INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on April 2, 2019 by staff from the Department of Drug and Alcohol Programs, Bureau of Quality Assurance for Prevention and Treatment. Based on the findings of the on-site inspection, Positive Pathways 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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709.25 LICENSURE Fiscal Management
§ 709.25. Fiscal management.
The project shall obtain the services of an independent certified public accountant for an annual financial audit of activities associated with the project ' s drug/alcohol abuse services, in accordance with generally accepted accounting principles which include reference to the drug and alcohol treatment activities.
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Observations
The project failed to obtain the services of an independent public accountant for an annual audit of financial activities associated with the project's drug/alcohol abuse services.The facility's administrative records were reviewed on April 1-2, 2019 for documentation of an annual audit of financial activities associated with the project's drug/alcohol abuse services. The project's fiscal year runs from July 1 to June 30. The project did not document an independent financial audit for the 2017/2018 fiscal year.The findings were reviewed with the facility staff during the licensing process.
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Plan of Correction
Plan of Correction:
709.25 Fiscal Management: Corrective Action Plan In response to the Fiscal Management deficiency in section 709.25. Positive Pathways has obtained the services of an independent accountant on April 19, 2019 for the future purpose of an annual financial audit of activities associated with the project ' s drug/alcohol abuse services, in accordance with generally accepted accounting principles which include reference to the drug and alcohol treatment activities. The annual audit will be completed within six months following the end of Positive Pathways' fiscal year. The project director will be directly responsible for completion of the task. |
709.30 (1) LICENSURE Client rights
§ 709.30. Client rights.
The project shall develop written policies and procedures on client rights and document written acknowledgement by clients that they have been notified of those rights.
(1) A client receiving care or treatment under section 7 of the act (71 P. S. § 1690.107) shall retain civil rights and liberties except as provided by statute. No client may be deprived of a civil right solely by reason of treatment.
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Observations
The facility failed to provide written documention that the client was notified of the rights in eight of eight client records.Eight client records were reviewed on April 2, 2019. Eight required documentation the client was informed of the rights. Client records 1, 2, 3, 4, 5, 6, 7 and 8 did not document that the client was informed of the rights. These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
On 5/1/2019, Positive Pathways revised and implemented changes to correct the deficiency related to client rights. Client rights are documented in the client handbook. As of 5/1/2019, clients will sign-off on a signature page indicating they have received the client handbook and been informed of their client rights. The signature page will be scanned into the client's EMR chart. The clinical supervisor is responsible for compliance to the corrected plan of action. This will be reflected in the clinical supervisor's monthly chart audit results. Deficiencies discovered in the monthly chart audits will be addressed with the Program Director, with the counselor/staff person in question, and in the weekly staff meeting to help educate all others related to proper policy adherence. |
715.9(a)(2) 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:
(2) Verify the individual 's identity, including name, address, date of birth, emergency contact and other identifying data.
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Observations
The facility failed to verify the emergency contact in one of three patient records reviewed. Three patient records were reviewed on April 2, 2019. Three required verification of an emergency contact. Patient record # 2 did not document an emergency contact.These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
Positive Pathways, on 5/1/2019, implemented policies and procedures to ensure compliance with 715.9(a)(2) Intake: Positive Pathways will document emergency contact information on all individuals upon intake/assessment. This will be evidenced in the client's EMR chart. All staff were educated on the deficiency and planned change at the 4-8-19 and 4-15-19 staff meetings. The clinical supervisor is responsible for compliance to the corrected plan of action. This will be reflected in the clinical supervisor's monthly chart audit results. Deficiencies discovered in the monthly chart audits will be addressed with the Program Director, with the counselor/staff person in question, and in the weekly staff meeting to help educate all others related to proper policy adherence. |
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 the narcotic treatment physican determined evidence of a 1 year history of addiction in three of three records reviewed. Three buprenorphine client records were reviewed on April 2, 2019. Three required the documentation of the determination of a 1 year history of dependency. There was no documentation that the physician determined the 1 year history of addiction in patient records # 1, 2 and 3. These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
715.9(a)(4) Intake: Positive Pathways, on 5/1/2019, began documenting, in the client's EMR chart, the determination of a 1 year history of addiction upon intake. All staff were educated on the deficiency and planned change at the 4-8-19 and 4-15-19 staff meetings. Positive Pathways' physician was further trained and educated on 4-22-2019 related to proper documentation of his determination when completing an intake. The clinical supervisor is responsible for compliance to the corrected plan of action. This will be reflected in the clinical supervisor's monthly chart audit results. Deficiencies discovered in the monthly chart audits will be addressed with the Program Director, with the counselor/staff person in question, and in the weekly staff meeting to help educate all others related to proper policy adherence. |
715.10(f) LICENSURE Pregnant patients
(f) The narcotic treatment program shall ensure that each female patient is fully informed of the possible risk to her or her unborn child from continued use of illicit drugs and from use of, or withdrawal from a narcotic drug administered or dispensed by the program in comprehensive maintenance or detoxification treatment.
