INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on August 24-25, 2015 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Axiom Family Counseling 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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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.
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Observations
Based on a review of client records on August 24-25, 2015 the facility failed to inform the client, in writing, of a decision to involuntarily terminate the client's treatment in one of two client records.
The findings include:
Ten client records were reviewed on August 24-25, 2015. Two records required written notification to the client informing him/her of the decision to terminate the client's treatment. The facility failed to document notification to the client in client record # 9.
Client # 9 was admitted on January 6, 2015 and involuntarily discharged on July 20, 2015. There was no documentation provided that the client was informed, in writing, of a decision to involuntarily terminate the client's treatment.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Lead Counselor has discussed in clinical staff meetings audit issues including notification of termination letter and how to rectify.
Training will be held by the Lead Counselor to discuss the updated termination letter and associated updated termination process including processes involving informing client in writing of decision to involuntary termination client's treatment with all clinical staff as well as administrative staff.
Lead Counselor will be responsible for follow up with training rosters, training surveys and training certificates.
Ongoing chart auditing will be conducted by all clinicians with oversight conducted by lead counselor to ensure discharges and termination letters follow appropriate process. |
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.
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Observations
Based on the review of patient records, the facility failed to document a complete initial urinalysis for each prospective patient in four of seven patient records.
The findings include:
Ten patient records were reviewed on August 24-25, 2015. Eight records were reviewed as buprenorphine patients. All patients are required to complete a drug screen urinalysis prior to the administration of buprenorphine, a narcotic agent and at least monthly thereafter. A complete urine drug screen includes receiving the results from the CLIA and Department of Health approved laboratory. The facility did not document a complete initial drug-screening urinalysis in patient records # 4, 6, 7 and 8.
Patient # 4 was admitted on April 8, 2015. The patient received their first dose of buprenorphine on April 8, 2015. The initial urine screen had been collected by the facility on April 8, 2015 using the cup method. However, there was no documentation that the initial urine screen had been sent out to a laboratory for urinalysis.
Patient # 6 was admitted on January 28, 2015. The patient received their first dose of buprenorphine on January 30, 2015. The results from the CLIA and Department of Health approved laboratory were not received until January 31, 2015.
Patient # 7 was admitted on December 10, 2014. The patient received their first dose of buprenorphine on December 12, 2014. The results from the CLIA and Department of Health approved laboratory were not received until December 24, 2014.
Patient # 8 was admitted on February 19, 2015. The patient received their first dose of buprenorphine on February 20, 2015. The results from the CLIA and Department of Health approved laboratory were not received until February 26, 2015.
These finding were reviewed with facility staff during the licensing inspection.
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Plan of Correction
Lead Counselor has discussed in clinical staff meetings audit issues including the completion of drug screen urinalysis prior to the administration of Buprenorphine and at least monthly thereafter. Notification was also sent to all treating physicians.
Staff Training was held to discuss specific processes in order to ensure drug screen urinalysis is completed prior to the administration of buprenorphine, a narcotic agent and at least monthly thereafter.
Ongoing chart auditing will occur by all clinical staff as well as administrative staff to ensure drug screening results are received prior to the administration of Buprenorphine. |