INITIAL COMMENTS
|
This report is a result of an on-site licensure renewal inspection conducted on February 28, 2018 by staff from the Department of Drug and Alcohol Programs, Bureau of Quality Assurance for Prevention and Treatment, Program Licensure Division. Based on the findings of the on-site inspection, PA Treatment & Healing 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
|
715.9(a)(1) 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:
(1) Verify that the individual has reached 18 years of age.
|
Observations
The facility failed to document verification of age and identity prior to administration in three of four client records reviewed on February 28, 2018.
Client #1 was admitted on December 28, 2017, and began buprenorphine treatment on 1-31-2018.
Client # 2 was admitted on January 2, 2018, and began buprenorphine treatment on 2-10-2018.
Client # 3 was admitted on January 3, 2018, and began buprenorphine treatment on 1-31-2018.
These findings were reviewed with the facility staff during the licensing process.
|
Plan of Correction
The facility failed to document verification of age and identity prior to administration of medication in a narcotic treatment program. The clinical staff person will obtain documentation that will verify the age and identity of any client entering the narcotic treatment program at the time of admission. The agency will ensure compliance with this regulation through training clinical staff and review of client files by the facility director. This agency will be in compliance with this standard by 4/2/2018 |
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.
|
Observations
The facility failed to maintain an onsite photograph including the patient's name and birth date in three of four client records reviewed on February 28, 2018.
Client #1 was admitted on December 28, 2017.
Client # 2 was admitted on January 2, 2018.
Client # 3 was admitted on January 3, 2018.
These findings were reviewed with the facility staff during the licensing process.
|
Plan of Correction
The facility failed to maintain an onsite photograph including client's name and birthdate. The agency will ensure ongoing compliance with this regulation through training staff to obtain and maintain a picture identification in each client file that documents the client's name and age from the time of admission and updating every three years. The facility director will continue to ensure this procedure through supervision and quality client chart reviews. The agency will be in compliance with this standard on 4/2/2018. |
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:
|
Observations
The facility failed to document progress notes in four of five client records reviewed on February 28, 2018.
Client #1 was admitted on December 28, 2017. Progress notes in the record were not dated.
Client # 2 was admitted on January 2, 2018. An individual progress note for 2-9-2018 was not documented.
Client # 4 was admitted on January 4, 2018. An individual progress note for 1-25-2018 was not documented. One progress note in the record was not dated.
Client # 5 was admitted on January 12, 2018. An individual progress note for 2-12-2018 was not documented. One progress note in the record was not dated.
These findings were reviewed with the facility staff during the licensing process.
|
Plan of Correction
The facility failed to document progress notes in four client records. The facility director will review with clinical staff the required documentation relevant to recording the client's involvement with the treatment program during supervision. The facility director will ensure compliance with this regulation through ongoing supervision and quality reviews of client files. The agency will be in compliance with this standard as of 4/2/2018. |