INITIAL COMMENTS
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This report is a result of an on-site licensure renewal and methadone monitoring inspection conducted on July 12-13, 2023 by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, WPIC Narcotic Addiction Treatment Program 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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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 a review of patient records, the facility failed to document monthly random urinalysis in one of ten patient records.
Patient #1 was admitted on October 31, 2022 and discharged on March 24, 2023. There was no random monthly urine screen documented for the month of November 2022.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
NATP Nurse Manager will ensure that all patients are offered a monthly UDS. Because they are randomized, the last day of the month, the Nurse Manager will closely identify patients the last week of the month to ensure a UDS has been scheduled for the following month. Effective 8/1/23. |
715.20(1) 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.
(1) The transferring narcotic treatment program shall transfer patient files which include admission date, medical and psychosocial summaries, dosage level, urinalysis reports or summary, exception requests, and current status of the patient, and shall contain the written consent of the patient.
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Observations
Based on a review of patient records, the facility failed to document that patient files were transferred to the receiving D/A treatment facility within seven days in two of two patient records.
Patient #1 was admitted on October 31, 2022 and discharged / transferred to another D/A treatment facility on March 24, 2023. There was a release of information documented for the receiving facility; however, there was no documentation that the required information from the patient file was sent to the receiving facility.
Patient #2 was admitted on December 12, 2022 and discharged / transferred to another D/A treatment facility on January 13, 2023. There was a release of information documented for the receiving facility; however, there was no documentation that the required information from the patient file was sent to the receiving facility.
These findings were reviewed with facility staff during the licensing process.
This is a repeat citation from the August 21-22, 2022 annual licensing inspection.
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Plan of Correction
NATP Supervisors will review the discharge process with clinicians in a staff meeting by 8/1/23. Supervisors will review discharge summaries on a monthly basis to ensure that patients being transferred are clearly identified, as well as the associated documents sent to the new provider. The administrative staff will then upload the releases of information and the transfer documents into the EMR. Effective 8/1/23. |
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
Based on a review of patient records, the facility failed to document an annual evaluation of the patient ' s status completed by the counselor and signed by the medical director in one of four patient records.
Patient #9 was admitted on April 22, 2009 and is currently an active patient. The last annual evaluation completed by the counselor was dated June 10, 2022. There was no annual evaluation documented for 2023.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
NATP Supervisors will review the annual evaluation with clinicians in staff meeting by 8/1/23. Supervisors will ensure they are completed through weekly supervision and monthly chart audits. Effective 8/1/23. |
711.93(c)(2) LICENSURE Consent to Release-Informed & Voluntary
711.93. Client records.
(c) Confidentiality.
(2) The project shall obtain an informed and voluntary consent from the client for the disclosure of information contained in the client record. The consent shall be in writing and include, but not be limited to:
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Observations
Based on a review of client records, the facility failed to document a valid consent to release information prior to the disclosure of information contained in the client record in one of ten client records.
Client #9 was admitted on April 22, 2009 and is currently an active client. Client #9 signed a consent to release information for the funding source which expired on June 10, 2023. There was no updated consent to release information for the funding source in client record #9. It was confirmed with facility that the facility is actively billing for services provided to patient #9.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
NATP Supervisors will review consents with clinicians in staff meeting by 8/1/23. Supervisors will ensure that all consents are completed in weekly supervision and in monthly chart audits. Effective 8/1/23 |