INITIAL COMMENTS
|
This report is a result of an on-site licensure renewal inspection and buprenorphine monitoring inspection conducted on January 17, 2024 through January 18, 2024 by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, Northeast Treatment Centers, 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:
|
Plan of Correction
|
709.24 (a) (3) LICENSURE Treatment/rehabilitation management.
§ 709.24. Treatment/rehabilitation management.
(a) The governing body shall adopt a written plan for the coordination of client treatment and rehabilitation services which includes, but is not limited to:
(3) Written procedures for the management of treatment/rehabilitation services for clients.
|
Observations
Based on review of client records and the policy and procedure manual, the facility failed to follow the project's written procedures for the management of treatment/rehabilitation services in two of two applicable client records reviewed.
The facility's policy and procedure manual stated that the emergency contact will be contacted within 12 hours after a client is discharged from the facility against medical advice, per the requirement in Licensing Alert 02-21.
Client #18 was admitted to the inpatient non-hospital on September 5, 2023 and left against medical advice on September 9, 2023. The facility contacted the client's probation and parole officer within 12 hours and designated that as the emergency contact notification. However, the client's mother was the designated emergency contact; therefore, there was no documentation of follow-up to the emergency contact within 12 hours, in the record, at the time of the inspection.
Client #22 was admitted to the inpatient non-hospital activity on October 11, 2023 and left against medical advice on October 11, 2023. There was no documentation of follow-up to the emergency contact within 12 hours, in the record, at the time of the inspection.
These findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
The AMA Follow Up policy was emailed to all program staff on 1/10/2024 by the Program Director. The Program Director provided training regarding the policy, implementation of the policy, and documentation of the follow-up call to the emergency contact to the treatment team during an all-staff meeting on 1/10/2024. The Program Director will provide training during individual supervision sessions. The Program Director will monitor AMA discharge charts for compliance with the policy.
The program will be in compliance as of 2/10/2024.
|
709.28 (c) 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.
|
Observations
Based on a review of client records, the facility failed to obtain a written informed and voluntary consent from the client for the disclosure of information contained in the client record in one of twenty-two client records reviewed.
Client #1 was admitted to the intake, evaluation and referral activity on May 10, 2023 and was discharged on May 10. 2023. The client was referred and transported to another treatment provider; however, there was no consent to release information form signed by the client documented in the record prior to the disclosure.
This finding was reviewed with facility staff during the licensing process.
|
Plan of Correction
The Program Director will provide training to the support staff regarding the use of the Release of Information form on 2/12/2024. The training will include how and why the program must obtain a written informed and voluntary consent from the client for the disclosure of information contained in the client record. The Records Management Supervisor will monitor charts for compliance. The Program Director will follow up during individual supervision as needed.
The program will be in compliance on 2/13/2024.
|
709.28 (c) (1) 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:
(1) Name of the person, agency or organization to whom disclosure is made.
|
Observations
Based on a review of client records, the facility failed to document the name of the person, agency, or organization to whom a disclosure was to be made to on release of information forms in three of twenty-two client records reviewed.
Client #1 was admitted to the intake, evaluation and referral activity on May 10, 2023 and was discharged on May 10. 2023. A release of information form was signed and dated by the client on May 10, 2023; however, the release form was blank and did not include the name of the person, agency, or organization to whom the disclosure was to be made to.
Client #3 was admitted to the intake, evaluation and referral activity on June 12, 2023 and was discharged on June 12, 2023. There were two release of information forms that were signed and dated by the client on June 12, 2023; however, both release forms were blank and neither one included the name of the person, agency, or organization to whom the disclosure was to be made to.
Client #4 was admitted to the intake, evaluation and referral activity on September 12, 2023 and was discharged on September 12, 2023. There were two release of information forms that were signed and dated by facility staff/witness on September 12, 2023; however, both release forms were blank and neither one included the name of the person, agency, or organization to whom the disclosure was to be made to.
These findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
The Program Director will provide training to the support staff regarding the use of the Release of Information form on 2/12/2024. The training will include how and why the program must obtain a written informed and voluntary consent from the client for the disclosure of information contained in the client record writing and include, but not be limited to: (1) Name of the person, agency or organization to whom disclosure is made. The Records Management Supervisor will monitor charts for compliance. The Program Director will follow up during individual supervision as needed.