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Observations
The facility failed to document that each female patient was fully informed of the possible risks to her and her unborn child in one of one patient record. Three buprenorphine patient records were reviewed on April 2, 2019. One record reviewed was a female patient. There was no documentation provided that patient record #1 was informed of the risks. These findings were reviewed with facility staff during the licening process.
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Plan of Correction
On 5/1/2019, Positive Pathways revised the intake packet to include information fully informing each female patient of the possible risk to her or her unborn child from continued use of illicit drugs and from use of, or withdrawal from a narcotic drug administered or dispensed by the program in comprehensive maintenance or detoxification treatment. Each female will sign off on this notification and will be included in the patient's EMR chart. All staff were educated on the deficiency and planned change at the 4-8-19 and 4-15-19 staff meetings. The clinical supervisor is responsible for compliance to the corrected plan of action. This will be reflected in the clinical supervisor's monthly chart audit results. Deficiencies discovered in the monthly chart audits will be addressed with the Program Director, with the counselor/staff person in question, and in the weekly staff meeting to help educate all others related to proper policy adherence. |
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
The facility failed to complete an initial drug- screening urinalysis for each prospective patient in two of three patient records. Three buprenorphine patient records were reviewed on April 2, 2019. All three required an initial urinalysis. Patients # 2 and 3 did not document an initial urinalysis for a prospective patient. Patient # 2 was admitted on November 26, 2018. The patient received the first prescription for Suboxone on November 26, 2018. The initial urinalysis documented was completed on November 28, 2018. Patient # 3 was admitted on December 19, 2018. The patient received the first prescription for Suboxone on December 19, 2018. The initial urinalysis documented was completed on December 24, 2018. These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
Positive Pathways will complete an initial urine screen for each individual prospective client as evidenced in the patient EMR chart and reflected in Positive Pathways' Policies and Procedures. Record of the initial urine screen will documented in the client's EMR chart and reviewed by the physician prior to writing of a buprenorphine prescription. This practice has been implemented on 5/1/2019 and all staff were educated on this at both 4-8-19 and 4-15-19 staff meetings. The clinical supervisor will be responsible for ensuring compliance by completing monthly chart audits. Deficiencies discovered in the monthly chart audits will be addressed with the Program Director, with the counselor/staff person in question, and in the weekly staff meeting to help educate all others related to proper policy adherence. |
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
The facility failed to document that the patient was provided at least 1 hour of individual counseling per month in two of three patient records reviewed. Three buprenorphine patient records were reviewed on April 2, 2019. All three required 1 hour of individual counseling per month. Patients # 1 and 3 did not document the required counseling. Patient # 1 was admitted on October 4, 2018 and was still an active patient at the time of the licensing inspection. There were no individual counseling session documented for February and March, 2019. Patient # 3 was admitted on December 19, 2018 and was still an active patient at the time of the licensing inspection. There were no individual counseling session documented for December, 2018 and January, February and March, 2019. These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
Positive Pathways conducted a training by the clinical supervisor with all clinical staff at staff meeting on 4-8-19 to review the regulation:
A narcotic treatment program shall provide each patient an average of 2.5 hours of psychotherapy per month during the patient first 2 years, 1 hour of which shall be individual psychotherapy.
This is evidenced by staff meeting minutes from 4-8-19. Additional review and follow-up was conducted on 4-15-19 with all clinical staff to ensure understanding and implementation. This is evidenced in staff meeting minutes from 4-15-2019. The clinical supervisor is responsible for compliance to the corrected plan of action. This will be reflected in the clinical supervisor's monthly chart audit results. Deficiencies discovered in the monthly chart audits will be addressed with the Program Director, with the counselor/staff person in question, and in the weekly staff meeting to help educate all others related to proper policy adherence. |