INITIAL COMMENTS
|
This report is a result of an on-site licensure renewal and methadone monitoring inspection conducted on September 28, 2023 through September 29, 2023, by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. 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:
|
Plan of Correction
|
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.
|
Observations
Based on a review of eight client records, the facility failed to obtain an informed and voluntary consent from the client for the disclosure of information in one record reviewed.
Client # 3 was admitted on June 15, 2015 and was discharged on August 9, 2023. The record did not contain an informed and voluntary consent form to the funding source; however, there was evidence of billing.
These findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
It was reviewed with all staff at our clinical meeting on 10/25/23 the importance of obtaining all consents and updating them on an annual basis. Going forward all intakes and annuals will be checked for by the clinical supervisor during the chart review process to assure to ensure all required consents are active. A review of all active clients consents were reviewed by clinical supervisor and billing department to ensure active consents are in EMR and any claims were corrected. |
709.28 (d) LICENSURE Confidentiality
§ 709.28. Confidentiality.
(d) A copy of a client consent shall be offered to the client and a copy maintained in the client record.
|
Observations
Based on a review of client records, the facility failed to ensure that a copy of all informed and voluntary consent to release information forms were offered to the client in two of eight client records reviewed.
Client # 1 was admitted on February 14, 2022 and was discharged on June 5, 2023. A release of information form to a treatment provider was signed and dated by the client on May 18, 2023; however, there was no documentation that a copy of the form was offered to the client.
Client # 3 was admitted on June 15, 2015 and was discharged on August 9, 2023. A release of information form to a government agency was signed and dated by the client on September 9, 2022; however, there was no documentation that a copy of the form was offered to the client.
The findings were discussed with facility staff during the licensing process.
|
Plan of Correction
Training on 10/17/23 was completed by director reviewing consents and the importance of documenting whether or not patient was offered a copy and if they accept or decline.
All consents will be reviewed by clinical supervisor at admission and annual. Consents completed prior to annual will be sent to director for review on a daily basis to ensure compliance.
All active consents were reviewed by Clinical Supervisor and update consents were obtained as needed. 10/25/2023 |
715.20(4) LICENSURE Patient transfers
A narcotic treatment program shall develop written transfer policies and procedures which shall require that the narcotic treatment program transfer a patient to another narcotic treatment program for continued maintenance, detoxification or another treatment activity within 7 days of the request of the patient.
(4) The receiving narcotic treatment program shall document in writing that it notified the transferring narcotic treatment program of the admission of the patient and the date of the initial dose given to the patient by the receiving narcotic treatment program.
|
Observations
Based on a review of patient records, the receiving narcotic treatment program failed to document in writing that it notified the transferring narcotic treatment program of the admission of the patient and the date of the initial dose in two of three applicable records reviewed.
Patient # 7 was transferred to the facility on May 22, 2023 and was discharged on June 12, 2023. There was no documentation that the receiving narcotic treatment program notified the transferring narcotic treatment program of the admission of the patient and the date of the initial dose.
Patient # 8 was transferred to the facility on June 12, 2023 and was active at the time of the inspection. There was no documentation that the receiving narcotic treatment program notified the transferring narcotic treatment program of the admission of the patient and the date of the initial dose.
These findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
Medical review of intake process was completed with medical staff on 10/17/23. Transfer requirements and appropriate means of documenting transfer was reviewed and directive for utilization of checklist was made to ensure completion.
RN and/or Clinical Supervisor will complete a brief audit before patient receives initial dose that all required items are documented and in the EMR chart |
715.23(c)(1-7) LICENSURE Patient records
(c) An annual evaluation of each patient 's status shall be completed by the patient 's counselor and shall be reviewed, dated and signed by the medical director. The annual evaluation period shall start on the date of the patient 's admission to a narcotic treatment program and shall address the following areas:
(1) Employment, education and training.
(2) Legal standing.
(3) Substance abuse.
(4) Financial management abilities.
(5) Physical and emotional health.
(6) Fulfillment of treatment objectives.
(7) Family and community supports.
|
Observations
Based on a review of patient records, the facility failed to ensure an annual evaluation of each patient ' s status was completed by the patient ' s counselor and reviewed, dated and signed by the medical director in one of two applicable records reviewed.
Patient # 3 was admitted on June 15, 2015 and was discharged on August 9, 2023. An annual evaluation was due to be completed by June 15, 2023, however, the most recent annual evaluation documented was completed on June 15, 2022.
These findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
Review of annual documentation was completed on 10/17/23 in all staff meeting. System was developed to utilize for non compliant patients and utilization of hold system to ensure required services are being completed. ED and CS will monitor annual completion by utilization of report system on a weekly basis |
709.92(a)(3) LICENSURE Treatment and rehabilitation services
709.92. Treatment and rehabilitation services.
(a) An individual treatment and rehabilitation plan shall be developed with a client. This plan shall include, but not be limited to, written documentation of:
(3) Proposed type of support service.
|
Observations
Based on a review of client records, the facility failed to document the proposed type of support services on the individual treatment and rehabilitation plan in one of two applicable client records reviewed.
Client # 5 was admitted on May 19, 2023 and was still active at the time of the inspection. The individual treatment and rehabilitation plan was completed on June 13, 2023; however, the plan did not include documentation of the proposed type of support services.
These finding was reviewed with facility staff during the licensing process.
|
Plan of Correction
10/17/23 training on treatment plan development was completed with clinical staff by clinical supervisor. Clinical supervisor will check for integration of support services when signing off on treatment plans daily to ensure issue does not continue. Updated treatment plan was complete for client #5 with primary counselor on 10/12/2023 reflect support service needs |
709.93(a)(11) 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:
(11) Follow-up information.
|
Observations
Based on a review of client records and the facility ' s policy and procedures, the facility failed to ensure a complete client record included information relative to the client's involvement with the project, to include follow-up information within 30 days of discharge, in two of three applicable records reviewed.
Client # 1 was admitted on February 14, 2022 and was discharged on June 5, 2023. The client record did not contain documentation of follow-up information.
Client # 7 was admitted on May 22, 2023 and was discharged on June 12, 2023. A follow up was due to be completed by July 12, 2023; however it was not completed until August 7, 2023.
This is a repeat citation from the April 21, 2023 annual licensing renewal inspection.
These findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
Training on discharge follow up policy was completed by Facility Director with all staff on 10/25/23. Executive Director will monitor and verify the completion of discharge follow through by monitoring report in EMR. Upcoming discharge follow ups 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 timely follow ups. |