INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on April 1-2, 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 on-site inspection, Positive Pathways 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
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 on April 1-2, 2019 for documentation of an annual audit of financial activities associated with the project's drug/alcohol abuse services. The project's fiscal year runs from July 1 to June 30. The project did not document an independent financial audit for the 2017/2018 fiscal year.
The findings were reviewed with the facility staff during the licensing process.
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Plan of Correction
709.25 Fiscal Management: Corrective Action Plan In response to the Fiscal Management deficiency in section 709.25. Positive Pathways has obtained the services of an independent accountant on April 19, 2019 for the future purpose of 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. The annual audit will be completed within six months following the end of Positive Pathways' fiscal year. The project director will be directly responsible for completion of the task. |
709.28 (c) (2) 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:
(2) Specific information disclosed.
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Observations
The facility failed to document a complete release of information form prior to the disclosure of information in three of four client records.
Four client records were reviewed on April 1-2, 2019. All four required documentation of releases of information. Client records # 1, 2 and 3 documented specific information to be released that exceeded the parameters of 255.5.
In client record #1, a release of information, signed on September 27, 2018 allowed for the release of treatment plans, records of service and record of significant client contact to a third party payor.
In client record #2, a release of information, signed on October 3, 2018 allowed for the release of treatment plans, records of service and record of significant client contact to a third party payor.
In client record # 3, a release of information, signed on December 18, 2018 allowed for the release of treatment plans, records of service and record of significant client contact to a third party payor.
These findings were reviewed with the facility staff during the licensing process.
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Plan of Correction
Positive Pathways revised and implemented, on 5/1/2019, its ROI to reflect strictly the following:
The following information is requested: (patient √ items to be released).
__Whether the client is or is not in treatment
__The prognosis of the client
__The nature of the project
__A brief description of the progress of the client
__A short statement as to whether the client has relapsed into drug, or alcohol abuse and the frequency of such relapse
The clinical supervisor is responsible for adherence to the utilization of the new ROI. This will be reflected in the clinical supervisor's monthly chart audit results. Deficiencies discovered in the monthly chart audits will be addressed with the Program Director, with the counselor/staff person in question, and in the weekly staff meeting to help educate all others related to proper policy adherence. |
709.30 (1) 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.
(1) A client receiving care or treatment under section 7 of the act (71 P. S. § 1690.107) shall retain civil rights and liberties except as provided by statute. No client may be deprived of a civil right solely by reason of treatment.
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Observations
The facility failed to provide written documention that the client was notified of the rights in four of four client records.
Four client records were reviewed on April 1-2, 2019. Four required documentation the client was informed of the rights.
Client records 1, 2, 3 and 4 did not document that the client was informed of the rights.
These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
On 5/1/2019, Positive Pathways revised and implemented changes to correct the deficiency related to client rights. Client rights are documented in the client handbook. As of 5/1/2019, clients will sign-off on a signature page indicating they have received the client handbook and been informed of their client rights. The signature page will be scanned into the client's EMR chart. The clinical supervisor is responsible for compliance to the corrected plan of action. This will be reflected in the clinical supervisor's monthly chart audit results. Deficiencies discovered in the monthly chart audits will be addressed with the Program Director, with the counselor/staff person in question, and in the weekly staff meeting to help educate all others related to proper policy adherence. |
715.9(a)(1) 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:
(1) Verify that the individual has reached 18 years of age.
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Observations
The facility failed to verify the individual reached 18 years of age in one of four records reviewed.
Four buprenorphine client records were reviewed on April 1-2, 2019. Four required verification of age.
Client record #3 did not document verification of the client's age.
These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
Positive Pathways, on 5/1/2019, implemented policies and procedures to ensure compliance with 715.9(a)(1) Intake: Positive Pathways will collect photo IDs on all individuals upon intake/assessment. The photo ID will be scanned into the client's EMR chart. All staff were educated on the deficiency and planned change at the 4-8-19 and 4-15-19 staff meetings. The clinical supervisor is responsible for compliance to the corrected plan of action. This will be reflected in the clinical supervisor's monthly chart audit results. Deficiencies discovered in the monthly chart audits will be addressed with the Program Director, with the counselor/staff person in question, and in the weekly staff meeting to help educate all others related to proper policy adherence.
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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 four records reviewed.
Four buprenorphine client records were reviewed on April 1-2, 2019. Four required verification of identity.
Client record #3 did not document verification of the client's identity.