The program will be in compliance on 2/13/2024. |
709.28 (c) (3) 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:
(3) Purpose of disclosure.
|
Observations
Based on a review of client records, the facility failed to document the purpose of the disclosure on consent to release information forms in ten of twenty-two client records reviewed.
Client #3 was admitted to the intake, evaluation and referral activity on June 12, 2023 and was discharged on June 12, 2023. A release of information form to the funding source was signed and dated by the client on June 12, 2023; however, the purpose of the disclosure was not included on the release form.
Client #5 was admitted to the intake, evaluation and referral activity on September 25, 2023 and was discharged on September 25, 2023. A release of information form to the funding source was signed and dated by the client on September 25, 2023; however, the purpose of the disclosure was not included on the release form.
Client #7 was admitted to the intake, evaluation and referral activity on October 3, 2023 and was discharged on October 3, 2023. A release of information form to the funding source was signed and dated by a witness on October 3, 2023; however, the purpose of the disclosure was not included on the release form.
Client #8 was admitted to the inpatient non-hospital detoxification activity on October 3, 2023 and was discharged on October 7, 2023. There were release of information forms to a funding source, a government agency, a urinalysis laboratory, and a pharmacy that were all signed and dated by a witness on October 3, 2023; however, the purpose of the disclosures were not included on any of the release forms. Additionally, there was a release of information form to a family member that was signed and dated by the client on October 4, 2023; however, the purpose of the disclosure was not included on the release form.
Client #9 was admitted to the inpatient non-hospital detoxification activity on October 6, 2023 and was discharged on October 11, 2023. There were release of information forms to a funding source and a urinalysis laboratory that were signed and dated by the client on October 6, 2023; however, the purpose of the disclosure was not included on either release form.
Client #10 was admitted to the inpatient non-hospital detoxification activity on October 20, 2023 and was discharged on October 24, 2023. There were release of information forms to a funding source, a government agency, a urinalysis laboratory, and a pharmacy that were all signed and dated by the client on October 20, 2023; however, the purpose of the disclosure was not included on any of the release forms.
Client #11 was admitted to the inpatient non-hospital detoxification activity on November 1, 2023 and was discharged on November 6, 2023. There were release of information forms to a funding source, a government agency, a urinalysis laboratory, another treatment provider, a probation and parole office, and a pharmacy that were all signed and dated by a witness on November 1, 2023; however, the purpose of the disclosure was not included on any of the release forms.
Client #12 was admitted to the inpatient non-hospital detoxification activity on November 2, 2023 and was discharged on November 7, 2023. There were release of information forms to a funding source, a government agency, a urinalysis laboratory, and an emergency contact that were all signed and dated by the client on November 2, 2023; however, the purpose of the disclosure was not included on any of the release forms.
Client #14 was admitted to the inpatient non-hospital detoxification activity on October 9, 2023 and was discharged on October 13, 2023. There were release of information forms to a funding source, a government agency, and a urinalysis laboratory that were signed and dated by the client on October 9, 2023; however, the purpose of the disclosure was not included on any of the release forms.
Client #20 was admitted to the inpatient non-hospital activity on September 25, 2023 and was discharged on October 8, 2023. There were release of information forms to a funding source, a urinalysis laboratory, and a pharmacy that were signed and dated by the client on September 25, 2023; however, the purpose of the disclosure was not included on any of the release forms. Additionally, there were release of information forms to another treatment provider and a government agency that were signed and dated by a witness on September 25, 2023; however, the purpose of the disclosure was not included on both release forms.
These findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
The Program Director will provide training to the support staff regarding the use of the Release of Information form on 2/12/2024. The training will include how and why the program must obtain a written informed and voluntary consent from the client for the disclosure of information contained in the client record and include, but not be limited to: (3) Purpose of disclosure. . The Records Management Supervisor will monitor charts for compliance. The Program Director will follow up during individual supervision as needed.
The program will be in compliance on 2/13/2024.
|
709.28 (c) (4) 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:
(4) Dated signature of client or guardian as provided for under 42 CFR 2.14(a) and (b) and 2.15 (relating to minor patients; and incompetent and deceased patients).
|
Observations
Based on a review of client records, the facility failed to document the dated signature of a client on release of information forms in nine of twenty-two client records reviewed.
