INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted by staff from the Department of Drug and Alcohol Programs, Bureau of Quality Assurance Prevention and Treatment on January 14, 2020. Based on the findings of the on-site inspection, Merakey Delaware County was found to not 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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704.11(c)(1) LICENSURE Mandatory Communicable Disease Training
704.11. Staff development program.
(c) General training requirements.
(1) Staff persons and volunteers shall receive a minimum of 6 hours of HIV/AIDS and at least 4 hours of tuberculosis, sexually transmitted diseases and other health related topics training using a Department approved curriculum. Counselors and counselor assistants shall complete the training within the first year of employment. All other staff shall complete the training within the first 2 years of employment.
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Observations
During a review of five staff records on January 14, 2020, the facility failed to ensure that all staff persons and volunteers shall receive a minimum of 6 hours of HIV/AIDS and at least 4 hours of tuberculosis, sexually transmitted diseases and other health related topics training using a Department approved curriculum. Counselors and counselor assistants shall complete the training within the first year of employment. Two staff were out of compliance.
Staff #4 was hired as a counselor on December 11, 2018 and should have received the HIV/AIDS and TB/STD training no later than December 11, 2019. There was no documentation of either training as of the date of the inspection.
Staff #5 was hired as a counselor on November 11, 2018 and should have received the HIV/AIDS and TB/STD training no later than November 11, 2019. There was no documentation of either training as of the date of the inspection.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Program Director has developed a training grid for all counselors to track all trainings completed and trainings that must be done per DDAP and County regulations. Staff #5 is registered for TB/STD on March 9 and HIV on April 23. Staff #4 has completed TB/STD training and is waited listed to complete HIV/AIDS. The Clinical Supervisor will be responsible to make sure the grid is updated monthly with completed trainings and will also discuss training compliance with all counselors in Supervisor to ensure this deficiency does not re-occur |
704.12(a)(6) LICENSURE OutPatient Caseload
704.12. Full-time equivalent (FTE) maximum client/staff and client/counselor ratios.
(a) General requirements. Projects shall be required to comply with the client/staff and client/counselor ratios in paragraphs (1)-(6) during primary care hours. These ratios refer to the total number of clients being treated including clients with diagnoses other than drug and alcohol addiction served in other facets of the project. Family units may be counted as one client.
(6) Outpatients. FTE counselor caseload for counseling in outpatient programs may not exceed 35 active clients.
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Observations
During a review of the Staffing Requirements Facility Summary Report on January 14, 2020, the project failed to keep FTE counselor caseloads for counseling in outpatient programs to 35 active clients.
Staff #5 was hired at the facility on June 27, 2016 and was promoted to counselor on November 1, 2018. Staff #5 had a caseload of 40:1.
Staff #6 was hired on November 1, 2010 as a counselor. Staff #6 had a caseload of 40:1.
These findings were reviewed with the project during the licensing process.
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Plan of Correction
Going forward all caseloads will be monitored by a Caseload grid for each counselor which will be developed and monitored weekly by the Clinical Supervisor. The grid will be revised weekly with additions and discharges of clientele to make sure that all counselors stay at the required 35 and under level for clients. The caseload grid has been implemented on February 18 and it is the Clinical Supervisor's responsible to make sure this deficiency does not re-occur |
705.28 (d) (4) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(4) Maintain a written fire drill record including the date, time, the amount of time it took for evacuation, the exit route used, the number of persons in the facility at the time of the drill, problems encountered and whether the fire alarm or smoke detector was operative.
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Observations
During a review of fire drill records on January 14, 2020, the facility failed to document a written fire drill record that included problems encountered and whether the fire alarm or smoke detector was operative.
The fire drills from January 2019 through December 2019 did not include problems encountered and whether the fire alarm or smoke detector was operative.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Program Director and the Facility Director will immediately add a section to the Fire Drill log to include a statement whether any problems were encountered during the fire drill and if the fire alarm or smoke detector was operative during the fire drill by February 28. The Facility Director will be responsible for completing the fire drill log with the required information after each fire drill. The Program Director's Assistant will meet with the Facility Director monthly to go over the fire log to ensure that this deficiency does not re-occur. |
709.28 (c) (2) 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 must be in writing and include, but not be limited to:
(2) Specific information disclosed.
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Observations
During a review of client files on January 14, 2020, the project failed to obtain an informed and voluntary consent from the client for the disclosure of information contained in the client record. The consent must be in writing and include specific information disclosed.
Client #3 was admitted on January 28, 2019 and was current at the time of the inspection. Client #3 had authorizations to a primary care physician, an emergency contact and a government agency that had "other" checked off, but no specific information listed to be disclosed. These three authorizations were signed and dated on January 28, 2019.
The findings were reviewed with project staff during the licensing process.
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Plan of Correction
The Admission Director will conduct a training on February 28th which would be the start date of the policy/procedure with the Register on how to complete the client consents with specific information including that the "other" check box must include specific information if checked off. The Direct of intake will be responsible to conduct bi-weekly audits on all intake charts to ensure this deficiency does not re-occur. |
709.30 (3) LICENSURE Client rights
709.30. Client rights.
The project shall develop written policies and procedures on client rights and document written acknowledgement by clients that they have been notified of those rights.
