INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on September 5-6, 2013 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Northwestern Human Services of PA Susquehanna 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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709.25(a) LICENSURE Fiscal Management
709.25. Fiscal management.
(a) The project shall obtain the services of an independent public accountant for an annual audit of financial activities associated with the project's drug/alcohol abuse services.
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Observations
Based on a review of administrative documentation, the project failed to obtain the services of an independent public accountant for an annual audit of financial activities associated with the project's drug/alcohol abuse services. The findings include:The facility's administrative records were reviewed for documentation of an annual audit of financial activities associated with the project's drug/alcohol abuse services on September 5-6, 2013. The facility's fiscal year runs from July 31 to July 30. The facility did not document an independent financial audit for the 2012 fiscal year.An interview with facility director confirmed the findings.
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Plan of Correction
0169
During our yearly inspection, a citation was received for not documenting an independent financial audit for the 2012 fiscal year. The County Director will request and obtain a copy of the annual audit of financial activities for the 2011-2012 fiscal year by October 31, 2013. The 2012 financial audit will be placed in the Drug and Alcohol Program Manual upon receipt. Moving forward, County Director will request a copy of the previous fiscal year's financial audit by January 31st of each following year. This audit will be placed in the Program Manual upon receipt. |
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
Based on the review of clinical documentation, the facility failed to document the basis for determining current dependency in one of five patient records.The findings include:Ten patient records were reviewed September 5-6, 2013. Five patient records were reviewed for physician documentation of the basis for determining current opiate dependency. Patient # 3 was admitted November 15, 2012. The was no documentation by the physician that recorded the patient's current dependency.The findings were confirmed by the facility director.
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Plan of Correction
M059
The Program Director will meet with each of the Psychiatrist to review regulation 715.9(a)(4) and 715.9(b-e), and the updates to the Patient Intake Physical Exam Form.
NHS Susquehanna Center has updated as of 9/17/13 the Patient Intake Physical Exam Form to include a section to document whether or not the individual is currently physiologically dependent upon a narcotic drug and has been physiologically dependent for at least 1 year prior to admission. This will prompt the Psychiatrist to document proof of this or allow space to document that the individual does not meet the criteria and is, therefore, not appropriate for Suboxone maintenance treatment.
The Program Director will review patient charts following their Suboxone Induction.
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709.93(a)(9) LICENSURE Client records
709.93. Client records.
(a) There shall be a complete client record on an individual which includes information relative to the client's involvement with the project. This shall include, but not be limited to, the following:
(9) Aftercare plan, if applicable.
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Observations
Based on a review of client records the facility failed to document an aftercare plan in one of two client record.The findings include:Ten client records were reviewed on September 5-6, 2013. An aftercare plan was required in one of two client records. The facility did not document an aftercare plan in client record # 1.In client record # 1, the client was admitted on May 3, 2013 and was successfully discharged on May 15, 2013. There was no documentation of an aftercare plan. This was discussed and confirmed with the facility director on September 6, 2013.
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Plan of Correction
1907
NHS Susquehanna Center has developed a new procedure for Discharging Clients and Aftercare Planning as of 9/17/13. All client charts must be reviewed by the Program Director prior to discharging the client. The Program Director will determine whether or not discharging the client is appropriate, and the type of discharge that is necessary. When applicable, the Program Director will review and approve the Aftercare Plan prior to discharging the client.
The Program Director will also be re-training staff on how and when to complete Aftercare Plans during the staff meeting on 9/17/13. The training will be documented in each employee's annual training record. This training will continue to be a part of the new hire paperwork training for all future employees. This training will be conducted by the Program Director.
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709.94(c) LICENSURE Project management services
709.94. Project management services.
(c) A telephone number shall be displayed conspicuously to the general public for emergency purposes.
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Observations
Based on a physical plant inspection, the facility failed to display a telephone number that can be accessed by the general public in case of an emergency.The findings include:A physical plant inspection was conducted on September 5, 2013. A telephone number that is conspicuously displayed to the general public is required at all outpatient treatment programs. The facility did not display an emergency telephone number that was available to the general public.The findings were confirmed by the facility director.
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Plan of Correction
During our yearly inspection, a citation was received for not having an emergency phone number visible during non-operating hours. The Program Director had the Administrative Assistant create a new hours of operation sign to include
the emergency phone numbers for Northumberland County, and other counties (in the surrounding areas of PA) sign was placed on the front entrance door.
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