Client #2 was admitted to the intake, evaluation and referral activity on May 29, 2023 and was discharged on May 29, 2023. A release of information form to a pharmacy was signed and dated by a witness on May 29, 2023; however, the dated signature of the client was not included on the release form.
Client #4 was admitted to the intake, evaluation and referral activity on September 12, 2023 and was discharged on September 12, 2023. There were release of information forms to a funding source and an emergency contact that were signed and dated by a witness on September 12, 2023; however, the dated signature of the client was not included on both release forms.
Client #6 was admitted to the intake evaluation and referral activity on May 16, 2023 and was discharged on May 16, 2023. There were release of information forms to a funding source and an emergency contact that were signed and dated by a witness on May 16, 2023; however, the dated signature of the client was not included on both release forms.
Client #7 was admitted to the intake evaluation and referral activity on October 3, 2023 and was discharged on October 3, 2023. A release of information form to a funding source was signed and dated by a witness on October 3, 2023; however, the dated signature of the client was not included on the release form.
Client #8 was admitted to the inpatient non-hospital detoxification activity on October 3, 2023 and was discharged on October 7, 2023. There were release of information forms to a funding source, a government agency, a urinalysis laboratory, and a pharmacy that were all signed and dated by a witness on October 3, 2023; however, the dated signature of the client was not included on any of the release forms.
Client #11 was admitted to the inpatient non-hospital detoxification activity on November 1, 2023 and was discharged on November 6, 2023. There were release of information forms to a funding source, a government agency, a urinalysis laboratory, another treatment provider, a probation and parole office, and a pharmacy that were all signed and dated by a witness on November 1, 2023; however, the dated signature of the client was not included on any of the release forms.
Client #15 was admitted to the inpatient non-hospital activity on May 29, 2023 and was discharged on July 13, 2023. A release of information form to an outside individual was signed and dated by a witness on May 30, 2023; however, the dated signature of the client was not included on the release form.
Client #20 was admitted to the inpatient non-hospital activity on September 25, 2023 and was discharged on October 8, 2023. There were release of information forms to a government agency and another treatment provider that were signed and dated by the facility staff on September 25, 2023; however, the dated signature of the client was not included on both release forms.
Client #21 was admitted to the inpatient non-hospital activity on May 16, 2023 and was discharged on May 28, 2023. There were release of information forms to a funding source, a government agency, another treatment provider, a pharmacy, and a urinalysis laboratory that were all signed and dated by facility staff on May 16, 2023; however, the dated signature of the client was not included on any of the release forms.
These findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
The Program Director will provide training to the support staff regarding the use of the Release of Information form on 2/12/2024. The training will include how and why the program must obtain a written informed and voluntary consent from the client for the disclosure of information contained in the client record and include, but not be limited to: (4) Dated signature of client or guardian as provided for under 42 CFR 2.14(a) and (b) and 2.15 (relating to minor patients; and incompetent and deceased patients). The Records Management Supervisor will monitor charts for compliance. The Program Director will follow up during individual supervision as needed.
The program will be in compliance on 2/13/2024.
|
709.28 (d) LICENSURE Confidentiality
§ 709.28. Confidentiality.
(d) A copy of a client consent shall be offered to the client and a copy maintained in the client record.
|
Observations
Based on a review of client records, the facility failed to document that a copy of a client consent was offered to the client in ten of twenty-two client records reviewed.
Client #5 was admitted to the intake, evaluation and referral activity on September 25, 2023 and was discharged on September 25, 2023. A release of information form to a funding source was signed and dated by the client on September 25, 2023; however, there was no other documentation indicating a copy of the form release was offered to the client.
Client #7 was admitted to the intake, evaluation and referral activity on October 3, 2023 and was discharged on October 3, 2023. A release of information form to a funding source was signed and dated by a witness on October 3, 2023; however, there was no other documentation indicating a copy of the release form was offered to the client.
