INITIAL COMMENTS
|
This report is a result of an on-site licensure renewal and methadone monitoring inspection conducted on February 13,14 and March 26, 2024 by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, Greene Treatment 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:
|
Plan of Correction
|
709.28 (c) (3) 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. The consent must be in writing and include, but not be limited to:
(3) Purpose of disclosure.
|
Observations
Based on a review of client records, the facility failed to document a purpose of disclosure on the release of information form in one of nine records.
Client # 6 was admitted on September 9, 2021 and still active at the time of the inspection. Two release of information forms, one form for a medical office and one form for an individual, were signed and dated by the client on March 13, 2024 but did not indicate a purpose of disclosure.
This finding was reviewed with the facility staff during the licensing process.
|
Plan of Correction
The Narcotic Treatment Program will review and maintain compliance with state regulation (709.28 (c) (3) regarding Confidentiality. The Treatment Center Director and Clinical Supervisors will implement training and review practices to ensure the correct and appropriate completion of all releases of information, including the documentation of the purpose of the release. This process will include the implementation of a revised ROI onboarding training at hire, ongoing annual trainings pertaining to the completion of releases of information, in addition to reviewing the content of all releases during the quality review process. All training will be administered by the clinical supervisors, and quality reviews will be completed during peer chart reviews by clinical staff and supervisors.
All clinical staff members participated in training on 4/3/24 to assure ongoing compliance in this area. |
715.6(d) LICENSURE Physician Staffing
(d) A narcotic treatment program shall provide narcotic treatment physician services at least 1 hour per week onsite for every ten patients
|
Observations
Based on a review of medical staff coverage, the facility failed to provide narcotic treatment physician services at least one hour per week onsite for every ten patients for one of eighteen weeks.
Physician service hours were reviewed from September 29, 2023 to February 1, 2024.
During the week of November 24, 2023 through November 30, 2023, the facility ' s census was 215 patients. The facility was required to provide 21.5 hours of onsite physician services, however they provided only provided 21 hours.
This finding was reviewed with the facility staff during the licensing process.
|
Plan of Correction
The Narcotic Treatment Program will review and maintain compliance with state regulation (715.6(d) regarding physician staffing. The Treatment Center Director, Medical Director and Clinical Supervisors will review the census and address any changes in physician staffing that need to be made to ensure compliance based on changes in the patient census. The Treatment Center Director will monitor patient census continuously and increase provider hours as needed. The Treatment Center Director will ensure all physician staffing information submitted will be accurate and documented properly to reflect facility operations. The Treatment Center Director will print accurate copies of the patient census report weekly to maintain with the physician time sheets to assure accurate timeframes are documented together. |
715.6(e) LICENSURE Physician Staffing
(e) A physician assistant or certified registered nurse practitioner may perform functions of a narcotic treatment physician in a narcotic treatment program if authorized by Federal, State and local laws and regulations, and if these functions are delegated to the physician assistant or certified registered nurse practitioner by the medical director, and records are properly countersigned by the medical director or a narcotic treatment physician. One-third of all required narcotic treatment physician time shall be provided by a narcotic treatment physician. Time provided by a physician assistant or certified registered nurse practitioner may not exceed two-thirds of the required narcotic treatment physician time.
|
Observations
Based on a review of medical staff coverage, the facility failed to provide one-third of all required narcotic treatment physician time to be provided by a narcotic treatment physician for two of eighteen weeks.
Physician service hours were reviewed from September 29, 2023 to February 1, 2024.
During the week of October 27, 2023 through November 2, 2023, the physician was required to provide seven hours. The physician provided five hours.
During the week of December 15, 2023 through December 21, 2023, the physician was required to provide seven hours. The physician provided five hours.
This finding was reviewed with the facility staff during the licensing process.
|
Plan of Correction
The Narcotic Treatment Program will review and maintain compliance with state regulation (715.6(e) regarding required physician hours. The Treatment Center Director, Medical Director and Clinical Supervisors will maintain adequate Physician treatment time to patient population, meaning that one-third of all required narcotic treatment physician time will be provided by a narcotic treatment physician. The Treatment Center Director will ensure all required physician hours submitted will be accurate and documented properly to reflect facility operations. The Treatment Center Director will print accurate copies of the patient census report weekly to maintain with the physician Assistant's time sheets to assure accurate timeframes are documented together. |