INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection and methadone monitoring inspection conducted on June 20, 2016 through June 22, 2016 by staff from the Department of Drug and Alcohol Programs, Bureau of Quality Assurance for Prevention and Treatment, Program Licensure Division. Based on the findings of the on-site inspections, Northeast Family Health Care, 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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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
Based on a review of client records, the facility failed to keep disclosures of client identifying information within the limits established by 4 Pa. Code 255.5 (b) for releases of information in client record #'s 5 and 13. Additionally, client record #'s 1 and 5 had consent to release information forms that were missing the expiration date and/or the identified purpose.
4 Pa. Code states that information released to judges, probation or parole officers, insurance company, health or hospital plan or governmental officials, pursuant to paragraphs (1), (2), (4),(7), (8) or subsection (a) of the code, is for the purpose of determining the advisability of continuing the client with the assigned project and shall be restricted to the following:
(1) Whether the client is or is not in treatment.
(2) Client's prognosis.
(3) The nature of the project.
(4) A brief description of the client's progress.
(5) A short statement as to whether the client has relapsed into drug or alcohol abuse and the frequency of such relapse.
#1 was admitted on 10/28/2014 and was an active client as of the date of the inspection. Two separate consent to release forms, one to a government agency and one to another treatment provider and both signed and dated on 06/14/16 was reviewed. There was no expiration date and purpose identified on both consent forms. A third consent to release form to a government agency was signed and dated on 07/17/15 that did not have an expiration date or an identified purpose.
#5 was admitted on 07/21/2015 and was discharged on 02/20/16. A consent to release information form was signed and dated on 10/29/15 to a government agency that allowed for the release of the "general medical record, including but not limited to history and physical, physician notes, nurse and other provider notes, social work/case management notes, psychiatric/mental health/developmental disabilities information, consultation reports, x-ray, test and study results." Additionally, a consent to release form to a doctor was signed and dated on 02/05/16 that did not have an expiration date.
#13 was admitted on 02/10/2015 and was still an active client at the time of the inspection. A consent to release information form was signed and dated on 03/19/15 to a government agency that allowed for the release of the "general medical record, including but not limited to history and physical, physician notes, nurse and other provider notes, social work/case management notes, psychiatric/mental health/developmental disabilities information, consultation reports, x-ray, test and study results."
The findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
The facility director reviewed the citation. In July 2016, Northeast Family Healthcare is implementing the SMART system for electronic medical records. All information contained in the release will meet PA Code 255.5 be completed electronically. The electronic release will have drop down boxes for expiration dates, this needs to be filled in. The release will also be customized to meet the PA code 255.5.
Until the new SMART systems are in place, all counselors were trained at a staff meeting on how to fill out the current release properly on June 23, 2016. The facility director does weekly chart audits to ensure charts are complete.
The counselor met with patient #1 who is still active on 7/7/16 to complete new consent to release forms with correct documentation. Pt #5 was discharged prior to inspection.
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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.
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Observations
Based on a review of patient records, the facility failed to provide documentation that a copy of the client consent was offered in client record #'s 3, 7, 8, 9, 10, 13, 17, and 20.
#3 was admitted on 10/05/2015 and was an active client at the time of the inspection. The following consent to release information forms did not contain verification that copies were offered to the client: one was to a government agency, dated 10/13/15 and one was to another government agency dated 06/01/16.
#7 was admitted on 01/29/2016 and was discharged on 03/30/2016. There was no verification that a copy of a consent to release information form to another treatment provider, dated 01/29/16, was offered to the client.
#8 was admitted on 06/05/2015 and was discharged on 06/09/2016. The following consent to release information forms did not contain verification that copies were offered to the client: one was to a family member, dated 06/03/16; two were to two separate government agencies, both dated 06/03/16; one was to the funding source, dated 06/03/16; and 1 was to another treatment provider, dated 06/22/15.
#9 was admitted on 04/27/2015 and was discharged on 09/29/2015. There was no verification that a copy of a consent to release information form to a government agency, dated 05/04/15, was offered to the client.
#10 was admitted on 09/03/2014 and was discharged on 11/10/2015. There was no verification that a copy of a consent to release information form to a doctor's office, dated 05/15/15, was offered to the client.
#13 was admitted on 02/10/2015 and was still an active client at the time of the inspection. There was no verification that a copy of a consent to release information form to a government agency, dated 03/19/15, was offered to the client.
#17 was admitted on 12/23/2015 and was discharged on 02/12/2016. The following consent to release information forms did not contain verification that copies were offered to the client: one was to a family member, dated 01/11/16, and one was to another treatment facility dated 01/16/16.
#20 was admitted on 07/24/2015 and was discharged on 11/27/2015. There was no verification that a copy of a consent to release information form to a government agency, dated 07/30/15, was offered to the client.
The findings were reviewed with the facility staff during the licensing process.
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Plan of Correction
The facility director reviewed the citation. The Quality Assurance Director has been informed of the citation and will have the release updated. The facility is upgrading to the SMART system for electronic medical records in July. The updated release will include a box for patient to accept or reject a copy of the release. Until the update to the new system, the current release has been updated to reflect accept or decline a copy of the release. The facility director does weekly chart audits to ensure documentation is correct.
Pts. #3 and 11 who are active were met with on 7/7/16 and received copies of their releases. Pts. 7, 8, 9, 10, 17 and 20 were discharges at the time of inspection. |
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, there was no written documentation that the facility notified the transferring facility of the admission and initial dosing of the patient in patient record #'s 4 and 7 as of the date of the inspection.
#4 was transferred from another NTP, admitted on 04/13/2016, and was still an active client at the time of the inspection.
#7 was transferred from another NTP, admitted on 01/29/2016, and was discharged on 03/30/2016.
The findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
The facility director reviewed the citation. The nursing staff has been trained by the nursing supervisor on 6/23/16 on the procedures to document in writing notification of the admission and initial dosing. The facility is upgrading tot he SMART system in July 2016 for electronic record keeping. The new system will have a transfer notification noted in its system for those patients transferring. The facility director conducts chart audits weekly. Documentation of transfer was completed on 7/6/16 for pt #4 by nurse noting the notification and the dosage of the transfer pt #4. Pt #7 was discharged prior to inspection. |
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, there were no annual evaluations, which are due on the anniversary of the patient's admission, completed by the patient's counselor in patient record #'s 8 and 10.
#8 was admitted on 06/05/2015 and was discharged on 06/09/2016.
#10 was admitted on 09/03/2014 and was discharged on 11/10/2015.
The findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
The facility director reviewed the citation. The facility is upgrading to the SMART system in July 2016. The new system is electronic and tracks due dates of required information. The annual evaluations are part of the due dates tracking system in SMART. All due dates are populated on the screen for each patient. In addition, the facility director will conduct audit reports of due dates for each counselor on a monthly basis to ensure documentation of annual evaluations are complete and due dates are met. |