INITIAL COMMENTS
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Based on the concerns arising from COVID-19, The Department of Drug and Alcohol Programs, Bureau of Program Licensure, has implemented temporary procedures for conducting an annual renewal inspection.
The inspection will be divided into two parts.
1, an abbreviated off-site inspection, will be conducted off site, and will require the submission of administrative information via email to a Licensing Specialist.
2, an abbreviated on-site inspection, will be conducted on-site at a later date and will include a review of client/patient records, and a physical plant inspection.
This report is a result of Part 2, an abbreviated on-site inspection, conducted on February 10, 2021 by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Not all regulations were reviewed, the remainder of the regulations were reviewed during Part 1.
Based on the findings of Part 2, an abbreviated on-site inspection, Visualize Change, LLC 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) (4) 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:
(4) Dated signature of client or guardian as provided for under 42 CFR 2.14(a) and (b) and 2.15 (relating to minor patients; and incompetent and deceased patients).
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Observations
Based on a review of seven client records, the project failed to 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, a dated signature of client or guardian as provided for under 42 CFR 2.14(a) and (b) and 2.15 (relating to minor patients; and incompetent and deceased patients).
Client #1 was admitted on January 22, 2021 and was current at the time of the inspection. An informed and voluntary consent from the client for the disclosure of information contained in the client record to a funder and an emergency contact dated January 22, 2021 did not included a signature from the client. On the client signature line, it stated " telehealth. "
Client #2 was admitted on December 15, 2020 and was current at the time of the inspection. An informed and voluntary consent from the client for the disclosure of information contained in the client record to a funder and an emergency contact dated December 15, 2020 did not included a signature from the client. On the client signature line, it stated " telehealth. "
Client #3 was admitted on March 9, 2018 and was discharged June 30, 2020. An informed and voluntary consent from the client for the disclosure of information contained in the client record to the client ' s husband dated April 11, 2020 did not included a signature from the client. On the client signature line, it stated " telehealth. "
Client #7 was admitted on September 27, 2019 and was current at the time of the inspection. Informed and voluntary consents from the client for the disclosure of information contained in the client record to a funder and an emergency contact dated September 14, 2020, to a government agency dated October 13, 2020, to another drug and alcohol facility dated February 4, 2021 and to a medical provider dated February 4, 2021 did not included a signature from the client. On the client signature line, it stated " telehealth. "
These findings were reviewed with the facility during the licensing process.
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Plan of Correction
The Facility Director will make ensure that all voluntary consent to treatment are signed in the initial assessment in person. If the client cannot attend, or the COVID pandemic continues, the consent taken orally via telehealth and then will be sent to the client's valid Email address via Docusign. The client will be instructed to sign the document and return it to Visualize Change via email. The newly signed document will be put in the client file alongside the original consent that was given at the time of the telehealth assessment. All effort will be made to have this occur on the same day. |
709.30 LICENSURE Client Rights
§ 709.30. Client rights.
The project shall develop written policies and procedures on client rights and document written acknowledgement by clients that they have been notified of those rights.
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Observations
Based on a review of seven client records, the project failed to develop written policies and procedures on client rights and document written acknowledgement by clients that they have been notified of those rights.
Client #1 was admitted on January 22, 2021 and was current at the time of the inspection. In the client record there was no documented written acknowledgement by the client that they had been notified of those rights. There was only a statement that said " telehealth " that was dated January 22, 2021.
Client #2 was admitted on December 15, 2020 and was current at the time of the inspection. In the client record there was no documented written acknowledgement by the client that they had been notified of those rights. There was only a statement that said " telehealth " that was dated December 15, 2020.
Client #6 was admitted on January 21, 2021 and was current at the time of the inspection. In the client record there was no documented written acknowledgement by the client that they had been notified of those rights. There was only a statement that said " telehealth " that was dated January 21, 2021.
These findings were reviewed with the facility during the licensing process.
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Plan of Correction
The Facility Director will make ensure that all Client Rights Documents are signed in the initial assessment in person. If the client cannot attend, or the COVID pandemic continues, the Client rights will be explained orally via telehealth and then will be sent to the client's valid Email address via Docusign. The client will be instructed to sign the document and return it to Visualize Change via email. The newly signed document will be put in the client file alongside the original Client Rights that were explained at the time of the telehealth assessment. All effort will be made to have this occur on the same day. |
715.10(e)(1) LICENSURE Pregnant patients
(e) A patient who is or becomes pregnant may not be started or continued on LAAM, except by the written order of a narcotic treatment physician who determines that LAAM is the best therapy for that patient.
(1) An initial pregnancy test shall be performed for each prospective female patient of childbearing potential before admission to LAAM comprehensive maintenance treatment.
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Observations
Based on a review of seven client records, the facility failed to perform an initial pregnancy test for each prospective female patient of childbearing potential before admission to LAAM comprehensive maintenance treatment in one record reviewed.
