INITIAL COMMENTS
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Based on the concerns arising from COVID-19, The Department of Drug and Alcohol Programs, Bureau of Quality Assurance for Prevention and Treatment, has implemented temporary procedures for conducting an annual renewal inspection. The inspection will be divided into two parts. 1, an abbreviated off-site inspection, will be conducted off site, and will require the submission of administrative information via email to a Licensing Specialist. 2, an abbreviated on-site inspection, will be conducted on-site at a later date and will include a review of client/patient records, and a physical plant inspection.This report is a result of Part 2, an abbreviated on-site inspection, conducted on September 9, 2020 by staff from the Department of Drug and Alcohol Programs, Bureau of Quality Assurance for Prevention and Treatment. Not all regulations were reviewed, the remainder of the regulations were reviewed during Part 1.Based on the findings of Part 2, an abbreviated 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:
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Plan of Correction
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715.23(b)(5) LICENSURE Patient records
(b) Each patient file shall include the following information:
(5) The results of all annual physical examinations given by the narcotic treatment program which includes an annual reevaluation by the narcotic treatment physician.
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Observations
Based on a review of client records on September 9, 2020, the facility failed to document an annual physical examination of the client in one record. Client #6 was admitted on May 2, 2019 and was still active at the time of the inspection. The annual physical was due no later than May 2, 2020; however, it was documented as being completed on July 22, 2020. The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
An adjustment to WFMC's monitoring system will occur by Facility Director and PA-C utilizing the electronic medical recording system, which identifies admission date, to ensure that all annual physical examinations occur prior to due date. PA-C will ensure all annual physicals are completed by random record reviews and checks system monthly. Facility Director will complete a record review of the identified deficiencies for active charts to ensure that corrections were made by 10/1/20, notation will occur on record review tool. |
709.92(b) LICENSURE Treatment and rehabilitation services
709.92. Treatment and rehabilitation services.
(b) Treatment and rehabilitation plans shall be reviewed and updated at least every 60 days.
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Observations
Based on a review of client records on September 9, 2020, the facility failed to document treatment plan updates at least every 60 days in client #'s 1, 2, 3 and 6. Client #1 was admitted on April 1, 2020 and discharged on August 17, 20202. A treatment plan update was completed on May 26, 2020 with the next one due on July 26, 2020; however, it was not completed until August 7, 2020.Client #2 was admitted on May 26, 2014 and discharged on March 2, 2020. A treatment plan update was completed on July 15, 2019 with the next one due on September 15, 2019; however, it was not completed until September 24, 2019. Client #3 was admitted on November 11, 2019 and was still active at the time of the inspection. A treatment plan update was completed on May 7, 2020 with the next one due on July 7, 2020; however, it was not completed until July 13, 2020. Client #6 was admitted on May 2, 2019 and was still active at the time of the inspection. A treatment plan update was completed on October 30, 2019 with the next one due December 30, 2019; however, it was not completed until January 25, 2020. In addition, another treatment plan update was completed on April 29, 2020 with the next one due on June 29, 2020; however, it was not completed until July 16, 2020. These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Training on time-frame regulations was completed by Facility Director with all clinical/medical staff on 10/21/20. As of 10/1/20, Executive Director will monitor and verify the completion of treatment plan updates through a monitoring report in EMR. Upcoming treatment plan updates will be reviewed during group clinical supervision on a weekly basis with counselors responsible for the completion. Clinical Supervisor will provide individual reports in weekly supervision and report will be reviewed by Facility Director each week to verify and ensure all signatures from Medical Director, counselor, patient, and supervisor are obtained in regulatory time-frame. |