Client #8 was admitted to the inpatient non-hospital detoxification activity on October 3, 2023 and was discharged on October 7, 2023. There were release of information forms to a funding source, a government agency, a urinalysis laboratory, and a pharmacy that were all signed and dated by a witness on October 3, 2023; however, there was no other documentation indicating a copy of any of the release form was offered to the client. Additionally, there was a release of information form to a family member that was signed and dated by the client on October 4, 2023; however, there was no other documentation indicating a copy of the release form was offered to the client.
Client #9 was admitted to the inpatient non-hospital detoxification activity on October 6, 2023 and was discharged on October 11, 2023. There were release of information forms to a funding source, an emergency contact, and a urinalysis laboratory that were signed and dated by the client on October 6, 2023; however, there was no other documentation indicating a copy of any of the release forms were offered to the client.
Client #10 was admitted to the inpatient non-hospital detoxification activity on October 20, 2023 and was discharged on October 24, 2023. There were release of information forms to a funding source, a government agency, a urinalysis laboratory, and a pharmacy that were all signed and dated by the client on October 20, 2023; however, there was no other documentation indicating a copy of any of the release forms were offered to the client.
Client #11 was admitted to the inpatient non-hospital detoxification activity on November 1, 2023 and was discharged on November 6, 2023. There were release of information forms to a funding source, a government agency, a urinalysis laboratory, another treatment provider, a probation and parole office, and a pharmacy that were all signed and dated by a witness on November 1, 2023; however, there was no other documentation indicating a copy of any of the release forms were offered to the client.
Client #12 was admitted to the inpatient non-hospital detoxification activity on November 2, 2023 and was discharged on November 7, 2023. There were release of information forms to a funding source, a government agency, a urinalysis laboratory, and an emergency contact that were all signed and dated by the client on November 2, 2023; however, there was no other documentation indicating a copy of any of the release forms were offered to the client.
Client #14 was admitted to the inpatient non-hospital detoxification activity on October 9, 2023 and was discharged on October 13, 2023. There were release of information forms to a funding source, a government agency, and a urinalysis laboratory that were signed and dated by the client on October 9, 2023; however, there was no other documentation indicating a copy of any of the release forms were offered to the client.
Client #20 was admitted to the inpatient non-hospital activity on September 25, 2023 and was discharged on October 8, 2023. There were release of information forms to a funding source, a urinalysis laboratory, and a pharmacy that were signed and dated by the client on September 25, 2023; however, there was no other documentation indicating a copy of any of the release forms were offered to the client. Additionally, there were release of information forms to another treatment provider and a government agency that were signed and dated by a witness on September 25, 2023; however, there was no other documentation indicating a copy of both release forms were offered to the client.
These findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
The Program Director will provide training to the support staff regarding the use of the Release of Information form on 2/12/2024. The training will include how and why the program must obtain a written informed and voluntary consent from the client for the disclosure of information contained in the client record, and a copy of a client consent shall be offered to the client and a copy maintained in the client record. The Records Management Supervisor will monitor charts for compliance. The Program Director will follow up during individual supervision as needed.
The program will be in compliance on 2/13/2024.
|
709.33 (a) LICENSURE Notification of termination.
§ 709.33. Notification of termination.
(a) Project staff shall 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.
|
Observations
Based on a review of client records, the facility failed to notify the client, in writing, of the decision to involuntarily terminate the client's treatment at the project, including the reason for termination, in two of two applicable client records reviewed.
Client #19 was admitted to the inpatient non-hospital activity on September 12, 2023 and was administratively discharged on September 24, 2023. There was no documentation, in the record, indicating that the client was notified in writing of the facility's decision to involuntarily terminate the client's treatment at the project.
Client #20 was admitted to the inpatient non-hospital activity on September 25, 2023 and was administratively discharged on October 8, 2023. There was no documentation, in the record, indicating that the client was notified in writing of the facility's decision to involuntarily terminate the client's treatment at the project.
These findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
On 2/6/2024, the Senior Director reviewed the termination letter policy and procedure with the Program Director. The Program Director will provide a letter to all clients who are administratively discharged. The letter shall include the reason for termination. The Records Management Supervisor will monitor charts for compliance. The Senior Director will follow up during individual supervision as needed.
