in other facets of the project. Family units may be counted as one client.
(6) Outpatients. FTE counselor caseload for counseling in outpatient programs may not exceed 35 active clients.
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Observations
Based on a review of counselor caseloads, the facility failed to assign twelve patients to a caseload.
The findings include:
The counselor caseload printouts were reviewed on May 26-27, 2015. At the time of the inspection, there were twelve active patients that were not assigned to a counselor caseload.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Clinical Director will review all new admissions and assign patients to a counselor caseload within 24 hours of admission.
If a counselor leaves in an unplanned fashion, that counselor's patients will be assigned to the Clinical Director, to a maximum of five patients. The remaining patients will be assigned to other counselors. If they need to temporarily exceed 35 patients, an exception for the emergency situation will be requested from DDAP for the emergency situation. |
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 patient records, the facility failed to have a narcotic treatment physician make a face-to-face determination of whether an individual is currently physiologically dependent upon a narcotic and has been physiologically dependent for at least 1 year prior to admission in two of eight patient records.
The findings include:
Eight buprenorphine patient records were reviewed on May 26 - 27, 2015. All buprenorphine patient records require a narcotic treatment physician make a face-to-face determination of whether an individual is currently physiologically dependent upon a narcotic and has been physiologically dependent for at least 1 year prior to admission. Patient records # 1 and 2 did not include a current and 1 year history of physiological dependence.
Patient #1 was admitted on 9/23/14 and discharged on 12/4/14. There was no documentation by a narcotic treatment physician of current physiological dependence on a narcotic and a one year history of physiological dependence.
Patient #2 was admitted on 6/30/14 and discharged on 1/12/15. There was no documentation by a narcotic treatment physician of current physiological dependence on a narcotic and a one year history of physiological dependence.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
By July 15, 2015, Medical Director will review with all physicians the process for determining and documenting the face to face determination of physiological dependency of at least one year.
By July 15, 2015 Lead Nurse will train all nurses to review intake paperwork to assure that physician has completed documentation of dependency.
Immediately Clinical Director will randomly check intakes for documentation of dependency. |
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 review of the patient records, the facility failed to obtain a complete drug screen urinalysis prior to the administration of buprenorphine, a narcotic agent and at least monthly thereafter. A complete drug screen includes receiving the results from the CLIA and Department of Health approved laboratory.
The findings include:
Eight buprenorphine patient records were reviewed on May 26 - 27, 2015. All patients are required to complete a drug screen urinalysis prior to the administration of buprenorphine, a narcotic agent and at least monthly thereafter. A complete urine drug screen includes receiving the results from the CLIA and Department of Health approved laboratory. The facility failed to obtain a complete drug screen urinalysis prior to the administration of buprenorphine, a narcotic agent and monthly thereafter in records # 1, 2, 3, 4, 5, 6, 7 and 8.
Patient #1 was admitted on 9/23/14 and was discharged on 12/4/14. Patient #1 received their first dose of buprenorphine on 9/23/14. The initial and monthly urine screens have been completed by the facility; however, none of the urine samples, including the initial were sent out to a laboratory for urinalysis.
Patient #2 was admitted on 6/30/14 and was discharged on 1/12/15. Patient #2 received their first dose of buprenorphine on 6/30/2014. The initial and monthly urine screens have been completed by the facility; however, none of the urine samples, including the initial were sent out to a laboratory for urinalysis.
Patient #3 was admitted on 12/16/14 and was discharged on 4/7/15. Patient #3 received their first dose of buprenorphine on 12/16/2014. The initial and monthly urine screens have been completed by the facility; however, none of the urine samples, including the initial were sent out to a laboratory for urinalysis.
Patient #4 was admitted on 9/8/14 and was discharged on 4/27/15. Patient #4 received their first dose of buprenorphine on 9/8/2014. The initial and monthly urine screens have been completed by the facility; however, none of the urine samples, including the initial were sent out to a laboratory for urinalysis.
Patient #5 was admitted on 12/16/14 and was discharged on 5/14/15. Patient #5 received their first dose of buprenorphine on 12/16/2014. The initial and monthly urine screens have been completed by the facility; however, none of the urine samples, including the initial were sent out to a laboratory for urinalysis.
Patient #6 was admitted on 12/22/14 and received their first dose of buprenorphine on that same day. The initial and monthly urine screens have been completed by the facility; however, none of the urine samples, including the initial were sent out to a laboratory for urinalysis.
Patient #7 was admitted on 2/27/15 and received their first dose of buprenorphine on that same day. The initial and monthly urine screens have been completed by the facility; however, none of the urine samples, including the initial were sent out to a laboratory for urinalysis.
Patient #8 was admitted on 10/21/14 and received their first dose of buprenorphine on that same day. The initial and monthly urine screens have been completed by the facility; however, none of the urine samples, including the initial were sent out to a laboratory for urinalysis.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Freedom Healthcare will engage the services of an approved outside testing agency, most likely Quest diagnostics, to test patients prior to being administered buprenorphine.
The Clinical Director shall be responsible for making sure the testing protocols are implemented and followed.
The corrective action plan shall be implemented by July 31, unless the exception is granted.
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