INITIAL COMMENTS
|
This report is a result of an on-site licensure renewal inspection conducted on December 18, 2017 through December 19, 2017 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, Newvitae, Inc. 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
|
705.28 (d) (4) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(4) Maintain a written fire drill record including the date, time, the amount of time it took for evacuation, the exit route used, the number of persons in the facility at the time of the drill, problems encountered and whether the fire alarm or smoke detector was operative.
|
Observations
Based on the review of the fire drill logs for November 2016 through November 2017, the facility failed to document whether the fire alarm or smoke detector was operative during each fire drill for the time period reviewed. Additionally, the fire drill logs for August 31, 2017, December 30, 2016, December 29, 2016 and November 18, 2016 were all missing the exit route used.
These findings were reviewed with facility staff during the licensing.
|
Plan of Correction
The Fire Drill form has been reviewed. The form does ask whether or not the smoke detector was operative or not. It also asks the route. The form was, at times, incorrectly completed. The person who conducts fire drills was retrained on the proper completion of the form. Plan is as follows:
1: Review the Fire Drill Form-- completed on 12/21/17
2: Meet with Fire Drill captain to discuss the non-compliance. Completed on 12/21/17
3: Retrain Fire drill captain. Completed 12/21/17.
Revised procedure:
A: Immediately following the fire drill, the fire drill captain will test the smoke alarm by pushing the test alarm button.
B: Drill Captain will document on the Fire Drill form whether or not the fire alarm was operative.
C: reviewed with Fire drill captain that every month, must indicate what exit route was used.
4: Confirm that new procedure is being followed. Completed 1/3/18 on fire drill completed on 12/29/17 by director.
|
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 the review of 18 client records, the facility failed to document an informed and voluntary consent to release information form prior to the disclosure of information in 3 client records. Additionally, 5 client records reviewed had consent to release forms that were missing required elements.
Client #3 was admitted on 11/24/17 to the partial hospitalization level of care and was an active client at the time of the inspection. There was a consent to release information form signed and dated by the client on 11/24/17 to an outside individual; however, it listed "other" for the purpose and did not specify the purpose for the disclosure.
Client #5 was admitted on 7/13/17 to the partial hospitalization level of care and was discharged on 8/29/17. There was a consent to release information form signed and dated by the client on 7/13/17 to an outside individual; however, it listed "other" for the purpose and did not specify the purpose for the disclosure. Additionally, there was documentation that the facility had billed the funding source; however, there was no consent to the funding source prior to the disclosure.
Client #6 was admitted on 4/4/17 to the partial hospitalization level of care and was discharged on 5/25/17. There was a facsimile sent to the funding source on 3/29/17; however, there was no consent to the funding source on file prior to the disclosure.
Client #8 was admitted on 9/1/17 to the outpatient level of care and was still an active client at the time of the inspection. There were two facsimiles sent to another treatment provider on 9/6/17 and 9/25/17, two facsimiles sent to the funding source on 9/22/17 and 9/25/17, and three facsimiles sent to a government agency on 8/29/17, 8/28/17 and 9/19/17; however, there were no consent to release forms to these entities to date prior to any of the disclosures. Additionally, there was a consent to release information form signed and dated by the client on 10/30/17 to an outside individual; however, it listed "other" for the purpose and did not specify the purpose for the disclosure.
Client #9 was admitted on 7/12/17 to the outpatient level of care and was still an active client at the time of the inspection. There was documentation that the facility had billed the funding source; however, there was no consent to the funding source on file prior to the disclosure.
Client #16 was admitted on 2/27/17 to the intake, evaluation and referral activity. There was a consent form signed and dated by the client on 2/27/17 to the funding source; however, it did not specify the purpose for the disclosure.
These findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
There were two problems identified:
1)incorrect use of the "other" category on a release form. The "other" category was not completed accurately by our office manager; there was no explanation clarifying the use for "other."
2)Misunderstanding of a new form specific to Magellan Health Choices. We thought that it served as a release of information for Magellan when in fact it was only a Consent to Treatment form. We now include a release specific for the Magellan Health Choices in respect to payment communications.
Plan:
1: Meet with Office manager to review proper use of the "Other:" section on a release form. COMPLETED 12/21/17
2: Inclusion of a separate release of information form specific to the Magellan Health choices payor. COMPLETED 12/21/17
3: Confirmation that the new procedure is in place since 12/21/17. Checked all new cases on 1/3/18. Both items are have now been corrected.
|
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.
|
Observations
Based on a review of 2 applicabble client records, 1 client record did not contain documentation that the facility informed female clients of the potential risks to her or her unborn child of continued use of illicit drugs, or withdrawal from a narcotic drug prescribed by the program.
Client #10 was admitted on 4/4/17 to the outpatient level of care and was an active client at the time of the inspection.
These findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
Plan:
1: Develop a document informing female clients of the potential risks of Buprenorphine use. (Completed 1/3/18)
Person Responsible: Todd Barlow, Director
2: Submit a sample document to our Medical Director for review. (Completed 1/3/2018)
Person Responsible: Todd Barlow, Director
3: Edit document based on Medical Director's counsel. (1/9/18)
Person Responsible: Sajeda Bhallo
Therapist/Assistant Director
4: Have all existing and any new female clients on Suboxone review and sign the form.
Person Responsible: individual Counselors -- document to be placed in file by Todd Barlow, director
5: Place in Psychiatrist intake packet to be used for all female residents.
Person Responsible: Sajeda Bhallo, therapist Assistant/director |
715.19(1) LICENSURE Psychotherapy services
A narcotic treatment program shall provide individualized psychotherapy services and shall meet the following requirements:
(1) A narcotic treatment program shall provide each patient an average of 2.5 hours of psychotherapy per month during the patient 's first 2 years, 1 hour of which shall be individual psychotherapy. Additional psychotherapy shall be provided as dictated by ongoing assessment of the patient.
|
Observations
Based on a review of client records, the facility failed to provide 2.5 hours of psychotherapy per month, including at least one hour of individual psychotherapy, during the patient's first 2 years of treatment for 2 out of 2 applicable client records reviewed.
Client #9 was admitted on 7/12/17 to the outpatient level of care and was an active client at the time of the inspection. During the months of September, October and November, the client only received a total of 2 hours and 45 minutes of psychotherapy.
Client #10 was admitted on 4/4/17 to the outpatient level of care and was an active client at the time of the inspection. During the months of September, October and November the client only received a total of 2 hours of psychotherapy.
These findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
Clients have been resisting attending at that required 2.5 hours per month.
Plan:
1: Signed document will be developed that all clients on buprenorphine are required to attend at minimum 2.5 hrs Completed 1/5/18. Todd Barlow Administrator
2: Each client will sign the document in their next session. Completed by 1/18/18 or next attended appointment. Individual Counselors will be responsible have the document of understanding explained and signed.
3: If pattern of infrequent counseling attendance persists, this fact will be documented in the file and discussed with the client. Lack of sufficient attendance will become a therapeutic issue. Person Responsible: Individual Therapist
|
709.91(b)(7) LICENSURE Intake and admission
709.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(7) Preliminary treatment and rehabilitation plan.
|
Observations
Based on a review of 7 outpatient client records, the facility failed to document a preliminary treatment plan in 3 client records.
Client #8 was admitted on 9/1/17 to the outpatient level of care and was an active client at the time of the inspection.
Client #9 was admitted on 7/12/17 to the outpatient level of care and was an active client at the time of the inspection.
Client #10 was admitted on 4/4/17 to the outpatient level of care and was an active client at the time of the inspection.
These findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
Plan:
1: Treatment Team was alerted to the new procedure for any client transferred between programs. This occurred in Team Meeting on 12/21/17. Person responsible: Todd Barlow, Director.
2: Effective immediately all transfer cases will also have a preliminary treatment plan developed during the first Transfer session. This form will be placed in the file and and signed by the therapist. Persons Responsible: Individual therapists.
3: Assurance that the new procedure is implemented will be handled by the Office Manager, Llolanda Velez, through her existing chart audits. |
709.93(a) 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:
|
Observations
Based on a review of 7 outpatient client records, the facility failed to provide a complete client record in 4 of 4 applicable client records.
Client #11 was admitted on 3/22/17 to the outpatient level of care and was discharged on 8/7/17. The record did not contain documentation of an aftercare plan or follow-up information.
Client #12 was admitted on 12/14/16 to the outpatient level of care and was discharged on 6/2/17. The record did not contain documentation of an aftercare plan or follow-up information.
Client #13 was admitted on 1/17/17 to the outpatient level of care and was discharged on 6/22/17. The record did not contain documentation of an aftercare plan or follow-up information.
Client #14 was admitted on 9/11/17 to the outpatient level of care and was discharged on 12/8/17. The record did not contain documentation of an aftercare plan or follow-up information.
These findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
The Aftercare and Follow Up procedure we use in our PHP program did not get expanded to include OP clients as well. This will now be implemented:
1: develop software system for OP to mirror what we currently do for our PHP program. completed by 1/19/18 Person Responsible: Todd Barlow, Director
2: instruct staff about the need for aftercare planning and followup. (This will not be difficult since the staff are used to the PHP procedure.) Person responsible: Todd Barlow, Director by 1/22/18.
3: Begin implementing both followup and aftercare by 2/11/18. (The software system will alert staff to assure compliance.) Person Responsible: Todd Barlow, director by 2/11/18.
|