(3) Clients have the right to inspect their own records. The project, facility or clinical director may temporarily remove portions of the records prior to the inspection by the client if the director determines that the information may be detrimental if presented to the client. Reasons for removing sections shall be documented in the record.
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Observations
During a licensing inspection conducted on January 14, 2020, the project failed to notify clients in seen of seven records reviewed, that they have the right to inspect their own records. The project failed to notify clients that the facility or clinical director may temporarily remove portions of the records prior to the inspection by the client if the director determines that the information may be detrimental if presented to the client. Reasons for removing sections shall be documented in the record.
There was no documentation that clients #1- #7 were made aware of these rights as of the date of inspection.
These findings were reviewed with the project staff during the licensing process.
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Plan of Correction
All Clients Rights will be reviewed with the client during the intake process at admission by the Register. This review will be also be acknowledged by the client signing a Documentation of Orientation to Patient Rights. Included in the Clients Rights Policy and the Documentation of Orientation to Patient Rights is the statement , "The Program Director may temporary remove portions of the record prior to the inspection by the patient if she/he determines that the information may be detrimental to the client Reasons for removing sections shall be documented and kept on file" The Documentation of Orientation to Patient Right will be signed by the Client and the Register or Witness. The client will be offered a copy of the Documentation of Orientation of the Patient Right. The Admission Director will be responsible to audit the Intake files bi-weekly to review the client's signed acknowledgement of the Documentation of the Patient Rights. The client rights policy will be posted in every group room and individual counselor's office and noted by the counselor to the current clients. The Admissions Director will meet with the Register on February 28 which would be the start day of the policy, to complete a training on the Clients Rights Policy and the signing of the Orientation of Patient Rights to ensure this deficiency does not re-occur |
709.34 (a) (1) LICENSURE Reporting of unusual incidents
§ 709.34. Reporting of unusual incidents.
(a) The project shall develop and implement policies and procedures to respond to the following unusual incidents:
(1) Physical assault or sexual assault by staff or a client.
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Observations
During a licensing inspection conducted on January 14, 2020, the project failed to develop and implement policies and procedures to respond to an unusual incident involving physical assault or sexual assault by staff or a client.
These findings were reviewed with the project staff during the licensing process.
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Plan of Correction
? The Merakey policy addressing 709.34 has been developed with specific procedures to be implemented to respond to an unusual incident involving physical assault or sexual assault by staff or a client. According to the policy, the Program Director or designee will fax a report within 48 hours utilizing the State DDAP Unusual Incident Report. The Drug and Alcohol staff will receive the policy directly on February 28th at which time the policy will be in effect. followed by a training on how to implement the specific facets of the policy on March 5th. Each staff member will again receive the information in supervision. The Program Director and the Clinical Supervisor will be responsible to ensure this deficiency does not re-occur. |
709.34 (a) (2) LICENSURE Reporting of unusual incidents
§ 709.34. Reporting of unusual incidents.
(a) The project shall develop and implement policies and procedures to respond to the following unusual incidents:
(2) Selling or use of illicit drugs on the premises.
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Observations
During a licensing inspection conducted on January 14, 2020, the project failed to develop and implement policies and procedures to respond to unusual incidents involving the selling or use of illicit drugs on the premises.
These findings were reviewed with the project staff during the licensing process.
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Plan of Correction
The Merakey policy addressing 709.34 has been developed with specific procedures to be implemented to respond to an unusual incident involving the selling or use of illicit substances on the premises. According to the policy, the Program Director or designee will fax a report within 48 hours utilizing the State DDAP Unusual Incident Report. The Drug and Alcohol staff will receive the policy directly on February 28th at which time the policy will be in effect followed by a training on how to implement the specific facets of the policy on March 5th. Each staff member will again receive the information in supervision. The Program Director and the Clinical Supervisor will be responsible to ensure this deficiency does not re-occur. |
709.34 (a) (3) LICENSURE Reporting of unusual incidents
§ 709.34. Reporting of unusual incidents.
(a) The project shall develop and implement policies and procedures to respond to the following unusual incidents:
(3) Death or serious injury due to trauma, suicide, medication error or unusual circumstances while in residential treatment or, when known by facility, for ambulatory services.
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Observations
During a licensing inspection conducted on January 14, 2020, the project failed to develop and implement policies and procedures to respond to an unusual incident involving the death or serious injury due to trauma, suicide, medication error or unusual circumstances while in residential treatment or, when known by facility, for ambulatory services.
These findings were reviewed with the project staff during the licensing process.
