INITIAL COMMENTS
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This report is a result of an onsite Provisional license follow-up inspection regarding the plans of correction for the September 11-12, 2018 licensure renewal inspection and methadone monitoring inspection. The follow-up inspection was conducted on February 7, 2019 by staff from the Department of Drug and Alcohol Programs, Bureau of Quality Assurance for Prevention and Treatment. Based on the findings of the onsite follow-up 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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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
As of the date of the Provisional license follow-up inspection on February 7, 2019, the facility failed to obtain an annual financial audit for the fiscal year ending December 31, 2017.
These findings were reviewed with facility staff during the licensing process.
This is a repeat citation from the September 11-12, 2018 licensing inspection.
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Plan of Correction
Facility Director had attempted to request an exception from fiscal audit due to financial constraints however, it was not granted. Facility Director will ensure that Fiscal Audit for FY ending 2017 is completed along with the Audit for FY 2018 by 6/30/19 to be reviewed as required. Additional audits will be completed annually as required. Documentation will be maintained on-site as required. |
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 November 3, 2018 to January 5, 2019.
The narcotic treatment physician services for the eleven weeks were reviewed on February 7, 2019.
The week of 11/3-11/9, 2018 required 8 hours of physician services. The facility documented 7.
The week of 11/10-11/16, 2018 required 8.8 hours of physician services. The facility documented 8.5.
The week of 11/17-11/23, 2018 required 9.2 hours of physician services. The facility documented 6.
The week of 11/24-11/30, 2018 required 9.1 hours of physician services. The facility documented 8.
The week of 12/1-12/7, 2018 required 8.7 hours of physician services. The facility documented 6.
The week of 12/8-12/14, 2018 required 8.3 hours of physician services. The facility documented 6.
The week of 12/15-12/21, 2018 required 8.3 hours of physician services. The facility documented 7.5.
The week of January 5-11, 2019 required 7.8 hours of physician services. The facility documented 4.
These findings were reviewed with facility staff.
This is a repeat citation from the September 11-12, 2018 licensing inspection.
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Plan of Correction
Facility Director held a training for Medical Director related to hours required for patients being treated ratio. Additionally, documentation was updated by Facility Director to assist in clear and concise documentation and Medical Director is directly responsible for ensuring appropriate number of hours is documented as per State ratio. Facility Director will monitor compliance by checking timesheets of Medical Director randomly and will maintain all documentation on site for review. |
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 one of five patient records reviewed on February 7, 2019.
A total of eight patient records were reviewed on February 7, 2019, five patient records were required to document verification of identity.
Patient record # 2 was missing verification of the individual 's identity which included the patient's name, address and date of birth. The patient was previously a patient and had been discharged. Patient was readmitted on 11/21/18. The facility did not obtain verification of ID for either admissions.
These findings were reviewed with facility staff during the licensing inspection.
This is a repeat citation for the September 11-12, 2018 licensing inspection.
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Plan of Correction
Facility Director held an immediate training for all staff both Clinical and Medical to ensure that all individuals have a photo ID or other approved identification in patient chart prior to receiving any medication from this facility. Clinical Supervisor will monitor progress through random chart audits. All documentation will be maintained on-site for inspection as required. This was competed 2/8/2019. |