INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on April 8th through 11th, 2019 of Williamsport Family Medical Center by staff from the Department of Drug and Alcohol Programs, Bureau of Quality Assurance for Prevention and Treatment, Program Licensure Division. Based on the findings of the on-site inspection, Williamsport Family Medical 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) (2) 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:
(2) Specific information disclosed.
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Observations
Based on the review of 15 client records, the facility failed to keep disclosures of client identifying information within the limits established by 4 Pa. Code 255.5(b) for releases of information in client record #10. Client #10 was admitted on on June 14, 2018 and was an active client as of the date of the inspection. A consent to release form was signed and dated on June 14, 2018 to a county government agency that allowed for the release of admission summary, progress notes, dose history, current dose, treatment plans, drug & alcohol assessment, psychological evaluation, laboratory tests, drug & alcohol treatment notes, discharge summary, physical exam and "coordinate services". The findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
On 4/15/19 Facility Director completed an in-house training with all staff on confidentiality and documentation standards for releases of information. During training examples of proper vs improper documentation were utilized. Additionally, 4 PA Code 255.5 regarding information that can be released to treatment providers vs other entities was reviewed. Continued monitoring will be completed monthly via chart audit review process by Clinical Supervisor and Facility Director starting May 2019 |
715.23(d)(2) LICENSURE Patient records
(d) A narcotic treatment program shall prepare a treatment plan that outlines realistic short and long-term treatment goals which are mutually acceptable to the patient and the narcotic treatment program.
(2) The narcotic treatment physician or the patient 's counselor shall review, reevaluate, modify and update each patient 's treatment plan as required by Chapters 157, 709 and 711 (relating to drug and alcohol services general provisions; standards for licensure of freestanding treatment activities; and standards for certification of treatment activities which are a part of a health care facility).
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Observations
Based on a review of eight outpatient maintenance client records, the facility failed to document treatment plan updates within the regulatory timeframe in four client records reviewed.Client #8 was admitted on November 10, 2016 and was still active at the time of the inspection. A treatment plan updated was completed on January 10, 2018 and the next update was due no later than March 11, 2018; however the next treatment plan update was completed on March 29, 2018. In addition, a treatment plan update was completed on January 11, 2019 and the next update was due no later than March 12, 2019; however, the next treatment plan update was completed on March 22, 2019.Client #10 was admitted on June 14, 2018 and was still active at the time of the inspection. A treatment plan update was completed on December 14, 2018 and the next update was due no later than February 12, 2019; however the next treatment plan update was completed on February 20, 2019.Client #11 was admitted on October 28, 2013 and was still active at the time of the inspection. The following treatment plan updates were not in compliance:(a) A treatment plan update was completed on December 20, 2017 and the next update was due no later than February 19, 2018; however, the next treatment plan update was completed on March 1, 2018.(b) A treatment plan update was completed on March 1, 2018 and the next update was due no later than May 2, 2018; however, the next treatment plan update was completed on May 10, 2018.(c) A treatment plan update was completed on July 3, 2018 and the next update was due no later than September 1, 2018; however the next treatment plan update was completed on September 17, 2018.(d) A treatment plan update was completed on December 19, 2018 and the next update was due no later than February 17, 2019; however, the next treatment plan update was completed on February 28, 2019.Client #14 was admitted on July 23, 2015 and was discharged on January 4, 2018. A treatment team update was completed on September 21, 2017 and the next update was due no later than November 21, 2017; however, the next treatment plan update was completed on December 1, 2017.These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
Training on time-frame regulations was completed by Facility Director with all clinical/medical staff on 4/19/19. As of 5/20/19, Executive Director will monitor and verify the completion of treatment plan updates through a monitoring report in EMR. Upcoming treatment plan updates will be reviewed during group clinical supervision on a weekly basis with counselors responsible for the completion. Clinical Supervisor will provide individual reports in weekly supervision and report will be reviewed by Facility Director each week to verify and ensure all signatures from Medical Director, counselor, patient, and supervisor are obtained in regulatory time-frame. |
709.91(b)(4) LICENSURE Intake and admission
709.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(4) Consent to treatment.
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Observations
Based on a review of seven outpatient drug-free client records, the facility failed to document a signed consent to treat in three records reviewed. Client #3 was admitted on October 18, 2018 and discharged on April 4, 2019. Client #6 was admitted on November 8, 2018 and was still active at the time of the inspection.Client #7 was admitted on January 31, 2019 and was still active at the time of the inspection.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
All individuals being admitted into the Drug-Free program will complete all regulatory documentation, specifically documentation of signed consent to treat. Facility Director and Clinical Supervisor provided re-education to all clinicians providing drug-free services on 5/1/19. All drug-free intakes will be reviewed by either Facility Director or Clinical Supervisor within first 7 days of treatment to ensure the completion of required documentation. Facility Director has completed a record review for #6 and #7 to ensure that consent to treat was completed and notation was made on record review tool. |
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 seven outpatient drug-free client records, the facility failed to document treatment plan updates within the regulatory timeframe in three client records reviewed.Client #2 was admitted on October 18, 2018 and was still active at the time of the inpsection. A treatment plan update was completed on December 20, 108 and the next update was due no later than February 18, 2019; however the next documented treatment plan update was on March 14, 2019.Client #4 was transferred into the drug-free outpatient services licensing activity on October 12, 2018 and was still active at the time of the inspection. A methadone treatment plan update was completed on August 7, 2018. The first treatment plan update in the drug-free program was on January 3, 2019 with a second update on March 19, 2019. There was a total of 147 days between August 7, 2018 and January 3rd, 2019 with 71 days between January 3, 2019 and March 19, 2019.Client #5 was admitted on October 16, 2018 and discharged on April 4, 2019. A treatment plan update was completed on December 6, 2018 and the next update was due no later than February 4, 2019; however the next documented treatment plan update was on April 5, 2019.These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
Training on time-frame regulations was completed by Facility Director with all Drug Free clinical staff on 4/19/19. As of 5/20/19, Executive Director will monitor and verify the completion of treatment plan updates through a monitoring report in EMR. Upcoming treatment plan updates will be reviewed during group clinical supervision on a weekly basis with counselors responsible for the completion. Clinical Supervisor will provide individual reports in weekly supervision and report will be reviewed by Facility Director each week to verify and ensure completion of updates in regulatory time-frame. |