INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on October 31, 2013, to November 1, 2013, by staff from the Program Licensure Division. Based on the findings of the on-site inspection, Pennsylvania Associates LLC DBA Mount Pocono 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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709.22(e) LICENSURE Governing Body
709.22. Governing body.
(e) If a facility is publicly funded, the governing body shall make available to the public an annual report which includes, but is not limited to:
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Observations
Based on a review of administrative documentation, the facility failed to include all of the required content in the annual report.
The findings included:
On October 31, 2013, the facility's administrative documentation was reviewed. The facility was required to document an annual report.
The 2012 annual report was provided and reviewed during the inspection; however, the facility failed to include a financial statement of income and expenses within the annual report.
The facility director was informed and confirmed that documentation did not include a financial statement.
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Plan of Correction
The clinic director has reviewed the standard and will ensure that the annual report inludes all items noted in standard 709.22. The clinic director will review the annual report prior to distribution to ensure all items are reflected in it. |
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 the review of patient records, the facility failed to ensure that an informed and voluntary consent to release information was obtained in four of ten records. The facility failed to stay within the limits imposed by 4 Pa. Code 255.5 (b) in one of ten records reviewed.
The findings included:
Twelve patient records were reviewed during the on-site review. Eight patient records were reviewed for consent to release information. The facility failed to ensure that an informed and voluntary consent to release information was obtained in two of eight records reviewed, # 4 and 7. The facility also failed to stay within the limits imposed by 4 Pa. Code 255.5 (b) in one record, # 8.
4 Pa. Code 255.5 (b) states:
(b) Restrictions. Information released to judges, probation or parole officers,
insurance company health or hospital plan or governmental officials, under subsection
(a)(1), (2), (4), (7) and (8), is for the purpose of determining the advisability
of continuing the client with the assigned project and shall be restricted to
the following:
(1) Whether the client is or is not in treatment.
(2) The prognosis of the client.
(3) The nature of the project.
(4) A brief description of the progress of the client.
(5) A short statement as to whether the client has relapsed into drug, or alcohol abuse and the frequency of such relapse.
A review of patient record # 4 revealed a consent to release information to a government entity that failed to contain the notification of patient receiving a copy of the consent.
A review of patient record # 7 revealed correspondence via facsimile to a government entity on August 28, 2013. The patient record did not contain a consent to release information to the government entity that was limited to that permitted by Pa Code 255.5 (b).
A review of patient record # 8 revealed correspondence to a legal entity on October 8, 2013. The correspondence included the results of urinalysis samples. The information was not limited to that permitted by Pa Code 255.5 (b).
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Plan of Correction
The clinic director has reviewed the standard 709.28(c) and will ensure that a confidentiality training for all staff will be completed by 1/31/14. The consent form will be updated to reflect the limits proposed in PA Code 255.5(b) by 12/31/13. The consent to release information will be given by the counselor to the lead counselor or clinic director for approval prior to distribution on an ongoing basis to ensure the consent meets the standard. |
709.32(b) LICENSURE Medication Control
709.32. Medication control.
(b) Verbal medication orders may be accepted but shall be put in writing and signed within 24 hours thereafter by the prescribing physician.
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Observations
Based on a review of patient records, the facility failed to ensure that verbal medication orders were put in writing and signed with 24 hours thereafter by the prescribing physician in one of one patient record.
The findings included:
Twelve patient records were reviewed during the on-site review. All verbal medication orders are required to be signed within 24 hours by the prescribing physician. Patient record # 7 contained documentation of a verbal medication order that was not signed by the prescribing physician within 24 hours.
Patient # 7 was admitted on August 12, 2013. The record contained a verbal order dated August 6, 2013. The order was signed by a physician other than the prescriber on August 8, 2013.
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Plan of Correction
The clinic director has reviewed the standard 709.32 and the clinic director will conduct a training with the medical department by 12/15/13 on the verbal order requirements. The lead nurse will ensure verbal orders are completed within 24 hours on an ongoing basis. |
715.9(c) LICENSURE Intake
(c) If a patient was previously discharged from treatment at another narcotic treatment program, the admitting narcotic treatment program, with patient consent, shall contact the previous facility for the treatment history.
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Observations
Based on a review of patient records, the facility failed to contact the previous narcotic treatment facility for the patient's treatment history in one of one patient records reviewed.
The findings included:
Twelve patient records were reviewed during the on-site review. One patient record required contacting a prior narcotic treatment facility for the previous treatment history that was reported by the patient.
Patient record # 6 contained documentation the patient had received narcotic treatment services previously at another narcotic treatment program. The patient record did not contain a consent to release information to the identified narcotic treatment program. The facility failed to document any attempt to obtain the patient's prior treatment history from the previously attended narcotic treatment facility.
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Plan of Correction
The clinic director has reviewed the standard 715.9 (c). A training on the procedure for obtaining information with patient consent for prior care at a treatment facility will be conducted by the clinic director by 12/31/13. The lead counselor will check/review new patients files on an ongoing to basis to ensure that any information from prior treatment places was documented that attempts were made and/or obtained. |
715.12(1-5) LICENSURE Informed patient consent
A narcotic treatment program shall obtain an informed, voluntary, written consent before an agent may be administered to the patient for either maintenance or detoxification treatment. The following shall appear on the patient consent form:
(1) That methadone and LAAM are narcotic drugs which can be harmful if taken without medical supervision.
