INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection and methadone monitoring inspection conducted on September 11-12, 2018 by staff from the Department of Drug and Alcohol Programs, Bureau of Quality Assurance for Prevention and Treatment, Division of Accountability and Program Improvement. Based on the findings of the on-site inspection, Clear Choices 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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704.11(c)(1) LICENSURE Mandatory Communicable Disease Training
704.11. Staff development program.
(c) General training requirements.
(1) Staff persons and volunteers shall receive a minimum of 6 hours of HIV/AIDS and at least 4 hours of tuberculosis, sexually transmitted diseases and other health related topics training using a Department approved curriculum. Counselors and counselor assistants shall complete the training within the first year of employment. All other staff shall complete the training within the first 2 years of employment.
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Observations
The facility failed to ensure that counselors received the HIV/AIDS and the tuberculosis, sexually transmitted diseases and other health related topics training within the first year of employment in one of one personnel records reviewed on September 11-12, 2018.
Employee # 3 was hired as a counselor on August 1, 2017. There was no documentation as of September 12, 2018 that the counselor had completed the required trainings.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Facility Director will have Medical Director complete TB/STD training on site on 10/31/18 to ensure all staff have appropriate training requirements. Additionally, each staff member will obtain the HIV/AIDS trainings as required within one year of employment. Clinical Supervisor will maintain training documentation on site for review as needed and Facility Director will maintain on-going compliance through random employee chart audits. |
709.25 LICENSURE Fiscal Management
§ 709.25. Fiscal management.
The project shall obtain the services of an independent certified public accountant for an annual financial audit of activities associated with the project ' s drug/alcohol abuse services, in accordance with generally accepted accounting principles which include reference to the drug and alcohol treatment activities.
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Observations
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 facility's administrative records were reviewed for documentation of an annual audit of financial on September 11-12, 2018. The project's fiscal year runs from January to December. The project did not document an independent financial audit for the 2017 fiscal year.
These findings were discussed with facility staff during the licensing process.
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Plan of Correction
Facility Director shall obtain either an exception for the fiscal audit from 2017 due to financial constraints this year or the independent audit for 2017 by the end of this year, 2018. Annual Audits will be completed by June 30 each subsequent year and the results will be available for review as needed. Facility Director will monitor compliance through random fiscal auditing. |
709.33 (a) LICENSURE Notification of termination.
§ 709.33. Notification of termination.
(a) Project staff shall notify the client, in writing, of a decision to involuntarily terminate the client ' s treatment at the project. The notice shall include the reason for termination.
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Observations
The facility failed to document the client was notified, in writing, of a decision to involuntarily terminate the client ' s treatment at the project in one of two client records reviewed on September 11-12, 2018.
There was no documention of written notification in client record # 12, of the decision to involuntarily terminate the client.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Facility Director shall hold an in house training to review with staff to inform all patients of involuntary termination even if the individual must receive notice in the mail. Training will be completed on 10/31/18 and documentation will be maintained on site for review. Clinical Supervisor will monitor compliance through random chart audits. |
709.33 (b) LICENSURE Notification of termination.
§ 709.33. Notification of termination.
(b) The client shall have an opportunity to request reconsideration of a decision terminating treatment.
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Observations
The facility failed to document the client had an opportunity to request reconsideration of a decision terminating treatment in one of two client records reviewed on September 11-12, 2018.
There was no documention in client record #12 of the opportunity to request reconsideration of the decision to terminate the client's treatment.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Facility Director will hold an in house training on 10/31/18 to review Patient Grievance Procedure to ensure that all patients can request reconsideration from termination as appropriate. Facility Director will maintain documentation of training for review as needed and Clinical supervisor will monitor compliance through random chart audits. |
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
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Observations
The facility failed to provide narcotic treatment physician services of at least 1 hour per week onsite for every ten patients for the weeks of May 2, 2018 to August 15, 2018.
The narcotic treatment physician services for the sixteen weeks of May 2, 2018 to August 15, 2018 were reviewed on September 11-12, 2018. All sixteen weeks required at least 9.4 hours or more a week of onsite narcotic treatment physician services. Fifteen of the sixteen weeks reviewed documented less hours a week of onsite narcotic treatment physician services than required.
