INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on July 26, 2107 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Familylinks, 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:
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Plan of Correction
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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 document an emergency contact in one of three client records reviewed on July 26, 2017.
Ten client records were reviewed. Three were reviewed as Suboxone clients and required documentation of an emegency contact. There was no emergency contact documented in client record # 6.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Emergency Contact Information will be collected during the time of Initial Intake/Assessment and will be reviewed with the client on going while receiving treatment. If the client refuses to release an emergency contact, the client will be asked to sign a statement of refusal and this statement will be witnessed by Therapist and will be filed in client records. During Chart Audits, Program Manager will review that this is being implemented and filed in client charts. Program manager reviewed and implemented this during a staff meeting on July 28, 2017. |
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 it informed each female patient of the possible risks in one of two client records reviewed on July 26, 2017.
Ten client records were reviewed. Two were reviewed as female Suboxone clients and required documentation that they had be informed of the possible risks. There was no documentation in client record # 6 that the client had been informed of the possible risks.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Each Female patient will be informed verbally of the possible risk of SUBOXONE by the Nurse/Medical Assistant. Each female will also review a document that explains the risk and will sign and date. The Medical Staff will sign off as a witness that the document was reviewed during the time of the Initial appointment during the Induction Phase. During Chart Audits, Program Manager will review that this document is being reviewed with each Female client. This was reviewed with Nursing staff on July 31 and implemented on July 31, 2017. |
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 document a complete an initial drug-screening urinalysis in three of three client records reviewed on July 26, 2017.
Ten client records were reviewed. Three were reviewed as Suboxone clients and required documentation of an initial drug-screening urinalysis. There was no documentation provided of the initial drug screening in client records # 4, 5 and 6.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Initial drug-screening urinalysis will be completed on each client during their initial induction phase as well as during med maintenance. The Nurse/Medical Assistant will complete the urinalysis. The Nurse/Medical Assistant will cut the test result panel out of the cup and photo copy test results for client file. The client name and date will be written on the photo copied drug-screening urinalysis. The Clinic will be switching to a dip stick drug screening urinalysis. Submission for CLIA Waiver for Dip Stick has been submitted on 8/24/17 for approval to use. Photo copy of result panel has been implemented on July 31, 2017 and photo copies of results are being placed in client files. During Chart Audits for review, Program Manager will be conducting an audit that the results are in each client file. |
709.92(a) LICENSURE Treatment and rehabilitation services
709.92. Treatment and rehabilitation services.
(a) An individual treatment and rehabilitation plan shall be developed with a client. This plan shall include, but not be limited to, written documentation of:
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Observations
The facility failed to document an individual treatment and rehabilitation plan that included the type and frequency of treatment and rehabilitative services in 7 of 7 client records reviewed on July 26, 2017.
Ten client records were reviewed. Seven required documentation of an individual treatment plan.
Client records # 1, 2, 3, 7, 8, 9 and 10 did not document the type and frequency of treatment and rehabilitative services on the treatment plan.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Treatment Plan updates have been made to the Electronic Record System EVOLV. When completing a Treatment Plan the frequency of treatment will be prompted to select for each treatment goal. In the ERS, Rehabilitative Services will be identified via a drop down menu to select appropriate services as well as the Therapist having the option to type a rehabilitative service on the treatment plan. Both of these updates have been completed and initiated in the Electronic Record System and checked via a submission for review by Program Manager on Aug 4, 2017. This information is populated to reflect in the treatment plan and can be identified in the Electronic Records and a printed copy will be placed in file. Program manager will review during chart and during submission from Therapist for review and approval when completed. |
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 document that treatment and rehabilitation plans were reviewed and updated at least every 60 days in 2 of 6 client records reviewed on July 26, 2017.
Ten client records were reviewed. Six required treatment plan updates. Treatment plan updates in client records # 2 and 7 were not completed at least every 60 days.
Client # 2 update, due to be completed by June 6, 2017, was completed on July 12, 2017.
Client # 7 updates were due to be completed by January 2 and March 2, 2017. There were no updates documented.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Treatment Plan Updates will be completed at least every 60 days with the client. The Therapist will complete plan updates to review with the client on or before every 60 days of treatment. If the client cancels or is a no-show for the appointment, the Therapist will sign the completed updated document on the scheduled date. The Therapist will document a note that the updated treatment plan is completed and signed by Therapist and will review with the client on the rescheduled appointment. At this time the Treatment Plan will be signed by the client and the Therapist again to show date of review. Program Manager will review and sign off on Treatment Plans and will be checking the dates to be consistent with Treatment. Chart reviews will also be conducted by the Program Manager on going for review. Date implemented and reviewed with staff July 28, 2017. |