INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on June 25-26, 2014 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, WPIC Narcotic Addiction Treatment Program 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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711.93(c)(1)(i) LICENSURE Confidentiality - Client Identity/Records
711.93. Client records.
(c) Confidentiality.
(1) A written procedure shall be developed by the project director which complies with 4 Pa. Code 255.5 (relating to projects and coordinating bodies: disclosure of client-oriented information). The procedure shall include, but not be limited to:
(i) Confidentiality of client identity and records.
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Observations
Based on observation during the physical plant inspection, the facility failed to maintain the confidentiality of the client records.
The findings include:
The physical plant inspection was conducted on June 26, 2014. At the time of the physical plant inspection, client records were found stored in boxes that were housed in a locked closet. Although the closet door was locked, the boxes were not secured. Also stored in the closet were items that would be used by non drug and alcohol staff, thus allowing non drug and alcohol staff access to drug and alcohol client records.
A security staff member was present during the physical plant inspection and confirmed the findings.
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Plan of Correction
Under the Direction of the Project Director or designee, all patient records will be securely stored in locked rooms effective 8/1/14 and will not be used for storage of any materials other than clinical records. Non-clinical staff will not have access to these storage areas. The Program Director, Nursing Supervisor, and Clinical Supervisor will maintain the keys for the locked medical record storage room. Effective 8/1/14, the Program Director will also provide education to all staff re: the security and access of the medical record storage room. |
711.94 (g) LICENSURE Medical Assistance Provider Agreement
711.94. Project management services.
(g) Outpatient projects which receive reimbursement under the medical assistance program shall have a current, signed provider agreement with the Department of Public Welfare and comply with 55 Pa. Code Part III (relating to Medical Assistance Manual).
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Observations
Based on the review of client records, the facility failed to document a physician's signature on the individual treatment plans for medical assistance clients within the time frame established by the Office on Medical Assistance in six of sixteen client records.
The findings include:
Sixteen client records were reviewed on June 25-26, 2014. Sixteen client records were reviewed for the completion of treatment plans and/or treatment plan updates. There was no documentation in client records # 2, 3, 4, 8, 13 and 14 that the physician reviewed the client's treatment plans.
Client # 2 was admitted on November 5, 2013. There was no documentation provided that the physician reviewed the treatment plans completed on 11/26/13, 3/21/14 and 5/27/14.
Client # 3 was admitted on December 2, 2013. There was no documentation provided that the physician reviewed the treatment plans completed on 12/10/13, 4/21/14 and 6/18/14.
Client # 4 was admitted on May 3, 2014. There was no documentation provided that the physician reviewed the treatment plans completed on 9/20/13, 11/22/13, 1/27/14, 3/14/14 and 5/16/14.
Client # 8 was admitted on January 9, 2014. There was no documentation provided that the physician reviewed the treatment plans completed on 1/27/14, 4/14/14 and 6/2/14.
Client # 13 was admitted on December 19, 2013 and discharged on February 4, 2014. There was no documentation provided that the physician reviewed the treatment plan completed on January 9, 2014.
Client # 14 was admitted on August 19, 2013 and discharged on February 12, 2014. There was no documentation provided that the physician reviewed the treatment plan completed on August 30, 2014.
The Facility Director and Clinical Supervisor were interviewed on June 26, 2014 and confirmed the findings.
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Plan of Correction
Under the direction of the Project Director or designee, effective 8/1/14, the program director will work with the information system department to ensure all issues related to physician signature on completed treatment plans are identified.
Education and training will be provided to the clinical staff by 8/1/14 regarding checking all completed treatment plans have a signature line for the physician. Effective 8/1/14, supervisory staff will conduct 5 chart audits per therapist per month to monitor completed physician signature on treatment plans.
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