INITIAL COMMENTS
|
This report is a result of an on-site licensure renewal inspection and methadone monitoring inspection conducted on April 23, 2015 through April 24, 2015 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Williamsport Family Medical Center 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:
|
Plan of Correction
|
715.14(a) LICENSURE Urine testing
(a) A narcotic treatment program shall complete an initial drug-screening urinalysis for each prospective patient and a random urinalysis at least monthly thereafter.
|
Observations
Based on the review of patient records, the facility failed to document a complete initial drug-screening urinalysis prior to the administration of a narcotic agent in one of eighteen records reviewed.The findings included:Eighteen patient records were reviewed on April 23, 2015 through April 24, 2015. Twelve patient records required a complete initial drug-screening urinalysis prior to the administration of a narcotic agent. Patient record #12 had documentation of the patient receiving an initial dose prior to the completion of a drug-screening urinalysis. Patient #12 was admitted into the program September 18, 2014 and was still an active client at the time of the inspection. The client's urinalysis was conducted on 09/18/2014 and the results were not reported back to the facility until 09/24/2014. The patient received an initial dose of 30 mg of methadone on 09/18/2014. The patient received a dose of 35 mg of methadone on 09/19/2014 and doses of 42 mg on 09/20/2014, 09/21/2014, 09/22/2014, 09/23/2014, and 09/24/2014.This is a repeat citation from the 04/16/2013 annual licensing and methadone monitoring inspection.These findings were reviewed with facility staff during the licensing and methadone monitoring process.
|
Plan of Correction
As of 6/22/15, Medical staff will document in the patient's record verifying that an initial drug-screening was completed, either with the lab in the event that a final paper report has not been faxed to the facility or by a physical copy of the report. This documentation will include all substances required by this regulation. The Medical Director will be responsible for verifying that the results are available prior to initial administration of medications by signing off on the drug screen report. Initial drug-screen will also be added to the patient's intake checklist requiring medical staff signature verifying completion to ensure compliance with regulation. Executive Director will sign off on intake checklist verifying that the initial drug-screen was received. If drug-screen results have not been verified as completed, the patient will not be administrated medication until the screen is completed. |
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.
|
Observations
Based on a review of patient records, the facility failed to document an annual evaluation of the patient's status in two of eighteen patient records reviewed. The findings include:Eighteen patient records were reviewed on April 23, 2015 through April 24, 2015. Six patient records required documentation of the patient's status via an annual evaluation. The facility failed to document an annual evaluation in patient record's, #15 and 16.Patient #15 was admitted into the program on October 14, 2013 and was successfully discharged on March 20, 2015. An annual evaluation of the patient's status was due to be completed by October 14, 2014. The facility provided the annual evaluation during the inspection; however, the counselor's signature was not dated and the doctor's signature was dated April 23, 2015, which was the day of the inspection.Patient #16 was admitted into the program on February 6, 2014 and was transferred out of the program on February 10, 2015. An annual evaluation of the patient's status was due to be completed by February 6, 2015; however, there was no documentation of an annual evaluation in the patient record at the time of the inspection.These findings were reviewed with facility staff during the licensing and methadone monitoring process.
|
Plan of Correction
As of 6/22/15, Executive Director will monitor and verify the completion of annual evals through a monitoring spreadsheet and a newly created annual checklist for all patients. Upcoming annual events will be reviewed during clinical supervision on a weekly basis with counselors responsible for the completion. The patient's annual evaluation will be updated on the chart monitoring check list that is used for on-going peer chart reviews to include required signatures. This checklist will be reviewed by Facility Director, once completed to verify and ensure all signature from Medical Director and compliance with this regulation. |