INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection and methadone monitoring conducted on September 23, 2024 through September 24, 2024 by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, John F. Kennedy Behavioral Health 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
Based on a review of client records, the facility failed to complete an informed and voluntary consent to release information form prior to the disclosure of information contained in the client record in one of seven client records reviewed.
Client # 6 was admitted on March 12, 2024 and was discharged on May 23, 2024. The emergency contact consent form was signed by the client on March 12, 2024; however, the consent expired on the same day. There was evidence of disclosures to the emergency contact after March 12, 2024, but there was no new or updated consent to release information form signed by the client prior to any disclosures made during the treatment episode.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
DDAP POC
9/24/24 709.28 (c) Confidentiality
(0276) Plan of Correction:
By November 15, 2024, all staff will receive training on the accurate completion of release of information forms. This training will focus on the accuracy of beginning and expiration dates as well as overall accuracy of all items contained in the release of information form.
This training will be provided by the Clinical Supervisor, who will also be responsible for reviewing consent forms for accuracy prior to supervisory approval and sign-off in Carelogic. This will ensure ongoing compliance with regulations governing informed and voluntary consent.
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715.12(1-5) LICENSURE Informed patient consent
A narcotic treatment program shall obtain an informed, voluntary, written consent before an agent may be administered to the patient for either maintenance or detoxification treatment. The following shall appear on the patient consent form:
(1) That methadone and LAAM are narcotic drugs which can be harmful if taken without medical supervision.
(2) That methadone and LAAM are addictive medications and may, like other drugs used in medical practices, produce adverse results.
(3) That alternative methods of treatment exist.
(4) That the possible risks and complications of treatment have been explained to the patient.
(5) That methadone is transmitted to the unborn child and will cause physical dependence.
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Observations
Based on a review of patient records, the narcotic treatment program failed to obtain an informed, voluntary, written consent before an agent was administered to the patient in one of three applicable patient records reviewed.
Patient # 1 was admitted on September 18, 2023 and was active at the time of inspection. There was no documentation of an informed consent to treat in the record prior to the administration of a narcotic agent.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
DDAP POC
9/24/24 715.12 (1-5) Informed Patient Consent
(M095) Plan of Correction:
Beginning November 15, 2024, staff will be instructed to ensure that a new consent to treatment is obtained for new clients and all clients who are formally discharged and subsequently return to treatment.
Our Quality Assurance Department will create a stand-alone Consent to Treatment Form which will be located under the MATP Administrative Record tab in Carelogic. The medical director or the clinical supervisor will be responsible for completing the document with each client.
The clinical supervisor will be responsible for ensuring compliance with this DDAP regulation during weekly chart reviews.
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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
Based on a review of client records, the facility failed to ensure treatment and rehabilitation plans were reviewed and updated at least every 60 days in three of three applicable client records reviewed.
Client # 1 was admitted on September 18, 2023 and was active at the time of inspection. A treatment plan update was completed on April 22, 2024 and the next update was due no later than June 22, 2024; however, the update was not completed until August 5, 2024.
Client # 2 was admitted on March 19, 2024 and was active at the time of inspection. The comprehensive treatment plan was completed on March 19, 2024 and the first update was due no later than May 19, 2024; however, the update was not completed until June 7, 2024.
Client # 6 was admitted on March 12, 2024 and was discharged on May 23, 2024. The comprehensive treatment plan was completed on March 13, 2024 and the first update was due no later than May 13, 2024; however, the update was not completed prior to the client's discharge.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
9/24/24 709.92 (b) Treatment and Rehabilitation Services
(1883) Plan of Correction:
Beginning November 15, 2024 staff will be trained to timely complete treatment plan updates within 60 days of the comprehensive treatment plan. In addition, staff will be trained to complete a treatment plan update, as appropriate, prior to a client's discharge from treatment.
This training will be provided by the Clinical Supervisor. The clinical supervisor will also be responsible for reviewing treatment plans for timeliness prior to supervisory approval and sign-off in Carelogic. This will ensure ongoing compliance with this DDAP regulations.
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