The program will be in compliance on 2/7/2024.
|
709.34 (c) (1) LICENSURE Reporting of unusual incidents
§ 709.34. Reporting of unusual incidents.
(c) To the extent permitted by State and Federal confidentiality laws, the project shall file a written unusual incident report with the Department within 3 business days following an unusual incident involving:
(1) Physical or sexual assault by staff or a client.
|
Observations
Based on review of the facility's unusual incident reports, the facility failed to notify the Department within 3 business days of a physical or sexual assault by staff or a client.
On May 17, 2023, a physical assault among two clients occurred at the facility; however, the incident was not reported to the Department as of the date of the inspection.
This finding was reviewed with facility staff during the licensing process.
|
Plan of Correction
On 2/6/2024, the Senior Director reviewed the unusual incident report policy and procedure with the Program Director. The Program Director to the extent permitted by State and Federal confidentiality laws, the file a written unusual incident report with the Department within 3 business days following an unusual incident involving: (1) Physical or sexual assault by staff or a client. The Senior Director will monitor for compliance. The Senior Director will follow up during individual supervision as needed. |
709.34 (c) (4) LICENSURE Reporting of unusual incidents
§ 709.34. Reporting of unusual incidents.
(c) To the extent permitted by State and Federal confidentiality laws, the project shall file a written unusual incident report with the Department within 3 business days following an unusual incident involving:
(4) Event at the facility requiring the presence of police, fire or ambulance personnel.
|
Observations
Based on review of the facility's unusual incident reports, the facility failed to notify the Department within 3 business days of an event at the facility requiring the presence of police, fire, or ambulance personnel.
On March 6, 2023 and on May 21, 2023, the police, fire, or ambulance was called to the facility; however, both of the incidents were not reported to the Department as of the date of the inspection.
These findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
On 2/6/2024, the Senior Director reviewed the unusual incident report policy and procedure with the Program Director. The Program Director to the extent permitted by State and Federal confidentiality laws, the file a written unusual incident report with the Department within 3 business days following an unusual incident involving: (4) Event at the facility requiring the presence of police, fire or ambulance personnel. The Senior Director will monitor for compliance. The Senior Director will follow up during individual supervision as needed.
The program will be in compliance on 2/7/2024.
|
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.
|
Observations
Based on a review of patient records, the facility failed to verify the individual's identity, including name, address, date of birth, emergency contact and other identifying data, prior to the administration of an agent, in two of eleven applicable client records reviewed.
Patient #8 was admitted to the inpatient non-hospital detoxification activity on October 3, 2023 and was discharged on October 7, 2023. There was no verification or documentation of the client's emergency contact in the record prior to the administration of an agent.
Patient #16 was admitted to the inpatient non-hospital activity on June 13, 2023 and was discharged on July 13, 2023. There was no verification or documentation of the client's emergency contact in the record prior to the administration of an agent.
These findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
The Program Director will provide training to the support staff regarding the use of the Release of Information form on 2/21/2024. The training will include the need to obtain a release of information form for an emergency contact for all clients receiving buprenorphine. A copy of the release of information will be maintained in the client record. The Records Management Supervisor will monitor charts for compliance. The Program Director will follow up during individual supervision as needed.
The program will be in compliance on 2/22/2024
|
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.
|
Observations
Based on a review of patient records, the facility failed to provide documentation that the narcotic treatment physician conducted the initial face-to-face with the client prior to the administration of a maintenance agent in one of eleven applicable patient records reviewed.
Patient #12 was admitted to the inpatient non-hospital detoxification activity on November 2, 2023 and was discharged on November 7, 2023. The physician prescribed the patient's first dose of medication on November 2, 2023; however, the initial face-to-face meeting with the physician was conducted and documented on November 3, 2023.
This finding was reviewed with facility staff during the licensing process.
|
Plan of Correction
The Program Director will provide training to the medical providers and nursing staff regarding the policy that a narcotic treatment physician must 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, and that 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 prior to the administration of a maintenance agent. Training will be provided individually and will be completed by 2/28/2024. The Records Management Supervisor will monitor charts for compliance.
