INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection and methadone monitoring inspection conducted on October 18 & 19, 2023 by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, PA Care, LLC dba State College Medical 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 (d) LICENSURE Confidentiality
§ 709.28. Confidentiality.
(d) A copy of a client consent shall be offered to the client and a copy maintained in the client record.
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Observations
Based on a review of the client records, the facility failed to document that a copy of a client consent was offered to the client and a copy maintained in the client record in one out of seven client records reviewed. Client #1 was admitted on May 31, 2023 and was still active at the time of the inspection. A release of information form for a drug and alcohol facility dated July 14, 2023, did not have documentation that the client was offered a copy of the consent form. This finding was reviewed with the facility staff during the licensing process.
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Plan of Correction
Staff will be retrained by Executive Director in Staff Meeting/Supervision on 11/8/23. All parts of a consent form will be reviewed. Clinical Supervisor will monitor completion of all consent forms signed on an ongoing basis. |
715.6(d) LICENSURE Physician Staffing
(d) A narcotic treatment program shall provide narcotic treatment physician services at least 1 hour per week onsite for every ten patients
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Observations
Based on a review of the physician timesheets, the facility failed to provide at least one hour of physician time a week, onsite for every ten patients. During the week of April 2-8, 2023, the patient census was 161. The facility was required to provide at least 16.1 physician hours. There were only 14.23 physician hours documented. During the week of May 7-13, 2023, the patient census was 160. The physician was required to provide 16.0 physician hours. There were only 7.25 physician hours documented.During the week of June 18-24, 2023, the patient census was 158. The physician was required to provide 15.8 physician hours. There were only 12.88 physician hours documented. These findings were reviewed with the facility staff during the licensing process.
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Plan of Correction
Executive Director will monitor patient census weekly and ensure that physician and physician assistant staffing meets the correct ratio requirements. |