INITIAL COMMENTS
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This report is a result of an on-site licensure renewal and buprenorphine inspection conducted on April 8, 2015 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Allied Addiction Recovery 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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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 one of ten patient records.The findings include:A total of ten patient records were reviewed on April 8, 2015. Ten patient records were reviewed for compliance in the Buprenorphine exception and were required to document verification of the individuals identity. One patient record did not include the documentation.Patient # 7 was admitted on July 11, 2014 and was discharged on September 29, 2014. There was no documentation verifying the individual's identity, including name, address, date of birth and other identifying data. These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
During a facility meeting on 4/9/2015, the Facility Director reviewed with staff the importance of ensuring copies of patient identification is present in the files during intake. The Office Manager will review files for the next 6 months to ensure 100% compliance. |
715.13(b) LICENSURE Patient identification
(b) A narcotic treatment program shall maintain onsite a photograph of each patient which includes the patient 's name and birth date. The narcotic treatment program shall update the photograph every 3 years.
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Observations
Based on the review of patient records, the facility failed to document an onsite photograph of each patient which includes the patient's name and birth date in one of ten patient records.The findings include:A total of ten patient records were reviewed on April 8, 2015. Ten patient records were reviewed for compliance with the Buprenorphine exception, and were required to maintain onsite, a photograph of each patient. One patient record did not include the documentation.Patient record # 7 was admitted on July 11, 2014 and was discharged on September 29, 2014. There was no documentation of an onsite photograph of the patient.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
During a facility meeting on 4/9/2015, the Facility Director reviewed with staff the importance of ensuring copies of patient identification is present in the files during intake. The Office Manager will review files for the next 6 months to ensure 100% compliance. |
709.93(a) 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:
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Observations
Based on the review of client records, the facility failed to document a complete client record on an individual which included progress notes and/or case consultation notes in five of ten client records. The findings include: Ten client records were reviewed on April 8, 2015. Ten client records were reviewed for progress notes and six client records were reviewed for case consultation notes. Client records # 3, 4 and 9 did not document progress notes or case consultation notes. Client records # 1 and 8 did not document progress notes. Client #1 was admitted on October 5, 2014. The record of service documented that the client had received counseling services on October 12, 2014. There was no progress note documented. Client #3 was admitted on August 19, 2014. The record of service documented that the client had received counseling services on October 11 and 18, 2014. There were no progress notes documented. There was no documentation of a case consultation note, due by December 31, 2014. Client #4 was admitted on December 6, 2014. The record of service documented that the client had received counseling services on February 14, 21 and March 31, 2015. There were no progress notes documented. There was no documentation of a case consultation note, due by March 31, 2015. Client #8 was admitted on June 13, 2014 and discharged on November 11, 2014. The record of service documented that the client had received counseling services on June 28, August 2, September 27, October 11 and October 18, 2014. There were no progress notes documented. Client #9 was admitted on November 11, 2014. The record of service documented that the client had received counseling services on November 8, 15, 29, 2014, December 13 and 20, 2014, January 24, February 7 and 14, 2015. There were no progress notes documented. There was no documentation of a case consultation note, due by March 31, 2015. These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
During a staff meeting on 4/9/2015, the Facility Director reaffirmed the need for all documentation contained on the contact record to be present in the clinical record. Administrative staff were instructed to check files weekly to ensure the presence of corresponding documents and the Clinical Supervisor will audit files monthly for 6 months for compliance. |