INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection and methadone monitoring inspection conducted on September 1-2, 2022 by staff from the Department of Drug and Alcohol Programs, Bureau of 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 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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715.20(4) 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.
(4) The receiving narcotic treatment program shall document in writing that it notified the transferring narcotic treatment program of the admission of the patient and the date of the initial dose given to the patient by the receiving narcotic treatment program.
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Observations
Based on a review of patient records, the facility failed to document a transfer acknowledgement that included the admission of the patient and the date of initial dose in one of three patient records.
Patient #2 was admitted as a transfer on November 5, 2021 and is currently an active patient. There was no documentation of transfer acknowledgement in patient record #2.
These findings were reviewed with facility staff throughout the licensing process.
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Plan of Correction
Clinical Supervisor will provide an in house training regarding notification of completion of transfer to sending facilities after completion of transfer. Facility Director will maintain documentation of training on site for review and Clinical Supervisor will monitor compliance through chart audits. Training will be completed by 10/15/22. |
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
Based on a review of patient records, the facility failed to document an annual clinical evaluation of the patient's status in one of three patient records.
Patient #8 was admitted on November 4, 2020 and discharged on March 17, 2022. There was no annual clinical evaluation of the patient's status documented in patient record #8.
These findings were reviewed with facility staff throughout the licensing process.
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Plan of Correction
Clinical Supervisor will provide an in house training regarding Annual Clinical Evaluations and the content of that documentation. Facility Director will maintain documentation of training on site for review and Clinical Supervisor will monitor compliance through chart audits. Training will be completed by 10/15/22. |