(2) That methadone and LAAM are addictive medications and may, like other drugs used in medical practices, produce adverse results.
(3) That alternative methods of treatment exist.
(4) That the possible risks and complications of treatment have been explained to the patient.
(5) That methadone is transmitted to the unborn child and will cause physical dependence.
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Observations
Based on a review of patient records, the facility failed to obtain an informed, voluntary, written consent prior to the administration of a narcotic agent for maintenance treatment in four of eight records.
The findings included:
Twelve patient records were reviewed during the on-site review. Eight patient records were reviewed for the completion of an informed, voluntary written consent prior to the administration of a narcotic agent. The facility failed to document the completion of an informed, voluntary, written consent prior to the administration of a narcotic agent in patient records # 1, 2, 3, and 5.
Patient # 1 was admitted into treatment on September 24, 2013. The patient received their initial dose of narcotic medication on September 26, 2013. The documentation of an informed, voluntary written consent was dated October 1, 2013. The consent was signed after the administration of the first dose of narcotic medication.
Patient # 2 was admitted into treatment on September 30, 2013. The patient received their initial dose of narcotic medication on September 30, 2013. The documentation of an informed, voluntary written consent was missing page 2. The patient did not date his signature to verify that the consent was signed off prior to administration of narcotic medication.
Patient # 3 was admitted into treatment on September 3, 2013. The patient received their initial dose of narcotic medication on September 9, 2013. The documentation of an informed, voluntary written consent was dated October 1, 2013. There was no documentation of an informed, voluntary written consent prior to the administration of a narcotic agent in patient record # 3.
Patient # 5 was admitted into treatment on September 24, 2013. The patient received their initial dose of narcotic medication on September 26, 2013. The documentation of an informed, voluntary written consent was dated October 7, 2013. The consent was signed after the administration of the first dose of narcotic medication.
The findings were reviewed and confirmed by the facility director.
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Plan of Correction
The clinic director has reviewed the standard 715.12(1-5) and will conduct a training for medical staff on consent before an agent may be administered by 12/15/13. The clinic director and lead nurse met and the consent form is on top of intake packet and is reviewed for signature prior to dosing. The intake packet is part of the medical file and follows the patient to the dosing station. New nurses will be trained in this procedure on an ongoing basis. |
709.91(b)(6) LICENSURE Intake and admission
709.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(6) Psychosocial evaluation.
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Observations
Based upon a review of patient records, the facility failed to document a psychosocial evaluation that included a composite picture of the patient, an assessment of the patient's problems/needs, assets/strengths, support systems, coping mechanisms, and negative factors.
The findings included:
Twelve patient records were reviewed during the on-site review. Eight patient records were reviewed for psychosocial evaluations. Four out of eight records lacked documentation of a psychosocial evaluation that included all of the required components, # 1, 5, 7 and 8.
Patient # 1 was admitted on September 24, 2013. The psychosocial evaluation failed to contain an assessment by the counselor of the patient's support systems and coping mechanisms.
Patient # 5 was admitted on September 24, 2013. The psychosocial evaluation failed to contain a composite picture of the patient and an assessment by the counselor that included the patient's problems/needs, coping mechanisms, and negative factors.
Patient # 7 was admitted on August 12, 2013. The psychosocial evaluation failed to contain an assessment by the counselor that included the patient's problems/needs, assets/strengths, support systems, coping mechanisms, and clinical impressions. The documentation included a repeat of the patient reported information and did not include an evaluation by the clinician of the required components.
Patient # 8 was admitted on August 13, 2013. The psychosocial evaluation failed to contain an assessment by the counselor of the patient's problems/needs, assets/strengths, coping mechanisms, and negative factors. The documentation included a repeat of the patient reported information and did not include an evaluation by the clinician of the required components.
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Plan of Correction
The clinic director has reviewed the standard 709.91(b)(6) and will ensure a documentation training by the lead counselor will be completed for clinical staff by 12/31/13. The psychosocial will be reviewed by the lead counselor to ensure it is complete on an ongoing basis. |
709.92(a) LICENSURE Treatment and rehabilitation services
709.92. Treatment and rehabilitation services.
(a) An individual treatment and rehabilitation plan shall be developed with a client. This plan shall include, but not be limited to, written documentation of:
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Observations
Based on a patient record review, the facility failed to develop individual treatment and rehabilitation plans with the patient in three of six records.
The findings included:
Twelve patient records were reviewed during the on-site review. Six patient records were reviewed for comprehensive treatment plans. Three records lacked documentation of a comprehensive treatment plan or were documented late, # 2, 3 and 5.
Patient # 2 was admitted on September 30, 2013. An individual treatment and rehabilitation plan was due to be developed with the patient by October 30, 2013. The individual treatment and rehabilitation plan was not documented at the time of the review.
Patient # 3 was admitted on September 3, 2013. An individual treatment and rehabilitation plan was due to be developed with the patient by October 3, 2013. The individual treatment and rehabilitation plan was documented on October 10, 2013.
Patient # 5 was admitted on September 24, 2013. An individual treatment and rehabilitation plan was due to be developed with the patient by October 24, 2013. The individual treatment and rehabilitation plan was not signed.
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Plan of Correction
The clinic director reviewed standard 709.92. A training will be conducted by lead counselor to all clinical staff on Treament Plan Development by 12/31/13. The lead counselor will review treatment plans to ensure they are comprehensive, accurate and meet the deadline requirements on an ongoing basis. |