The program will be in compliance on 2/29/2024.
|
715.12(1-5) LICENSURE Informed patient consent
A narcotic treatment program shall obtain an informed, voluntary, written consent before an agent may be administered to the patient for either maintenance or detoxification treatment. The following shall appear on the patient consent form:
(1) That methadone and LAAM are narcotic drugs which can be harmful if taken without medical supervision.
(2) That methadone and LAAM are addictive medications and may, like other drugs used in medical practices, produce adverse results.
(3) That alternative methods of treatment exist.
(4) That the possible risks and complications of treatment have been explained to the patient.
(5) That methadone is transmitted to the unborn child and will cause physical dependence.
|
Observations
Based on a review of patient records, the facility failed to obtain and informed, voluntary, written consent before an agent may be administered to the patient for maintenance or detoxification treatment in two of eleven applicable patient records reviewed.
Patient #8 was admitted to the inpatient non-hospital detoxification activity on October 3, 2023 and was discharged on October 7, 2023. The physician first prescribed an agent to the patient on October 4, 2023 at 10:37AM. The consent to treatment with an agent was documented and signed by the patient on October 4, 2023 at 1:01PM.
Patient #18 was admitted to the inpatient non-hospital activity on September 5, 2023 and was discharged on September 9, 2023. The physician first prescribed an agent to the patient on September 6, 2023. The consent to treatment with an agent was documented and signed by the patient on September 8, 2023.
These findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
The Program Director will have the Consent Form added to the intake form group. Program Director will provide training to the staff on 2/21/2024 regarding the change in procedure. Program Director will follow up in individual supervision. The Records Management Supervisor will monitor charts for compliance.
The program will be in compliance on 2/22/2024.
|
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.
|
Observations
Based on a review of patient records, the facility failed to ensure the completion of a random drug-screening analysis at least monthly after the initial drug-screen urinalysis in two of two applicable patient records reviewed.
Patient #15 was admitted to the inpatient non-hospital activity on May 29, 2023 and was discharged on July 13, 2023. There was no monthly urinalysis drug-screen documented in the record for the month of June 2023.
Patient #17 was admitted to the inpatient non-hospital activity on June 12, 2023 and was discharged on August 14, 2023. There was no monthly urinalysis drug-screen documented in the record for the month of July 2023.
These findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
The Care Coordinator will schedule clients for a monthly urinalysis drug-screen. The UDS schedule has been placed on the Care Coordinator and Program Director's calendars. The Program Director monitor the chart for compliance.
The program will be in compliance on 2/15/2024.
|
715.20(1) LICENSURE Patient transfers
A narcotic treatment program shall develop written transfer policies and procedures which shall require that the narcotic treatment program transfer a patient to another narcotic treatment program for continued maintenance, detoxification or another treatment activity within 7 days of the request of the patient.
(1) The transferring narcotic treatment program shall transfer patient files which include admission date, medical and psychosocial summaries, dosage level, urinalysis reports or summary, exception requests, and current status of the patient, and shall contain the written consent of the patient.
|
Observations
Based on a review of patient records, the narcotic treatment program failed to ensure that all patient files, to include admission date, medical and psychosocial summaries, dosage level, urinalysis reports or summary, exception requests, and current status of the patient, and shall contain the written consent of the patient, were transferred to another narcotic treatment program. transfer patient files in one of one applicable patient records reviewed.
Patient #21 was admitted on May 16, 2023 and was transferred to another narcotic treatment program on May 28, 2023. There was no documentation in the record that indicated the program transferred the patient's admission date, medical and psychosocial summaries, dosage level, urinalysis reports or summary, exception requests, and current status of the patient to the receiving narcotic treatment program.
This finding was reviewed with facility staff during the licensing process.
|
Plan of Correction
The Program Director will provide staff training on 2/21/2024 regarding the policy of: the narcotic treatment program transfer a patient to another narcotic treatment program for continued maintenance, detoxification or another treatment activity within 7 days of the request of the patient. (1) The transferring narcotic treatment program shall transfer patient files which include admission date, medical and psychosocial summaries, dosage level, urinalysis reports or summary, exception requests, and current status of the patient, and shall contain the written consent of the patient. A copy the documentation sent to the receiving program will be uploaded to the patient record. The Records Management Supervisor will monitor charts for compliance.
The program will be in compliance on 2/22/2024.
|
715.21(1)(i-iv) 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.
