INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on July 6-7, 2015 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Naaman 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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709.28(c) LICENSURE Confidentiality
709.28. Confidentiality.
(c) The project shall obtain an informed and voluntary consent from the client for the disclosure of information contained in the client record. The consent shall be in writing and include, but not be limited to:
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Observations
Based on a review of client records, the facility failed to obtain informed and voluntary consents in one of ten records reviewed.
The findings include:
Ten client records were reviewed on July 6-7, 2015. The facility failed to document an informed and voluntary consent in one client record, #7.
The findings include:
Client #7 was admitted to treatment on October 29, 2014 and still active at the time of inspection. Client record #7 contained a letter dated 2/18/15 stating the client was in a drug and alcohol treatment program and the client's course in treatment; however the letter did not identify the recipient of the letter or the purpose for the release of information. Additionally, since there was no identified recipient or listed purpose included on the letter it was not possible to determine that a valid consent to release information had been completed.
These findings were reviewed with facility staff during the inspection process.
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Plan of Correction
Informed and voluntary consent forms will be obtained for all clients prior to releasing any client information. All staff will be re-trained regarding the mandatory use of consents when sending information to a recipient via director's email, clinical supervision and reiterated at all-staff meeting on August 26, 2015 by director. Correspondence related to drug and alcohol treatment of a client will be addressed to the organization or individual where a valid consent to release information is completed and filed in chart.
Client #7 has current signed consents on file, as client #7 was still active at time of inspection. Clinical Director will conduct random chart reviews for ongoing compliance. Facility to be in full compliance by August 5, 2015. |
715.10(f) LICENSURE Pregnant patients
(f) The narcotic treatment program shall ensure that each female patient is fully informed of the possible risk to her or her unborn child from continued use of illicit drugs and from use of, or withdrawal from a narcotic drug administered or dispensed by the program in comprehensive maintenance or detoxification treatment.
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Observations
Based on a review of patient records, the facility failed to inform each female patient of the possible risk to her unborn child from continued use of illicit drugs and from use of or withdrawal from a narcotic drug administered or dispensed by the program in comprehensive maintenance treatment in one of one patient record.
The findings include:
Six patient records were reviewed on July 7, 2015, only one required documention verifying that the facility fully inform the patient of the possible risk to her and her unborn child, specifically patient # 13.
Patient # 13 was admitted into treatment on February 24, 2015. The patient received her initial dose of buprenorphine on May 28, 2015. There was no documentation showing that the facility informed the patient of the potential harm to her unborn child.
These findings were reviewed with facility staff during the inspection process.
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Plan of Correction
Female clients will be fully informed of the possible risk to her and her unborn child of continued use of illicit drugs and from the use of, or withdrawal from a narcotic drug administered or dispensed by the program by the Medical Director. A signed Suboxone consent form will be filed in the female's chart which will fully inform the client of risks associated with the use of Suboxone. Clinical staff will be re-trained by the Clinical Director regarding this regulation via email and supervision. Director will also reiterate this regulation at the all-staff meeting on August 26, 2015. Clinical Director will perform random chart audits to ensure compliance of all required documentation pertaining to female Suboxone clients being informed of risks to this narcotic. Facility to be in full compliance by 7/31/2015. |
715.12(1-5) LICENSURE Informed patient consent
A narcotic treatment program shall obtain an informed, voluntary, written consent before an agent may be administered to the patient for either maintenance or detoxification treatment. The following shall appear on the patient consent form:
(1) That methadone and LAAM are narcotic drugs which can be harmful if taken without medical supervision.
(2) That methadone and LAAM are addictive medications and may, like other drugs used in medical practices, produce adverse results.
(3) That alternative methods of treatment exist.
(4) That the possible risks and complications of treatment have been explained to the patient.
(5) That methadone is transmitted to the unborn child and will cause physical dependence.
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Observations
Based on a review of patient records, the facility failed to obtain an informed, voluntary, written consent prior to the administration of a narcotic agent for maintenance treatment in one of six patient records.
The findings include:
Six patient records were reviewed for signed consent forms on July 7, 2015. One patient record was reviewed for the completion of an informed, voluntary written consent prior to the administration of a narcotic agent. The facility failed to document the completion of an informed, voluntary, written consent prior to the administration of a narcotic agent in patient record # 13.
Patient # 13 was admitted into treatment on February 24, 2015. The patient received their initial dose of buprenorphine on May 28, 2015. There was no documentation of an informed, voluntary written consent prior to the administration of a narcotic agent in patient record # 13.
These findings were reviewed with facility staff during the inspection process.
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Plan of Correction
Informed, voluntary, written consent will be obtained prior to the administration of a narcotic agent. Staff will be re-trained by 8/5/2015 as to this mandatory regulation.
Client #13 was still active at time of inspection. Client's new job presented a barrier to attend scheduled appointments since the inspection. Client is scheduled for 8/5/15, at which time primary counselor will have client sign the consent to treatment form and file in client's chart.
Director will again reiterate ongoing compliance with regards to signed consents at all-staff meeting on August 26, 2015. Clinical Director will re-train via email and individual supervision regarding compliance immediately. Clinical Director will also conduct random chart reviews to ensure ongoing compliance. |