INITIAL COMMENTS
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This report is a result of an on-site inspection conducted for the approval to use a narcotic agent, specifically methadone, in the treatment of narcotic addiction. This inspection was conducted on March 5-6, 2014 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Clear Choices, LLC was found not to be in compliance with the applicable chapters of 4 PA Code and 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)(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
Based on the review of patient records, the facility failed to document verification that the individual has reached 18 years of age in one of seven patient records.
The findings include:
Ten patient records were reviewed March 5 - 6, 2014. Seven patient records were reviewed for documentation of verification that the individual has reached 18 years of age. Prior to administration of an agent, a narcotic treatment program shall screen each individual to determine eligibility for admission. One patient record did not include this documentation.
Patient # 2 was admitted into treatment on August 15, 2013, discharged on January 27, 2014. The initial dose of methadone was given to the patient on August 15, 2013. The facility failed to document verification that the individual has reached 18 years of age prior to administration of methadone.
The findings were reviewed with the project/facility director and were not disputed.
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Plan of Correction
Facility Director shall hold an inservice training for all staff regarding obtaining patient identifying information prior to admission which includes such things as photo ID, Birth Certificate, personal bills, etc., to ensure that the individual receiving services has reached the age of 18. Copies of identifying information shall become part of the patient's record. Facility Director shall conduct the training prior to 4/25/14 and will maintain documentation of the training on-site for review. Facility Director shall monitor compliance through random chart audits. |
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
Based on the review of patient records, the facility failed to document verification of the individuals identity, including name, address, date of birth, emergency contact and other identifying data, in one of seven patient records.
The findings include:
Ten patient records were reviewed on March 5 - 6, 2014. Seven patient records were reviewed for the verification of the individuals identity. One patient record did not include the documentation.
Patient # 2 was admitted into treatment on August 15, 2013, discharged on January 27, 2014. The initial dose of methadone was given to the patient on August 15, 2013. The facility failed to document verification of the individuals identity prior to the first administration of methadone.
The findings were reviewed with the project/facility director and were not disputed.
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Plan of Correction
Facility Director shall hold an inservice training for all staff regarding obtaining patient identifying information prior to admission which includes such things as photo ID, Birth Certificate, personal bills, etc., to ensure that we have verified the individual's identity. Copies of identifying information shall become part of the patient's record. Facility Director shall conduct the training prior to 4/25/14 and will maintain documentation of the training on-site for review. Facility Director shall monitor compliance through random chart audits. |
715.9(c) LICENSURE Intake
(c) If a patient was previously discharged from treatment at another narcotic treatment program, the admitting narcotic treatment program, with patient consent, shall contact the previous facility for the treatment history.
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Observations
Based on the review of patient records, the facility failed to contact the previous narcotic treatment facility for the patient's treatment history in one of one patient records reviewed.
The findings include:
Ten patient records were reviewed on March 5 - 6, 2014. One patient record required contacting the prior narcotic treatment facility for the previous treatment history that was reported by the patient.
Patient # 2 was admitted into treatment on August 15, 2013, discharged on January 27, 2014. Record #2 contained documentation the patient had received narcotic treatment services previously at other narcotic treatment program. The facility failed to document any attempt to obtain the patient's prior treatment history from the previously attended narcotic treatment facility.
The findings were reviewed with the project/facility director and were not disputed.
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Plan of Correction
Facility Director shall provide training related to reviewing dual enrollment forms for notification of previous treatment obtained by patient which was not previously disclosed by the patient. If notification is obtained in this manner, counselors will seek consent from the patient to attempt to obtain previous treatment documentation. Documentation will be maintained as part of the patient's record. Facility Director shall conduct the training by 4/25/14 and will maintain the training record for review. Facility Director will monitor compliance through random chart audits. |
715.23(b)(6) LICENSURE Patient records
(b) Each patient file shall include the following information:
(6) Results of laboratory tests or other special examinations given by the narcotic treatment program.
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Observations
Based on a review of patient records and an interview with the project/facility director, the facility failed to document the results of laboratory tests in four of four patient records.
The findings include:
Ten patient records were reviewed on March 5 - 6, 2014. Four patient records were required to have results of laboratory tests; specifically a tuberculosis Mantoux test (PPD). The facility failed to document the results of a Mantoux test in patient records # 2, 5, 6 and 7.
Patient # 2 was admitted into treatment on August 15, 2013, discharged on January 27, 2014. There was no documentation of the results of a Mantoux test in patient record # 2.
Patient # 5 was admitted into treatment on November 21, 2013 . There was no documentation of the results of a Mantoux test in patient record # 5.
Patient # 6 was admitted into treatment on November 21, 2013 . There was no documentation of the results of a Mantoux test in patient record # 6.
Patient #7 was admitted into treatment on January 9, 2014. There was no documentation of the results of a Mantoux test in patient record # 7.
The findings were reviewed with the project/facility director and were not disputed.
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Plan of Correction
Facility Director shall provide inservice training related to providing TB testing on-site, through previous providers, or by referral to a facility who can provide the testing. Documentation of TB testing shall be maintained as part of the patient's record. Facility Director shall complete the training by 4/25/14 and will maintain the training record for review. Facility Director shall monitor complaince through random chart audits. |