INITIAL COMMENTS
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This report is a result of an on-site inspection conducted for the approval to use a narcotic agent, specifically methadone and buprenorphine, in the treatment of narcotic addiction. This inspection was conducted on June 30 - July 1, 2014 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, White Deer Run, Inc. was found not to be in compliance with the applicable chapters of 4 PA Code and 28 PA Code which pertain to the facility.
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Plan of Correction
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715.9(a)(1) 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:
(1) Verify that the individual has reached 18 years of age.
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Observations
Based on the review of patient records, the facility failed to document verification that the individual has reached 18 years of age in two of eight patient records.The findings include:Eight patient records were reviewed on June 30 - July 1, 2014. Prior to administration of an agent, a narcotic treatment program shall screen each individual to determine eligibility for admission. Eight patient records were reviewed for documentation of verification that the individual has reached 18 years of age. Two patient records, #4 & #6, did not include the documentation.Patient record #4 was admitted on March 7, 2014 and was discharged on April 7, 2014. The initial dose of methadone was given to the patient on March 8, 2014. The facility failed to document verification that the individual has reached 18 years of age prior to administration of methadone.Patient record #6 was admitted on June 27, 2014. The initial dose of methadone was given to the patient on June 27, 2014. The facility failed to document verification that the individual has reached 18 years of age prior to administration of methadone. The findings were reviewed with the Quality Improvement Coordinator and were not disputed.
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Plan of Correction
During admission screening, staff will ask whether patient has photo identification they can bring with them into treatment.
During the intake process staff will ask for photo identification and make a copy of the photo identification for the chart. If a patient does not have photo identification, intake staff will conduct a search to verify the patients DOB, name, address and other identifying features using www.peoplefinders.com, if this site is able to verify the patient a sheet will be printed and placed in the chart. If this site is unable to verify intake staff will get written consent from the patient to contact their referral agency and/or family to verify the patient's information. If verification is unable to occur the patient will not be able to participate in methadone/buprenorphine protocol to detox from their drug of choice.
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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
Based on the review of patient records, the facility failed to document verification of the individuals identity, including name, address, date of birth, and other identifying data, in two of eight patient records.The findings include:Eight patient records were reviewed on June 30 - July 1, 2014. Prior to administration of an agent, a narcotic treatment program shall screen each individual to determine eligibility for admission. Eight patient records were required to document verification of the individuals identity. Two patient records, #4 & #6, did not include the documentation.Patient record #4 was admitted on March 7, 2014 and was discharged on April 7, 2014. The initial dose of methadone was given to the patient on March 8, 2014. The facility failed to document verification of the individuals identity prior to the administration of methadone.Patient record #6 was admitted on June 27, 2014. The initial dose of methadone was given to the patient on June 27, 2014. The facility failed to document verification of the individuals identity prior to the administration of methadone.The findings were reviewed with the Quality Improvement Coordinator and were not disputed.
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Plan of Correction
During admission screening, staff will ask whether patient has photo identification they can bring with them into treatment.
During the intake process staff will ask for photo identification and make a copy of the photo identification for the chart. If a patient does not have photo identification, intake staff will conduct a search to verify the patients DOB, name, address and other identifying features using www.peoplefinders.com, if this site is able to verify the patient a sheet will be printed and placed in the chart. If this site is unable to verify intake staff will get written consent from the patient to contact their referral agency and/or family to verify the patient's information. If verification is unable to occur the patient will not be able to participate in methadone/buprenorphine protocol to detox from their drug of choice.
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715.11 LICENSURE Confidentiality of patient records
A narcotic treatment program shall physically secure and maintain the confidentiality of all patient records in accordance with 42 CFR 2.22 (relating to notice to patients of Federal confidentiality requirements) and § 709.28 (relating to confidentiality).
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Observations
Based on a review of patient records, the facility failed to obtain an informed and voluntary consent to release information from the patient prior to the disclosure of information in one of eight patient records.The findings include:Eight patient records were reviewed on June 30 - July 1, 2014. Eight patient records were reviewed for the requirement to include an informed and voluntary consent from the patient prior to the disclosure of information. One patient record, #6, did not include a completed consent to release information form prior to the disclosure of information.Patient record #6 was admitted on June 27, 2014. A release of information form to a referral source did not include the specific information to be disclosed. The specific information section on the release of information form was blank. This form was signed by the patient and the staff member on 6-26-2014. The findings were reviewed with the Quality Improvement Coordinator and were not disputed.
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Plan of Correction
Clinical staff that has not completed the mandatory training will be required to attend confidentiality training within the time frame allotted. In addition, clinical staff will be scheduled to attend consent training.
If a clinical staff breaches patient confidentiality by making contact without valid consent the disciplinary actions will be as followed:
1st invalid consent-Receive a supervision-Individuals would have a one on one training with consent trainer
2nd invalid consent-Receive another supervision as well as another individual training with consent trainer and a meeting with their direct supervisor and clinical director. This meeting will outline that fact that next occurrence of an invalid consent we would be handling via progressive discipline
3rd invalid consent-Will be addressed via the progressive discipline policy (Employee improvement plan: Verbal, Written, Final)
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