These findings were reviewed with facility staff.
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Plan of Correction
Facility Director shall hold an in house training regarding required Physician hours related to patient base. Training will be completed on 10/31/18 and documentation will be maintained on site for review as needed. Facility Director shall monitor hours through random audits of physician timesheets to ensure compliance. |
715.9(a)(2) 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:
(2) Verify the individual 's identity, including name, address, date of birth, emergency contact and other identifying data.
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Observations
The facility failed to verify the individual 's identity in two of nine patient records reviewed on September 11-12, 2018.
Patient records # 9 and 11 were missing verification of the individual 's identity which included the patient's name, address and date of birth.
These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
Facility Director shall hold an in house training related to verification of patient identity prior to initiation of treatment on 10/31/18 and will maintain documentation of that training for review as needed. Clinical Supervisor will monitor compliance through random chart audits. |
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
The facility failed to document the narcotic treatment physician made the face-to-face determination prior to administration of an agent, in one of nine patient records reviewed on September 11-12, 2018.
Patient record # 2 was first dosed on July 30, 2018. The narcotic treatment physician's documented face-to-face determination was completed on August 6, 2018.
These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
Facility Director shall hold an in house training related to MD face to face documentation prior to initiating treatment on 10/31/18 and will maintain record of that training for review as needed. Clinical Supervisor will monitor compliance through random chart audits. |
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
The facility failed to document monthly urinalysis in two of twelve patient records reviewed on September 11-12, 2018.
Patient records # 4 and 6 did not document an August 2018 urinalysis.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Facility Director shall hold an in house training related to urinalysis requirements on 10/31/18 for all staff and will maintain documentation on site for review as needed. Each Counselor will monitor their caseloads to ensure compliance and Nurses will monitor all patients to ensure compliance. Clinical Supervisor will complete random chart audits to ensure compliance. |
715.17(c)(1)(i-vi)) LICENSURE Medication control
(c) A narcotic treatment program shall develop and implement written policies and procedures regarding the medications used by patients which shall include, at a minimum:
(1) Administration of medication.
(i) A narcotic treatment physician shall determine the patient 's initial and subsequent dose and schedule. The physician shall communicate the initial and subsequent dose and schedule to the person responsible for the administration of medication. Each medication order and dosage change shall be written and signed by the narcotic treatment physician.
(ii) An agent shall be administered or dispensed only by a practitioner licensed under the appropriate Federal and State laws to dispense agents to patients.
(iii) Only authorized staff and patients who are receiving medication shall be permitted in the dispensing area.
(iv) There shall be only one patient permitted at a dispensing station at any given time.
(v) Each patient shall be observed when ingesting the agent.
(vi) Administering and dispensing shall be conducted in a manner that protects the patient from disruption or annoyance from other individuals.
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Observations
The facility failed to document that each medication order and dosage change was written and signed by the narcotic treatment physician in three of nine patient records reviewed on September 11-12, 2018.
Patient records # 7, 11 and 12 documented orders that were written by someone other than the narcotic treatment physician. Documentation of the narcotic treatment physician's signature stated that the physician had "approved the order".
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Facility Director will hold an in house training related to ensure that all dose changes are written directly by the physician on 10/31/18. Physician will receive training as needed for the computerized records to ensure correct wording. Documentation of training will be maintained on site for review as needed and Clinical Supervisor will monitor through random chart audits. |
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.
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Observations
The facility failed to document that it notified, in writing, the transferring narcotic treatment program of the admission of the patient and the date of the initial dose given, in two of three patient records reviewed on September 11-12, 2018.
There was no documentation in patient records # 4 and 10, that the transferring program was notified, in writing, of the admission and the date of the initial dose.
These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
Facility Director shall hold a training on 10/31/18 regarding notification of transfer to sending treatment facilities. Documentation of that training will be maintained for review as needed and Clinical Supervisor will monitor compliance through random chart audits. |