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 16-19, 2014 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Addiction Medicine and Health Advocates, 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. The consent shall be in writing and include, but not be limited to:
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Observations
Based on a review of patient records, the facility exceeded the limitations imposed at 4 Pa. Code 255.5 (b) in four of nineteen records reviewed. Additionally, the facility failed to maintain confidentiality of patient records in accordance with 42 CFR, Part 2, Subpart C, Subsection 2.31 (a)(3) in ten of nineteen records reviewed.
The findings include:
Nineteen patient records were reviewed on June 16-19, 2014. The facility exceeded the limitations imposed at 4 Pa. Code 255.5 (b) in patient records # 2, 5, 6 and 15. Additionally, facility failed to maintain confidentiality of patient records in accordance with 42 CFR, Part 2, Subpart C, Subsection 2.31 (a)(3) in patient records # 1, 2, 3, 4, 5, 6, 8, 9, 10 and 11.
Patient # 1 was admitted on 11/29/13 and was still an active patient at the time of the inspection. The consent to release information to another treatment facility dated 11/29/13 failed to specify the information to be released.
Patient # 2 was admitted on 5/5/14 and was still an active patient at the time of the inspection. The consent to release for the funding source, dated 5/5/14, exceeded the limitations imposed at 4 Pa. Code 255.5 (b) in that it allowed for the release of the patients intake and assessment, physical exam including blood work, urinalysis, progress notes, and biopsychosocial and evaluation. The purpose of the release, which was for the reimbursement of transportation services, did not match the information which was to be released. The consent to release information to another treatment facility dated 5/5/14 failed to specify the information to be released.
Patient # 3 was admitted on 2/13/13 and was still an active patient at the time of the inspection. The consent to release information to the funding source and transportation source, both dated 2/12/14, failed to specify the information to be released.
Patient # 4 was admitted on 2/5/14 and was still an active patient at the time of the inspection. The consent to release information to another treatment facility dated 2/5/14 failed to specify the information to be released.
Patient # 5 was admitted on 3/27/14 and was still an active patient at the time of the inspection. The consent to release for the funding source, dated 3/27/14, exceeded the limitations imposed at 4 Pa. Code 255.5 (b) in that it allowed for the release of the patients intake and assessment, physical exam including blood work, urinalysis, progress notes, and biopsychosocial and evaluation. The purpose of the release, which was for the reimbursement of transportation services, did not match the information which was to be released. The consent to release information to another treatment facility dated 3/27/14 failed to specify the information to be released.
Patient # 6 was admitted on 3/14/14 and was still an active patient at the time of the inspection. The consent to release for the funding source, dated 3/14/14, exceeded the limitations imposed at 4 Pa. Code 255.5 (b) in that it allowed for the release of the patients intake and assessment, physical exam including blood work, urinalysis, progress notes, and biopsychosocial and evaluation. The purpose of the release, which was for the reimbursement of transportation services, did not match the information which was to be released. The consent to release information to another treatment facility dated 3/14/14 failed to specify the information to be released.
Patient # 8 was admitted on 12/13/13 and was discharged on 6/16/14. The consent to release information to another treatment facility dated 12/13/13 failed to specify the information to be released.
Patient # 9 was admitted on 10/2/13 and was still an active patient at the time of the inspection. The consent to release information to another entity dated 4/1/14 failed to specify the information to be released.
Patient # 10 was admitted on 8/2/13 and was still an active patient at the time of the inspection. The consent to release information to the funding source and transportation source dated 8/2/13 failed to specify the information to be released.
Patient # 11 was admitted on 1/30/14 and was still an active patient at the time of the inspection. The consent to release information to another treatment facility dated 1/30/14 failed to specify the information to be released.
Patient # 15 was admitted on 5/8/14 and was still an active patient at the time of the inspection. The consent to release for the funding source, dated 5/5/14, exceeded the limitations imposed at 4 Pa. Code 255.5 (b) in that it allowed for the release of the patients intake and assessment, physical exam including blood work, urinalysis, progress notes, and biopsychosocial and evaluation. The purpose of the release, which was for the reimbursement of transportation services, did not match the information which was to be released.
The Project Director confirmed the findings.
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Plan of Correction
The Clinical Coordinator will conduct supervision with the Intake Coordinator, review the content of 709.28(c), 42 CFR, Subsection 2.31(a)(3) and 4 Pa. 255.5(b)and discuss/educate the Intake Coordinator about the importance of being in compliance with the aforementioned regulations, to wit, the importance of being clear and specific regarding the information to be released to any entity granted permission by the patient. The Clinical Coordinator will also educate the Intake Coordinator about the need to stay within the restrictions imposed by
Pa. 255.5 regarding the extent and type of information to be released, even with the patient's permission. The Clinical Coordinator will be responsible for, and will monitor, compliance with the aforementioned regulations to ensure the safeguarding of patient confidentiality. The Clinical Coordinator will complete and update the Consent to Release Confidential Information forms in a manner consistent with the regulations (4 Pa 255.5 and 42 CFR Part 2, Subpart C, Subsection 2.31(a)(3)), distribute copies to the Intake Coordinator, and instruct him to use only these forms going forward. The aformentioned supervision will by conducted by July 22, 2014. |
715.13(a) LICENSURE Patient identification
(a) A narcotic treatment program shall use a system for patient identification for the purpose of verifying the correct identity of a patient prior to administration of an agent.
