INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection and 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 October 17-18, 2016 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Jade Wellness, LLC was found not to be in compliance with the applicable chapters of 28 PA Code which pertain to the facility.
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Plan of Correction
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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.
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Observations
The facility failed to obtain an informed and voluntary consent from the client prior to the disclosure of information in two of ten client records reviewed on October 17-18, 2016.
Ten client records were reviewed for informed and voluntary consent to release information forms.
Client # 3 was admitted to treatment on May 26, 2016. There was no documentation of a consent to release information to the funding source.
Client # 4 was admitted to treatment on April 24, 2016. There was no documentation of a consent to release information to the funding source.
The findings were reviewed with the facility staff during the licensing process.
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Plan of Correction
It shall be the job of the clinical supervisor to ensure that all records display documentation of a consent to release information to the appropriate funding source. The clinical supervisor will relay to the billing/utilization management department that any time a patient funding source changes a message is immediately displayed on the message board of the patient ECR. It will then be the job of the front desk OR patient therapist to have said patient complete an updated consent for their funding source at the very next time of contact. Following obtaining this consent, the message will then be end dated on the client message board in the ECR. In order to comply with state and federal confidentiality regulations the funding source will not be utilized until consent is obtained. |
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.
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Observations
The facility failed to document that a narcotic treatment physician made a face-to-face determination of whether an individual was currently physiologically dependent upon a narcotic drug and has been physiologically dependent for at least 1 year prior to admission for maintenance treatment and the basis for that determination in six of seven client records reviewed on October 17-18, 2016.
Ten clients records were reviewed. Seven records reviewed were Suboxone clients. In client records # 1, 2, 3, 4, 9 and 10 the face-to-face determination of current physiologically dependency and 1 year dependency were not documented by the narcotic treatment physician.
Client # 1 was admitted on 4/12/16. A nurse completed the medical history on 4/13/16 which included the documentation of the current and 1 year dependency. The history was co- signed by the physician on 4/13/16. The physical examination completed by the narcotic treatment physician on 4/12/2016, did not include the documentation of the current and 1 year dependency. There was no documentation that dependency was determination by a treatment physician.
Client # 2 was admitted on 6/8/16. A nurse completed the medical history on 6/8/16 which included the documentation of the current and 1 year dependency. The history was co- signed by the physician on 6/8/16. The physical examination completed by the narcotic treatment physician on 6/8/2016, did not include the documentation of the current and 1 year dependency. There was no documentation that dependency was determination by a treatment physician.
Client # 3 was admitted on 5/26/16. A nurse completed the medical history on 5/31/16 which included the documentation of the current and 1 year dependency. The history was co- signed by the physician on 5/31/16. The physical examination completed by the narcotic treatment physician on 5/31/2016, did not include the documentation of the current and 1 year dependency. There was no documentation that dependency was determination by a treatment physician.
Client # 4 was admitted on 5/24/16. A medical assistant completed the medical history on 5/27/16 which included the documentation of the current and 1 year dependency. The history was co- signed by the physician on 5/27/16. The physical examination completed by the narcotic treatment physician on 5/27/2016, did not include the documentation of the current and 1 year dependency. There was no documentation that dependency was determination by a treatment physician.
Client # 9 was admitted on 5/28/16. A nurse completed the medical history and physical exam documentation on 5/28/16, which included the documentation of the current and 1 year dependency. The physician signed the medical history and physical exam documentation on 5/28/16. The patient was first dosed on 5/28/16. There was no documentation that dependency was determination by a treatment physician.
Client # 10 was admitted on 4/11/16. A nurse completed the medical history on 4/13/16 which included the documentation of the current and 1 year dependency. The history was co- signed by the physician on 4/13/16. There was no documentation of a face to face determination by a treatment physician.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
It will be the job of the Clinical Supervisor to train each JADE physician to adequately document the 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 JADE treatment physician will make this determination by examining the client prior to client receiving any buprenorphine services and will date and time stamp said determination. |