These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
Positive Pathways, on 5/1/2019, implemented policies and procedures to ensure compliance with 715.9(a)(1) Intake: Positive Pathways will collect photo IDs on all individuals upon intake/assessment. The photo ID will be scanned into the client's EMR chart. All staff were educated on the deficiency and planned change at the 4-8-19 and 4-15-19 staff meetings. The clinical supervisor is responsible for compliance to the corrected plan of action. This will be reflected in the clinical supervisor's monthly chart audit results. Deficiencies discovered in the monthly chart audits will be addressed with the Program Director, with the counselor/staff person in question, and in the weekly staff meeting to help educate all others related to proper policy adherence. |
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 that the narcotic treatment physican determined evidence of a 1 year history of addiction in four of four records reviewed.
Four buprenorphine client records were reviewed on April 1-2, 2019. Four required the documentation of the determination of a 1 year history of dependency.
There was no documentation that the physician determined the 1 year history of addiction in records # 1, 2, 3 and 4.
These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
715.9(a)(4) Intake: Positive Pathways, on 5/1/2019, began documenting, in the client's EMR chart, the determination of a 1 year history of addiction upon intake. All staff were educated on the deficiency and planned change at the 4-8-19 and 4-15-19 staff meetings. Positive Pathways' physician was further trained and educated on 4-22-2019 related to proper documentation of his determination when completing an intake. The clinical supervisor is responsible for compliance to the corrected plan of action. This will be reflected in the clinical supervisor's monthly chart audit results. Deficiencies discovered in the monthly chart audits will be addressed with the Program Director, with the counselor/staff person in question, and in the weekly staff meeting to help educate all others related to proper policy adherence.
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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
The facility failed to document that each female patient was fully informed of the possible risks to her and her unborn child in two of two records.
Four buprenorphine patient records were reviewed on April 1-2, 2019. Two records reviewed were female patients. There was no documentation provided that patient records # 1 and 3 were informed of the risks.
These findings were reviewed with facility staff during the licening process.
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Plan of Correction
On 5/1/2019, Positive Pathways revised the intake packet to include information fully informing each female patient 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. Each female will sign off on this notification and will be included in the patient's EMR chart. All staff were educated on the deficiency and planned change at the 4-8-19 and 4-15-19 staff meetings. The clinical supervisor is responsible for compliance to the corrected plan of action. This will be reflected in the clinical supervisor's monthly chart audit results. Deficiencies discovered in the monthly chart audits will be addressed with the Program Director, with the counselor/staff person in question, and in the weekly staff meeting to help educate all others related to proper policy adherence.
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715.13(b) LICENSURE Patient identification
(b) A narcotic treatment program shall maintain onsite a photograph of each patient which includes the patient 's name and birth date. The narcotic treatment program shall update the photograph every 3 years.
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Observations
The facility failed to maintain an onsite photograph of each patient in one of four patient records.
Four buprenorphine patient records were reviewed on April 1-2, 2019. All required an onsite photograph.
Patient record # 3 did not document a photograph of the patient.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Positive Pathways, on 5/1/2019, implemented policies and procedures to ensure compliance with 715.13(b)
Patient identification: Positive Pathways will collect photo IDs on all individuals upon intake/assessment. The photo ID will be scanned into the client's EMR chart and updated every 3years. All staff were educated on the deficiency and planned change at the 4-8-19 and 4-15-19 staff meetings. The clinical supervisor is responsible for compliance to the corrected plan of action. This will be reflected in the clinical supervisor's monthly chart audit results. Deficiencies discovered in the monthly chart audits will be addressed with the Program Director, with the counselor/staff person in question, and in the weekly staff meeting to help educate all others related to proper policy adherence. |
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 complete a initial drug- screening urinalysis for each prospective patient in one of four patient records.
Four buprenorphine patient records were reviewed on April 1-2, 2019. All four required an initial urinalysis. Patient # 1 did not document an initial urinalysis for a prospective patient.
Patient # 1 was admitted on September 27, 2018. The patient received the first prescription for Suboxone on September 27, 2018. The initial urinalysis documented was completed on October 4, 2018.
These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
Positive Pathways will complete an initial urine screen for each individual prospective client as evidenced in the patient chart and reflected in Positive Pathways' Policies and Procedures. Record of the initial urine screen will documented in the client's EMR chart and reviewed by the physician prior to writing of a buprenorphine prescription. This practice has been implemented on 5/1/2019 and all staff were educated on this at both 4-8-19 and 4-15-19 staff meetings. The clinical supervisor will be responsible for ensuring compliance by completing monthly chart audits. |
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.
