INITIAL COMMENTS
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This report is a result of an on-site licensure renewal and buprenorphine inspection conducted on April 6-7, 2015 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Allied Addiction Recovery 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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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
Based on the review of client records, the facility failed to document that a client, who was being involuntarily terminated, was afforded the opportunity to receive detoxification of at least 7 days in two of two client records.
Ten client records were reviewed on April 6-7, 2014. Ten client records were reviewed as buprenorphine clients. Two records reviewed were involuntarily terminated from the program. There was no documentation in client records # 9 and 10 that the client was afforded the opportunity to receive detoxification of at least 7 days.
Client # 9 was admitted as a buprenorphine client on August 10, 2014 and was involuntarily terminated on January 11, 2015. There was no documentation that the client was given the opportunity to receive detoxification of at least 7 days.
Client # 10 was admitted as a buprenorphine client on August 27, 2014 and was involuntarily terminated on November 30, 2014. There was no documentation that the client was given the opportunity to receive detoxification of at least 7 days.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
An involuntary discharge form has been developed by the Facility Director that will be used to document whether an involuntarily discharged client accepted or refused the opportunity to receive detoxification of at least 7 days. This form was introduced at a staff meeting on 4/8/15 to all clinical & medical staff. The Clinical Supervisor will ensure through discharge file audits that the form is in place and utilized for the next 6 months. |
709.94(g) LICENSURE Project management services
709.94. 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 a review of the client records, the facility failed to comply with 55 Pa. Code Part III (relating to Medical Assistance Manual) in three of five client records.
The findings include:
Ten client records were reviewed on April 6-7, 2015. Five of the ten client records' funding was through Medical Assistance and required a physician's signature on the treatment plans within 15 days. The individual treatment plans contained in client records # 3, 5 and 8 did not contain a physician's signature as established by the Office of Medical Assistance.
Client # 3 was admitted on October 19, 2014. The comprehensive treatment plan was completed on December 7, 2014. There was no documentation of a physician's signature as established by the Office of Medical Assistance.
Client # 5 was admitted on September 28, 2014.. The comprehensive treatment plan was completed on November 23, 2014. There was no documentation of a physician's signature as established by the Office of Medical Assistance.
Client # 8 was admitted on June 22, 2014. The comprehensive treatment plan was completed on July 22, 2014. There was no documentation of a physician's signature as established by the Office of Medical Assistance.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The standardized form used in our other sites that documents treatment plans contain a physician's signature as established by the Office of Medical Assistance, has been implemented in this site. Administrative Assistants removed the old form on 4/8/2015 replacing it with the new form. Clinical and Medical staff were informed by the Clinical Supervisor during a meeting on 4/8/15. The Clinical Supervisor will perform chart audits for the next 6 months to ensure the new form is being used. |