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Observations
Based on a review of patient records, the facility failed to document photo identification of each patient which includes the patient's name and birth date in two of nineteen records reviewed.
The findings include:
Nineteen client records which required documentation of photo identification were reviewed June 16-19, 2014. The facility failed to document photo identification of each patient which includes the patient's name and birth date in records # 8 and 10.
Patient # 8 was admitted on 12/13/13 and was discharged on 6/16/14. The facility failed to document photo identification in this patient record.
Patient # 10 was admitted on 8/2/13 and was still an active patient at the time of the inspection. The facility failed to document photo identification in this patient record.
The Project Director confirmed the findings.
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Plan of Correction
The Clinical Coordinator will conduct supervision with the Intake Coordinator and review the content of 715.13(a)regarding patient identification. The Clinical Coordinator will educate the Intake Coordinator regarding the importance of obtaining and placing in each patient chart a current photo identification that contains the patient name and date of birth. The Clinical Coordinator will ensure that photo identification is received and place in the records of the clients outlined in the citation, and all clients going forward. The Clinical Coordinator will be responsible for and monitor adherence to 715.13(a). The aforementioned supervision will take place and be completed no later than July 22, 2014. |
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 monthly random urinalysis in two of nineteen patient records reviewed.
The findings include:
Nineteen patient records which required documentation of a monthly random urinalysis were reviewed June 16-19, 2014. The facility failed to document a monthly random urinalysis in patient records # 5 and 10.
Patient # 5 was admitted on 3/27/14 and was still an active patient at the time of the inspection. The facility failed to document a monthly random urinalysis in this patient record for the month of April 2014.
Patient # 10 was admitted on 8/2/13 and was still an active patient at the time of the inspection. The facility failed to document a monthly random urinalysis in this patient record for the month of December 2013.
The Project Director confirmed the findings.
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Plan of Correction
The Clinical Coordinator will conduct supervision with the Nursing Supervisor and review the content of 715.14(a). The Clinical Coordinator will educate the Nursing Supervisor regarding the importance of documenting each patient monthly random urinalysis and placing a copy of said urinalysis in each patient chart. The Clinical Coordinator will be responsible for, and monitor, compliance with 715.14(a). Said supervision will be conducted and completed by July 22, 2014 |
715.19(1) LICENSURE Psychotherapy services
A narcotic treatment program shall provide individualized psychotherapy services and shall meet the following requirements:
(1) A narcotic treatment program shall provide each patient an average of 2.5 hours of psychotherapy per month during the patient 's first 2 years, 1 hour of which shall be individual psychotherapy. Additional psychotherapy shall be provided as dictated by ongoing assessment of the patient.
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Observations
Based on a review of patient records, the facility failed to document an average of 2.5 hours of psychotherapy per month during the patient's first 2 years, 1 hour of which shall be individual psychotherapy in two of sixteen applicable patient records reviewed.
The findings include:
Sixteen patient records which required documentation of an average of 2.5 hours of psychotherapy per month during the patient's first 2 years, 1 hour of which shall be individual psychotherapy were reviewed June 16-19, 2014. The facility failed to document 1 hour of individual psychotherapy in patient records # 9 and 10.
Patient # 9 was admitted on 10/2/13 and was still an active client at the time of the inspection. The facility failed to document 1 hour of individual psychotherapy in this patient record for the months of October 2013, April 2014 and May 2014.
Patient # 10 was admitted on 8/2/13 and was still an active client at the time of the inspection. The facility failed to document 1 hour of individual psychotherapy in this patient record for the month of May 2014. Additionally, the facility failed to document an average of 2.5 hours of psychotherapy for the months of December 2013, January 2014 and February 2014. Based on the record of service, this patient did not receive any services during December 2013, January 2014 and February 2014.
The Project Director confirmed the findings.
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Plan of Correction
The Clinical Coordinator will conduct a group supervision with all clinical staff and review the content of 715.19(1). The Clinical Coordinator will educate clinicl staff about the importance of being in compliance with the requirements of 715.19(1)for each patient on their caseload each month that the patient remains in treatment and their treatment falls under this requirement. The Clinical Coordinator will also educate clinical staff regarding the requirement that each patient subject to 715.19(1) be seen for at least one hour of individual therapy each month regardless of how many hours of group therapy they may have had. The Clinical Coordinator will be responsible for, and will monitor compliance with, the requirements outlined in 715.19(1). This group supervision will be conducted and completed by July 22, 2014 |