INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on January 17 - 18, 2019 by staff from the Department of Drug and Alcohol Programs, Bureau of Quality Assurance for Prevention and Treatment. Based on the findings of the on-site inspection, The Care Center dba SPHS Care 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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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 obtain a written, informed and voluntary consent from the client prior to releasing the client's name and urine sample to a laboratory for drug testing in one of eleven client records reviewed on January 17 - 18, 2019.
Client # 1 was admitted on February 2, 2018. The disclosure occurred on June 12, 2018. There was no written consent from the client documented or a qualified service organization agreement (QSOA) with the laboratory.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Program Supervisor conducted a mandatory staff meeting scheduled on Thursday, January 24, 2019 for the purposes of re-educating all staff on Drug and Alcohol Confidentiality. All staff will sign the meeting minutes verifying understanding that staff will be required to obtain informed consent authorizing clients' release of minimum necessary information to the site's drug urinalysis laboratory. It is the expectation that staff who were absent will review in individual supervision with the Program Supervisor.
Program Director met with Administrative Assistant (staff in charge of activating, de-activating, and modifying Electronic Health Record forms) on Wednesday, January 30, 2019. An electronic release of information form specific to the site's drug urinalysis laboratory was added to the intake form group to be completed at assessment for every Drug and Alcohol client. Obtaining permission via signature from clients is the process that was put in place in lieu of the unreturned QSOA agreement that was sent to a laboratory in the past. The Program Supervisors announced the addition of the electronic form that has gone into effect.
As follow-up procedure, the Program Supervisor will conduct random chart reviews for one month to ensure releases are being completed. In addition, Program Supervisor will check the releases for clients who are being staffed during that one month time span for individual supervision as an extra layer of checking to make sure releases are being completed as advised in the absence of a laboratory QSOA. The corrective action will be in place on January 30, 2019. |
709.34 (c) (2) 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:
(2) Death or serious injury due to trauma, suicide, medication error or unusual circumstances.
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Observations
The facility failed to file a written unusual incident report with the Department within 3 business days following an unusual incident involving a death of client in two of eleven client records reviewed on January 17 - 18, 2019.
Client # 6 was admitted January 1, 2018 and discharged May 8, 2018.
Client # 8 was admitted February 5, 2018 and discharged March 6, 2018.
The findings were reviewed with facility staff during the licensing process.
This is a repeat citation from the 2017 licensing inspection.
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Plan of Correction
The Program Director will contact the Program Supervisor at the beginning of every month for the remainder of 2019 to check on the occurrence of any unusual incidents. For any unusual incidents that take place, the Program Director will request verification from the Program Supervisor confirming the sending of the report to DDAP. Verification can include receipt of a faxed report or a copy of the email sent to : RA-DAAPI_DIVISION@PA.GOV
The Program Supervisor will follow up with any staff in individual and/or team meetings for debriefing purposes.
This process will be in effect from January 22, 2019 through December 31, 2019. |
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 facility's physician failed to document in the patient's record evidence of a one year history of addiction prior to the administration of a narcotic agent in three of three patient records reviewed on January 17 - 18, 2019.
Patient # 1 was admitted February 2, 2018 and was prescribed Suboxone on July 20, 2018.
Patient # 2 was admitted September 12, 2018 and was prescribed Suboxone on October 6, 2018.
Patient # 3 was admitted November 29, 2018 and was prescribed Suboxone on December 1, 2018.
In addition, the facility's physician failed to document in the patient's record the basis for the determination of current dependency prior to the administration of a narcotic agent in patient records # 2 and 3.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Program Supervisor collaborated with the Administrative Assistant on January 21, 2019 to finalize the revision of the evaluation form for clients who are being assessed for a narcotic agent. Physicians who intend on prescribing Suboxone to prospective and appropriate clients will now be required to elaborate on indicators that justify the Physician's determination of a client's physiological dependence, which must comprise a minimum of 1 year's time, on opiates/opioids. In addition to a reference to the collection of this information in a previous intake assessment, the updated SUBOXONE EVALUATION contains a mandatory field in the electronic form that requires physicians to provide proof of a client's physiological dependence. The statement that was added to the form is : The following are indicative of current physiological addiction to heroin or other opiate drugs for this patient.
The Program Supervisor has been monitoring physician's completion of this section of the form and it has met satisfactory requirements thus far (e.g. Early signs of withdrawal -lacrimation, rhinorrhea, pupillary dilation, piloerection,- Loss of appetite, increased body temperature, pulse rate, blood pressure and respiratory rate). Also included will be the Physician's documentation providing evidence for 1 year history of narcotic addiction (e.g. track marks, visible scars, etc.) The Program Supervisor will continue to check all completed SUBOXONE EVALUATIONS to ensure the expectation is upheld.
The corrective action was implemented January 21, 2019. |