INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection and methadone monitoring inspection conducted on May 2 - 4, 2018 by staff from the Division of Accountability and Program Improvement. Based on the findings of the on-site inspection, Polaris Renewal Services Inc. 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
The facility obtained a written, informed and voluntary consent from the client. However, the facility's consent to release information form did not allow the client's verbal revocation of the consent in thirteen of fourteen client records reviewed on May 2 - 4, 2018.The consent to release information form included the following statement: "If I revoke this authorization, I need to do so in writing and mail or hand deliver it to the HIPAA Privacy Officer of the PRS Provider Entity named above, at the address set forth above." The facility failed to adhere to the requirements in the federal confidentiality regulations by requiring the client to revoke the consent in writing in the following client records.Client # 1 was admitted on August 10, 2015. The consents were signed by the client on August 18, 2017.Client # 2 was admitted on September 18, 2015. The consents were signed by the client on September 18 and September 19, 2017.Client # 4 was admitted on November 1, 2017. The consents were signed by the client on November 1, 2017.Client # 5 was admitted on December 8, 2017. The consents were signed by the client on December 8, 2017.Client # 6 was admitted on January 10, 2018. The consents were signed by the client on January 10, 2018.Client # 7 was admitted on November 15, 2017. The consents were signed by the client on November 15, 2017.Client # 8 was admitted on August 2, 2017 and discharged on December 24, 2017. The consents were signed by the client on August 2 and December 14, 2017.Client # 9 was admitted on August 1, 2016 and discharged on April 2, 2018. The consents were signed by the client on July 19, 2017 and March 6, 2018.Client # 10 was admitted on March 1, 2016 and discharged on April 5, 2018. The consents were signed by the client on February 27, 2018.Client # 11 was admitted on January 12, 2016 and discharged on November 7, 2017. The consents were signed by the client on July 26, 2017.Client # 12 was admitted on June 21, 2017 and discharged on December 12, 2017. The consents were signed by the client on June 21 and October 19, 2017.Client # 13 was admitted on August 1, 2016 and discharged on April 6, 2018. The consents were signed by the client on August 28, 2017.Client # 14 was admitted on April 29, 2015 and discharged on January 9, 2018. The consents were signed by the client on September 5, 2017.The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
All of the consent form templates used in the SMART management system have all been updated to remove the statement that the revocation must be mailed or hand delivered to Polaris. The Director trained the staff on May 9 and instructed that all patients with that statement on their releases would need to sign all new consents with the updated form. The counselors will update each patient's release forms during individual sessions. The Clinical Supervisor and Director will be responsible for checking each clinical record has updated releases. All releases will be updated within 90 days which is August 9, 2018. |
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
The narcotic treatment program failed to document in writing that it notified the transferring facility of the date of the initial dose given to the patient by the receiving facility in three of three patient records reviewed on May 2 - 4, 2018.Patient # 4 was admitted on November 1, 2017. The initial dose was given on November 1, 2017.Patient # 5 was admitted on December 8, 2017. The initial dose was given on December 8, 2017.Patient # 7 was admitted on November 15, 2017. The initial dose was given on November 16, 2017.The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The transfer notification document has been changed to reflect the date of admission, date of first dose, and the amount of first dose at Polaris. The Office Administrator will send this document to notify clinics of a patient's successful transfer to Polaris. In addition, when the nursing staff calls to verify admission and date of first dose, they will document this in a nursing note located in the clinical record. The Clinical Supervisor and Director will be responsible for checking all transfer in charts to make sure the required information has been sent to the transferring clinic. |
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 seven patient records reviewed on May 2 - 4, 2018. In addition, the facility failed to document an annual evaluation in one of seven patient records.Patient # 1 was admitted on August 10, 2015. The annual evaluation was completed on August 9, 2017.Patient # 2 was admitted on September 18, 2015. The annual evaluation was completed on September 19, 2017.Patient # 9 was admitted on August 1, 2016 and discharged on April 2, 2018. The annual evaluation was completed on August 1, 2017.Patient # 10 was admitted on March 1, 2016 and discharged on April 5, 2018. The annual evaluation was completed on February 27, 2018.Patient # 14 was admitted on April 29, 2015 and discharged on January 9, 2018. No annual evaluation was documented in 2017.The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The annual form template located in the SMART management system has been changed to include a signature for the Medical Director. The staff have been trained on this on 5/9/18. The Clinical Supervisor and Director will review clinical services due reports and the clinical records to ensure that all patients have a completed annual that is signed by the medical director. |