INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection and methadone monitoring inspection conducted on August 1-2, 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, Clear Choices, 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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709.25 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 facility failed to document an annual financial audit for the fiscal year ending June 30, 2018.
The facility's administrative records were reviewed for documentation of an annual audit on August 1-2, 2019. The project's fiscal year runs from July 1 to June 30. The project did not document an independent financial audit for the July 1, 2017 to June 30, 2018 fiscal year.
These findings were reviewed with facility staff during the licensing inspection.
This is a repeat citation from the September 11 - 12, 2018 inspection.
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Plan of Correction
Facility Director will submit an exception request for the Financial Audit from FY 2018 due to completing a Financial Review based on monetary constraints. If not approved, Facility Director will attempt to have additional documentation completed to update the review into an audit for FY 2018 by 10/31/2019. Facility Director will complete all future Fiscal Audits annually. Facility Director will maintain documentation in site for review as needed. |
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 ensure that the narcotic treatment physician documented current dependency and evidence of a 1 year history of addiction in one of eight patient records.
Ten patient records were reviewed on August 1-2, 2019. All were reviewed as a narcotic treatment patients. Eight were reviewed as new patients and required documentation of current dependency and evidence of a 1 year history of addiction.
In patient record # 8, there was no documentation of the determination of current dependency and 1 year history.
These findings were reviewed with facility staff during the licensing process.
This is a repeat citation from the September 11 - 12, 2018 inspection.
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Plan of Correction
Facility Director will complete an in-service for all staff including both Medical and Clinical staff regarding the regulatory requirement to ensure that there is documentation of a one year history of dependence is maintained in each patient's record. Clinical Supervisor will document the training and will monitor continued compliance through random chart audits. Staff Training will be completed prior to 9/30/2019. |
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 ensure that each female patient was fully informed of the risk to her or her unborn child in one of one patient record.
Ten patient records were reviewed on August 1-2, 2019. All were reviewed as a narcotic treatment patients. Eight were reviewed as new patients and required an informed consent. One of the eight was female.
In patient record # 8, there was no documentation that the female had been informed of the risks.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Facility Director will complete an in-service for all staff including both Medical and Clinical staff regarding the regulatory requirement to ensure that each female patient is fully informed of the potential risks related to medications and pregnancy in each patient's record. Current open female client records will be reviewed and any missed notifications will be provided immediately. All new patients will be provided notification of risks and pregnancy from intake. Clinical Supervisor will document the training and will monitor continued compliance through random chart audits. Staff Training will be completed prior to 9/30/2019. |
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 document that each prospective patient completed an initial drug-screening urinalysis in two of eight patient records.
Ten patients records were reviewed on August 1-2, 2019. Eight were reviewed as new narcotic treatment patients and required an initial urinalysis.
Patient # 1 was admitted on July 8, 2019. There was no documentation of an urinalysis as of August 1, 2019. Patient first dose was received on July 8, 2019.
Patient # 8 was admitted on February 4, 2019. The initial urinalysis documented is dated February 15, 2019. Patient first dose was received on February 4, 2019.
These findings were reviewed with facility staff during the licensing process.
This is a repeat citation from the September 11 - 12, 2018 inspection.
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Plan of Correction
Facility Director will complete an in-service for all staff including both Medical and Clinical staff regarding the regulatory requirements for initial urinalysis and monthly urinalysis for each individual to ensure that there is documentation in each patient's record. New potential intakes will be screened prior to the administration of medication beginning immediately and beyond. Clinical Supervisor will document the training and will monitor continued compliance through random chart audits. Staff Training will be completed prior to 9/30/2019. |
709.93(a)(8) LICENSURE Client records
709.93. Client records.
(a) There shall be a complete client record on an individual which includes information relative to the client's involvement with the project. This shall include, but not be limited to, the following:
(8) Case consultation notes.
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Observations
The facility failed to document case consultation notes in two of six patient records.
Ten patient records were reviewed on August 1-2, 2019. Six required documentation of a case consultation. Per policy, case consultations are to be conducted quarterly. Patient records # 8 and 10 did not document a case consultation.
Patient # 8 was admitted on February 4, 2019. A case consultation was due to be completed between April and June, 2019. There was no documentation of a case consultation.
Patient # 10 was admitted on December 3, 2019. A case consultation was due to be completed between January and March, 2019 and April and June, 2019. There was no documentation of a case consultation.
These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
Facility Director will complete an in-service for all staff including both Medical and Clinical staff regarding the regulatory requirement of Case Consultations to ensure that there is documentation maintained in each patient chart. Clinical Supervisor will document the training and will monitor continued compliance through random chart audits. Staff Training will be completed prior to 9/30/2019. |