INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection and methadone monitoring conducted on July 12, 2021 through July 13, 2021 by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, Aldie Foundation Inc. 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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709.33 (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 client records, the facility failed to notify clients, in writing, of the decision to involuntarily terminate the client's treatment in one of two applicable client records reviewed.
Client #7 was admitted on September 25, 2020 and was discharged March 25, 2021.
These findings were discussed with facility staff during the licensing process.
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Plan of Correction
The CEO, Clinical Director, and Assistant Clinical Director have reviewed the deficiency. A procedure has been established to provide written notification to each involuntarily terminated client. Part of this process will be ensuring that accurate email addressed are on file for each client, as regular mail is often not the best method to provide the communication. The primary therapist with also make a notation in the electronic record that written communication has been sent. The CEO discussed the procedure at a full staff meeting on July 21st. The Clinical Director will reinforce compliance at the August 4th Clinical Team meeting. |
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 client records, the facility failed to provide the client an opportunity to request reconsideration of the decision to terminate treatment in two of two applicable client records reviewed.
Client #5 was admitted on November 11, 2014 and was discharged July 12, 2021.
Client #7 was admitted on September 25, 2020 and was discharged March 25, 2021.
These findings were discussed with facility staff during the licensing process.
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Plan of Correction
The CEO, Clinical Director, and Assistant Clinical Director have reviewed the deficiency. The CEO also discussed the issue at a full staff meeting on July 21, 2021. A procedure has been established to provide an opportunity for a client that has been discharged to request reconsideration. This information will be communicated to the client in writing, either via email, text or regular mail. The primary therapist will provide evidence of such communication and the end result in the client record. The Clinical Director will further reinforce compliance at the August 4, 2021 Clinical Team Meeting, and the matter will be addressed as part of ongoing clinical supervision. |
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
Based on a review of patient records, the facility failed to document the results of an annual physical examination given by the narcotic treatment program, which is to include an annual reevaluation by the narcotic treatment physician in one of three applicable patient records reviewed.
Patient #6 was admitted on March 19, 2019 and was discharged April 5, 2021. The last documented physical exam in the record was the initial physical exam completed on March 19, 2019.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The deficiency has been reviewed by the CEO, Clinical Director, and Assistant Clinical Director. The impetus for the deficiency is likely a change in protocol during the COVID-19 pandemic. The Clinical Director has also discussed the matter with the physicians, and has confirmed that clients are receiving annual physical examinations, and that the results are documented in the client record. The Clinical Director will further reinforce the requirement at the August 4, 2021 Clinical Team meeting. Compliance will thereafter be monitored as part of ongoing clinical supervision. |