Client #6 was admitted on January 21, 2021 and was current at the time of the inspection. The facility failed to document an initial pregnancy test before administering a narcotic agent.
These findings were reviewed with the facility during the licensing process.
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Plan of Correction
The Facility Director will ensure that all female client are given an instant pregnancy test at the time of the MAT Induction. The client will give a urine sample to staff and staff will open a new instant urine dip test in front of the client. The client and staff will observe the dip test as long as necessary to determine if the client is pregnant or not. |
715.10(f) LICENSURE Pregnant patients
(f) The narcotic treatment program shall ensure that each female patient is fully informed of the possible risk to her or her unborn child from continued use of illicit drugs and from use of, or withdrawal from a narcotic drug administered or dispensed by the program in comprehensive maintenance or detoxification treatment.
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Observations
Based on a review of seven client records, the narcotic treatment program failed to ensure that one applicable female patient was fully informed of the possible risk to her or her unborn child from continued use of illicit drugs and from use of, or withdrawal from a narcotic drug administered or dispensed by the program in comprehensive maintenance or detoxification treatment.
Client #6 was admitted on January 21, 2021 and was current at the time of the inspection. The facility failed to document the patient was fully informed of the possible risk to her or her unborn child from continued use of illicit drugs and from use of, or withdrawal from a narcotic drug administered or dispensed by the program in comprehensive maintenance or detoxification treatment.
These findings were reviewed with the facility during the licensing process.
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Plan of Correction
The Facility Director will ensure that each female client is fully informed of the possible risk to her or her unborn child from continued use of illicit drugs and from use of withdrawal from narcotic drug administered or dispensed by the program. The Medial Director will explain these risks to the client and the client will sign a form stating that she understands the risks to her and her unborn child. |
715.14(a) LICENSURE Urine testing
(a) A narcotic treatment program shall complete an initial drug-screening urinalysis for each prospective patient and a random urinalysis at least monthly thereafter.
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Observations
Based on a review of seven client records, the narcotic treatment program failed to complete an initial drug-screening urinalysis for each prospective patient and a random urinalysis at least monthly thereafter in one record reviewed.
Client #6 was admitted on January 21, 2021 and was current at the time of the inspection. The facility failed to document an initial drug-screening urinalysis prior to administering a narcotic agent.
These findings were reviewed with the facility during the licensing process.
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Plan of Correction
The Facility Director will ensure that all clients are given an instant urine test at the time of induction into the MAT program. The client will give a urine sample to staff and staff will open a new instant urine dip test for fentanyl in front of the client. The client and staff will observe the dip test as long as necessary to determine if the client has fentanyl in their system. The staff and client will also observe the POC urine cup to see if there are any drugs in the client's system that might interfere with MAT. The Medical Director will be given the results of the urine test. |
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 client records, the facility failed to review, and update treatment and rehabilitation plans at least every 60 days.
Client #4 was admitted on May 23, 2019 and was discharged on June 30, 2020. The client had a treatment and rehabilitation plan dated October 3, 2019 that should have been updated by December 3, 2019 but was not completed until December 5, 2019. Another treatment and rehabilitation plan dated March 31, 2020 was due to be updated by May 31, 2020 but was not completed until June 9, 2020.
These findings were reviewed with the facility during the licensing process.
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Plan of Correction
The Facility Director will hold a training to make sure all counselors understand the Updated Treatment Plan requirement of 60 days and that it does not need a client signature on that date. The client can sign at a later date. Going forward all treatment plans will be updated within 60 days. |
709.92(c) LICENSURE Treatment and rehabilitation services
709.92. Treatment and rehabilitation services.
(c) The project shall assure that counseling services are provided according to the individual treatment and rehabilitation plan.
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Observations
Based on a review of seven client records, the project failed to assure that counseling services are provided according to the individual treatment and rehabilitation plan.
Client #3 was admitted on March 9, 2018 and was still current at the time of the inspection. The facility failed to follow the individual treatment and rehabilitation plan dated January 4, 2021 that indicated individual sessions biweekly. During the weeks of January 4, 2021 - January 16, 2021 only one individual session was documented and during the weeks of January 17, 2021- January 30, 2021 only one individual session was documented.
Client #4 was admitted on May 23, 2019 and was discharged on June 30, 2020. The facility failed to follow the individual treatment and rehabilitation plan dated March 31, 2020 that indicated individual sessions biweekly. There was only an individual session documented for March 31, 2020 and no other until April 29, 2020.
These findings were reviewed with the facility during the licensing process.
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Plan of Correction
The Facility Director will hold a training to make sure all counselors understand the need to be accurate when specifying the treatment options on the client treatment plans. The counselors will schedule the client to reflect the stated modality on the treatment plan. |