(1) A narcotic treatment program may involuntarily terminate a patient from the narcotic treatment program if it deems that the termination would be in the best interests of the health or safety of the patient and others, or the program finds any of the following conditions to exist:
(i) The patient has committed or threatened to commit acts of physical violence in or around the narcotic treatment program premises.
(ii) The patient possessed a controlled substance without a prescription or sold or distributed a controlled substance, in or around the narcotic treatment program premises.
(iii) The patient has been absent from the narcotic treatment program for 3 consecutive days or longer without cause.
(iv) The patient has failed to follow treatment plan objectives.
|
Observations
Based on a review of patient records, the facility failed to document that an involuntary termination of a patient that the program deems would be in the best interests of the health and safety of the patient and others, or the program finds the patient committed or threatened to commit acts of physical violence in or around the narcotic treatment program premises, in one of one applicable patient records reviewed.
Patient #19 was admitted on September 12, 2023 and was administratively discharged on September 24, 2023. There was documentation, in the record, of the patient being rude or disengaged during several group sessions. Even though the patient was administratively discharged, there was no other documentation that indicated the patient was terminated due to the health or safety of others or for threats or physical acts of violence.
This finding was reviewed with facility staff during the licensing process.
|
Plan of Correction
The Program Director will provide training to the staff on 2/21/2024 regarding the program policy of: Involuntary terminations shall be initiated only when all other efforts to retain the patient in the program have failed. (1) A narcotic treatment program may involuntarily terminate a patient from the narcotic treatment program if it deems that the termination would be in the best interests of the health or safety of the patient and others, or the program finds any of the following conditions to exist: (i) The patient has committed or threatened to commit acts of physical violence in or around the narcotic treatment program premises. (ii) The patient possessed a controlled substance without a prescription or sold or distributed a controlled substance, in or around the narcotic treatment program premises. (iii) The patient has been absent from the narcotic treatment program for 3 consecutive days or longer without cause. (iv) The patient has failed to follow treatment plan objectives. The Program Director will monitor the client record for compliance with the policy an proper documentation of discharge reason in the instance of an administrative discharge.
The program will be in compliance on 2/22/2024.
|
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.
|
Observations
Based on a review of patient records, the facility failed to provide an involuntarily terminated patient with the opportunity to receive detoxification of at least 7 days in one of one applicable patient records reviewed.
Patient #19 was admitted on September 12, 2023 and was administratively discharged on September 24, 2023. The patient was administratively discharged; however, there was no documentation, in the record, that the patient was afforded the opportunity to receive detoxification of at least 7 days.
This finding was reviewed with facility staff during the licensing process.
|
Plan of Correction
On 2/21/2024, the Program Director will provide the staff training regarding the policy of providing an involuntarily terminated patient with the opportunity to receive detoxification of at least 7 days. The Program Director will monitor the client record for compliance.
The program will be in compliance on 2/22/2024
|
715.24(4)(iii) LICENSURE Narcotic detoxification
If a narcotic treatment program provides narcotic detoxification services, the narcotic treatment program shall develop and implement narcotic detoxification policies and procedures which include the following:
(4) Minimum requirements for short-term narcotic detoxification treatment are as follows:
(iii) The narcotic treatment program shall develop a treatment plan. The patient's counselor shall monitor the patient's progress toward the goal of short-term narcotic detoxification and possible drug-free treatment referral.
|
Observations
Based on a review of patient records, the narcotic treatment program failed to develop a treatment plan which shall monitor the patient's progress toward the goal of short-term narcotic detoxification and possible drug-free treatment referral in one of four applicable patient records reviewed.
Client #10 was admitted to the inpatient non-hospital detoxification activity on October 20, 2023 and was discharged on October 24, 2023. There was no treatment plan/nursing treatment plan, documented in the patient record, at the time of the inspection.
This finding was reviewed with facility staff during the licensing process.
|
Plan of Correction
The Program Director will provide the nursing staff with induvial training regarding developing a treatment plan which shall monitor the patient's progress toward the goal of short-term narcotic detoxification and possible drug-free treatment referral. The training will be completed by 2/28/2024. The Records Management Supervisor will monitor charts for compliance.