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Observations
The facility failed to document that the patient was provided at least 1 hour of individual counseling per month in two of four patient records reviewed.
Four buprenorphine patient records were reviewed on April 1-2, 2019. All four required 1 hour of individual counseling per month. Patients # 3 and 4 did not document the required counseling.
Patient # 3 was admitted on December 18, 2018 and was still an active patient at the time of the licensing inspection. There were no individual counseling session documented form December 18, 2018 to March 31, 2019.
Patient # 4 was admitted on November 28, 2018 and was discharged on February 15, 2091. The patient had only one-half hour of individual counseling session documented from November 28, 2018 to January 31, 2019.
These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
Positive Pathways conducted a training by the clinical supervisor with all clinical staff at staff meeting on 4-8-19 to review the regulation:
A narcotic treatment program shall provide each patient an average of 2.5 hours of psychotherapy per month during the patient first 2 years, 1 hour of which shall be individual psychotherapy.
This is evidenced by staff meeting minutes from 4-8-19. Additional review and follow-up was conducted on 4-15-19 with all clinical staff to ensure understanding and implementation. This is evidenced in staff meeting minutes from 4-15-2019. The clinical supervisor is responsible for compliance to the corrected plan of action. This will be reflected in the clinical supervisor's monthly chart audit results. Deficiencies discovered in the monthly chart audits will be addressed with the Program Director, with the counselor/staff person in question, and in the weekly staff meeting to help educate all others related to proper policy adherence.
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715.21(2) LICENSURE Patient termination
A narcotic treatment program shall develop and implement policies and procedures regarding involuntary terminations. Involuntary terminations shall be initiated only when all other efforts to retain the patient in the program have failed.
(2) A patient terminated involuntarily, except a patient who commits or threatens to commit acts of physical violence, shall be afforded the opportunity to receive detoxification of at least 7 days. The detoxification may take place at the facility or the patient may be referred to another narcotic treatment program or hospital licensed and approved by the Department for detoxification.
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Observations
The facility failed to develop policies that addressed that a patient terminated involuntarily shall be afforded the opportunity to receive detoxification of at least 7 days.
The policy and procedure manual was reviewed on April 1-2, 2019. There were no policies or procedures documented regarding the affording the patient the opportunity of a detoxification.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Positive Pathways revised and implemented, on 5/1/2019, policy to reflect the requirements of 715.21: Involuntary Termination. See Below:
§ 715.21(1)-(2) Patient Termination. The program will 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.
A client may be discharged from Positive Pathways should one or more of the following conditions are present:
1. A client misses three consecutive appointments without sufficient cause or neglects to cancel.
2. Ninety days have expired after a client has left treatment against the advice of staff or without informing staff.
3. The client has failed to meet the requirements of the treatment plan.
4. It is deemed that the termination would be in the best interests of the health or safety of the patient and others.
The client is given the reason for the discharge as part of the aftercare plan that is offered at the time of discharge. The physician will provide the patient with a minimum 7 day detoxification prescription.
A client has the right to request re-admittance after 30 day written discharge. Upon consultation with the Clinical Supervisor, a client may be readmitted to treatment.
The physician is directly responsible for writing the 7 day detox prescription and the Program Director will be notified within 24 hours of the involuntary discharge and corresponding prescription. |
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
The facility failed to ensure that the treatment and rehabilitation plans were reviewed and updated at least every sixty days in two of three client records.
Four client records were reviewed on April 1-2, 2019. Three required treatment updates. Client records # 2 and 3 documented updates that were not completed at least every sixty days.
Client # 2 had a treatment plan update due to be completed by January 28, 2019. The update was completed on February 7, 2019.
Client # 3 had a treatment plan update due to be completed by February 19, 2019. The update was completed on March 27, 2019.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Positive Pathways, specifically the clinical supervisor, reviewed the deficiency related to 709.92(b)
Treatment and rehabilitation services: treatment and rehabilitation plans shall be reviewed and updated at least every sixty days, with staff on 4-8-19 and 4-15-19. In addition to this review, the clinical supervisor will provide yearly clinical training on clinical documentation and due dates. This will be evidenced in the staff training plans and personnel files. Monthly chart audits will also be conducted by the clinical supervisor to ensure compliance. Deficiencies discovered in the monthly chart audits will be addressed with the Program Director, with the counselor/staff person in question, and in the weekly staff meeting to help educate all others related to proper policy adherence |