INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection and methadone monitoring inspection conducted on October 1 - 3, 2018 by staff from the Department of Drug and Alcohol Programs, Bureau of Quality Assurance for Prevention and Treatment, Division of Accountability and Program Improvement. Based on the findings of the on-site inspection, Fayette Treatment Center, LLC d/b/a Greene Treatment Center 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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715.23(c)(1-7) LICENSURE Patient records
(c) An annual evaluation of each patient 's status shall be completed by the patient 's counselor and shall be reviewed, dated and signed by the medical director. The annual evaluation period shall start on the date of the patient 's admission to a narcotic treatment program and shall address the following areas:
(1) Employment, education and training.
(2) Legal standing.
(3) Substance abuse.
(4) Financial management abilities.
(5) Physical and emotional health.
(6) Fulfillment of treatment objectives.
(7) Family and community supports.
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Observations
The facility's medical director failed to review, date and sign an annual evaluation of each patient's status in four of four patient records reviewed during the annual inspection conducted on October 1 - 3, 2018.Patient # 1 was admitted August 23, 2017 and discharged September 18, 2018. The annual evaluation was completed on September 13, 2018.Patient # 7 was admitted August 23, 2017. The annual evaluation was completed on August 9, 2018.Patient # 13 was admitted September 1, 2017. The annual evaluation was completed on September 1, 2018.Patient # 14 was admitted August 9, 2017. The annual evaluation was completed on August 3, 2018.The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The facility's Medical Director failed to review, date, and sign an annual evaluation of each patient's status in four of four patient records reviewed during the annual inspection conducted on October 1-3, 2018.
The signature settings in the SMART software system have been corrected by the CRNP to reflect the required Medical Director's signature on the Annual Clinical Evaluation service note. The Medical Director will review, date, and sign off on all Annual Clinical Evaluations as required by DDAP regulations starting 10/4/18. The Annual Clinical Evaluation will be considered incomplete by the SMART software system until the Medical Director sign's the note.
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709.91(b)(6) LICENSURE Intake and admission
709.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(6) Psychosocial evaluation.
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Observations
The facility failed to document a psychosocial evaluation during the intake process in two of eight client records reviewed on October 1 - 3, 2018.Client # 5 was admitted May 21, 2018 and was discharged August 21, 2018.Client # 12 was admitted June 20, 2018 and was discharged September 21, 2018.The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Narcotic Treatment Program failed to document psychosocial evaluations during the intake process in two of the eight client records reviewed on October 1-3, 2018.
The counselors will complete a psychosocial evaluation within 14 days of admission. The clinical supervisor will ensure that all intake paperwork that is required in 709.91(6) will be completed within the 14 days of admission of each new client. Clinical supervisor will conduct chart audits on all new admissions when all intake paperwork has been completed. Implementation will be on 10/10/18.
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