The program will be in compliance on 2/29/2024.
|
709.52(a)(2) LICENSURE Tx type & frequency
709.52. 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:
(2) Type and frequency of treatment and rehabilitation services.
|
Observations
Based on a review of client records, the facility failed to document the type and frequency of treatment and rehabilitation services in the client's individual treatment and rehabilitation plan in two of five applicable client records reviewed.
Client #17 was admitted to the non-hospital inpatient activity on June 12, 2023 and was discharged on August 14, 2023. The individual treatment and rehabilitation plan was completed on June 21, 2023; however, the plan did not include the frequency of the treatment and rehabilitation services being provided to the client.
Client #19 was admitted to the non-hospital inpatient activity on September 12, 2023 and was discharged on September 24, 2023. The individual treatment and rehabilitation plan was completed on September 19, 2023; however, the plan did not include the frequency of the treatment and rehabilitation services being provided to the client.
These findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
The Program Director will provide the counselors with induvial training regarding developing a treatment plan which includes the frequency of the treatment and rehabilitation services being provided to the client. The training will be completed by 2/28/2024. The Records Management Supervisor will monitor charts for compliance.
The program will be in compliance on 2/29/2024.
|
709.52(a)(3) LICENSURE Support service type
709.52. 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:
(3) Proposed type of support service.
|
Observations
Based on a review of client records, the facility failed to document the proposed type of support services in the client's individual treatment and rehabilitation plan in two of five applicable client records reviewed.
Client #17 was admitted to the non-hospital inpatient activity on June 12, 2023 and was discharged on August 14, 2023. The individual treatment and rehabilitation plan was completed on June 21, 2023; however, the proposed type of support services was not documented in the plan.
Client #19 was admitted to the non-hospital inpatient activity on September 12, 2023 and was discharged on September 24, 2023. The individual treatment and rehabilitation plan was completed on September 19, 2023; however, the proposed type of support services was not documented on the plan.
These findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
The Program Director will provide the counselors with induvial training regarding developing a treatment plan which includes the proposed type of support services was not documented on the plan. The training will be completed by 2/28/2024. The Records Management Supervisor will monitor charts for compliance.
The program will be in compliance on 2/29/2024.
|
709.53(a)(10) LICENSURE Discharge Summary
709.53. Client records.
(a) There shall be a complete client record on an individual which includes information relative to the client's involvement with the project. This shall include, but not be limited to, the following:
(10) Discharge summary.
|
Observations
Based on a review of client records, the facility failed to maintain a complete client record, which is to include a discharge summary, in three of eight applicable client records reviewed.
Client #20 was admitted inpatient non-hospital activity on September 25, 2023 and was discharged on October 8, 2023. There was no documentation of a discharge summary, in the record, at the time of the inspection.
Client #21 was admitted inpatient non-hospital activity on May 16, 2023 and was discharged on May 28, 2023. There was no documentation of a discharge summary, in the record, at the time of the inspection.
Client #22 was admitted inpatient non-hospital activity on October 11, 2023 and was discharged on October 11, 2023. There was no documentation of a discharge summary, in the record, at the time of the inspection.
These findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
The Program Director will provide the counselors with induvial training regarding completion of discharge summaries. The training will be completed by 2/28/2024. The Records Management Supervisor will monitor charts for compliance.
The program will be in compliance on 2/29/2024.
|
709.44(a)(4) LICENSURE Referral contact
709.44. Client records.
(a) The project shall maintain a client record on an individual which shall include, but not be limited to:
(4) Referral contact.
|
Observations
Based on a review of client records, the facility failed to maintain a client record on an individual which shall include, but not be limited to, referral contacts in one of seven applicable client records reviewed.
Client #1 was admitted to the intake, evaluation and referral activity on May 10, 2023 and was discharged on May 10. 2023. The client was referred and transported to another treatment provider; however, there was no documentation in the record of the referral contact at the time of the inspection.
This finding was reviewed with facility staff during the licensing process.
|
Plan of Correction
The Operations Coordinator will provide the staff with induvial training regarding completion of releases of information for all referral contacts. The training will be completed by 2/28/2024. The Records Management Supervisor will monitor charts for compliance.
The program will be in compliance on 2/29/2024.
|