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 October 14-17, 2008 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, WPIC Narcotic Addiction Treatment Program was found not to be in compliance with the applicable chapters of 28 PA Code which pertain to the facility. Deficiencies were identified during this inspection and plan of correction is due on November 17, 2008.
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Plan of Correction
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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 16 patient records on 10-5-08, the facility failed to provide signed release forms prior to the disclosure of patient information in three of nine patient records where required.
Finding:
The facility did not have consent to release information forms signed prior to the disclosure of the required transfer information in patient records # 3, 6 and 7. A medical note indicating that the facility contacted the previous facility to verify the dose amount and the last day dosed was documented in patient records #3, 6, and 7.
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Plan of Correction
Under the direction of the Clinical Administrator, the Program Director or his designee will ensure through quality assurance chart reviews that signed releases are obtained from clients prior to communicating and disclosing and receiving client information. The necessity of the completion of the above activity shall be reviewed with medical/clinical staff by 11/30/08. Reviews will begin immediately. |
715.20(4) LICENSURE Patient transfers
A narcotic treatment program shall develop written transfer policies and procedures which shall require that the narcotic treatment program transfer a patient to another narcotic treatment program for continued maintenance, detoxification or another treatment activity within 7 days of the request of the patient.
(4) The receiving narcotic treatment program shall document in writing that it notified the transferring narcotic treatment program of the admission of the patient and the date of the initial dose given to the patient by the receiving narcotic treatment program.
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Observations
Based on conversations with the directors and the review of the fifteen patient records on 10-15-08, the facility failed to document notification of the transfer to the referring facility in three of three patient records where required.
Finding:
The facility did not document the notification of the transfer to the referring facility in patient records # 3, 6,and 7.
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Plan of Correction
Under the direction of the Clinical Administrator, the Program Director or his designee will ensure through quality assurance chart review that medical/clinical staff document the notification of client transfer to referring treatment facilities. The necessity of the completion of the above activity shall be reviewed with medical/clinical staff by 11/30/08. Reviews will begin immediately. |
715.23(c)(1-7) LICENSURE Patient records
(c) An annual evaluation of each patient 's status shall be completed by the patient 's counselor and shall be reviewed, dated and signed by the medical director. The annual evaluation period shall start on the date of the patient 's admission to a narcotic treatment program and shall address the following areas:
(1) Employment, education and training.
(2) Legal standing.
(3) Substance abuse.
(4) Financial management abilities.
(5) Physical and emotional health.
(6) Fulfillment of treatment objectives.
(7) Family and community supports.
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Observations
Based on a review of fifteen patient records on 10-16-08, the facility failed to provide the medical directors signature on the annual evaluations in four of four patient records where required.
Finding:
Fifteen patient records were reviewed and four were required to have the annual evaluations. Patient records # 8, 9, 10 and 11 did not have the medical directors signature.
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Plan of Correction
The program has sent a letter to DAPL requesting that the NATP medical director title be transferred to Dr. Campopiano from Dr. Douaihy. The on site schedule of Dr. Campopiano will allow much greater flexibility for the document to be signed by medical director as per regulation.
Medical director to monitor and oversee the signing of annual evaluations on an ongoing basis. This shall be put into effect upon notification from DAPL that transfer is acceptable
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715.28(c)(1-5) LICENSURE Unusual incidents
(c) A narcotic treatment program shall file a written Unusual Incident Report with the Department within 48 hours following an unusual incident including the following:
(1) Complaints of patient abuse (physical, verbal, sexual and emotional).
(2) Death or serious injury due to trauma, suicide, medication error or unusual circumstances.
(3) Significant disruption of services due to a disaster such as a fire, storm, flood or other occurrence.
(4) Incidents with potential for negative community reaction or which the facility director believes may lead to community concern.
(5) Drug related hospitalization of a patient.
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Observations
Based on a review of the facility's incident reports on 10-14-08, the facility failed to document the reports were submitted to the Department.
Finding:
The facility did not document the reports were submitted to the Department. Incident reports were documented by the facility for two deaths dated 5-9-08 and 9-10-08, and an incident regarding a staff member dated 7-2008. In addition, upon reviewing the discharge patient list on 10-15-08, the list documented four deceased patients, while the incident log documented only two incidents relating to the death of patients. The facility failed to submit incident reports to the Department as required.
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Plan of Correction
Under the direction of the Clinical Administrator, the Program Director or his designee will oversee the completion and faxing of Department Incident Reports as per Unusual Incidents regulation.
Director shall immediately put this process into effect and monitor on an ongoing basis.
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