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Plan of Correction
The Merakey policy addressing 709.34 has been developed with specific procedures to be implemented to respond to an unusual incident involving the death or serious injury due to trauma, suicide, medication error or unusual circumstances while in the facility. According to the policy, the Program Director or designee will fax a report within 48 hours utilizing the State DDAP Unusual Incident Report. The Drug and Alcohol staff will receive the policy directly on February 28th at which time the policy will be in effect followed by a training on how to implement the specific facets of the policy on March 5th. Each staff member will again receive the information in supervision. The Program Director and the Clinical Supervisor will be responsible to ensure this deficiency does not re-occur. |
709.34 (a) (4) LICENSURE Reporting of unusual incidents
§ 709.34. Reporting of unusual incidents.
(a) The project shall develop and implement policies and procedures to respond to the following unusual incidents:
(4) Significant disruption of services due to disaster such as fire, storm, flood or other occurrence which closes the facility for more than 1 day.
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Observations
During a licensing inspection conducted on January 14, 2020, the project failed to develop and implement policies and procedures to respond to an unusual incident involving significant disruption of services due to disaster such as fire, storm, flood, or other occurrence which closes the facility for more than 1 day.
These findings were reviewed with the project staff during the licensing process.
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Plan of Correction
The Merakey policy addressing 709.34 has been developed with specific procedures to be implemented to respond to an unusual incident involving the significant disruption of services due disaster such as fire, storm, flood, or other occurrence which j closes the facility for more than one day. According to the policy, the Program Director or designee will fax a report within 48 hours utilizing the State DDAP Unusual Incident Report. The Drug and Alcohol staff will receive the policy directly on February 28th at which time the policy will be in effect followed by a training on how to implement the specific facets of the policy on March 5th. Each staff member will again receive the information in supervision. The Program Director and the Clinical Supervisor will be responsible to ensure this deficiency does not re-occur. |
709.34 (a) (5) LICENSURE Reporting of unusual incidents
§ 709.34. Reporting of unusual incidents.
(a) The project shall develop and implement policies and procedures to respond to the following unusual incidents:
(5) Theft, burglary, break-in or similar incident at the facility.
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Observations
During a licensing inspection conducted on January 14, 2020, the project failed to develop and implement policies and procedures to respond to an unusual incident involving theft, burglary, break-in or similar incident at the facility.
These findings were reviewed with the project staff during the licensing process.
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Plan of Correction
The Merakey policy addressing 709.34 has been developed with specific procedures to be implemented to respond to an unusual incident involving theft, burglary, break-in or similar incident at the facility. According to the policy, the Program Director or designee will fax a report within 48 hours utilizing the State DDAP Unusual Incident Report. The Drug and Alcohol staff will receive the policy directly on February 28th at which time the policy will be in effect followed by a training on how to implement the specific facets of the policy on March 5th. Each staff member will again receive the information in supervision. The Program Director and the Clinical Supervisor will be responsible to ensure this deficiency does not re-occur. |
709.34 (a) (6) LICENSURE Reporting of unusual incidents
§ 709.34. Reporting of unusual incidents.
(a) The project shall develop and implement policies and procedures to respond to the following unusual incidents:
(6) Event at the facility requiring the presence of police, fire or ambulance personnel.
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Observations
During a licensing inspection conducted on January 14, 2020, the project failed to develop and implement policies and procedures to respond to an unusual incident involving an event at the facility requiring the presence of police, fire or ambulance personnel.
These findings were reviewed with the project staff during the licensing process.
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Plan of Correction
The Merakey policy addressing 709.34 has been developed with specific procedures to be implemented to respond to an unusual incident involving an event at the facility requiring the presence of police, fire or ambulance personnel. According to the policy, the Program Director or designee will fax a report within 48 hours utilizing the State DDAP Unusual Incident Report. The Drug and Alcohol staff will receive the policy directly on February 28th at which time the policy will be in effect followed by a training on how to implement the specific facets of the policy on March 5th. Each staff member will again receive the information in supervision. The Program Director and the Clinical Supervisor will be responsible to ensure this deficiency does not re-occur. |
709.34 (a) (7) LICENSURE Reporting of unusual incidents
§ 709.34. Reporting of unusual incidents.
(a) The project shall develop and implement policies and procedures to respond to the following unusual incidents:
(7) Fire or structural damage to the facility.
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Observations
During a licensing inspection conducted on January 14, 2020, the project failed to develop and implement policies and procedures to respond to an unusual incident involving fire or structural damage to the facility.
These findings were reviewed with the project staff during the licensing process.
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Plan of Correction
The Merakey policy addressing 709.34 has been developed with specific procedures to be implemented to respond to an unusual incident involving fire or structural damage to the facility. According to the policy, the Program Director or designee will fax a report within 48 hours utilizing the State DDAP Unusual Incident Report. The Drug and Alcohol staff will receive the policy directly on February 28th at which time the policy will be in effect followed by a training on how to implement the specific facets of the policy on March 5th. Each staff member will again receive the information in supervision. The Program Director and the Clinical Supervisor will be responsible to ensure this deficiency does not re-occur. |
709.34 (a) (8) LICENSURE Reporting of unusual incidents
§ 709.34. Reporting of unusual incidents.
(a) The project shall develop and implement policies and procedures to respond to the following unusual incidents:
(8) Outbreak of a contagious disease requiring Centers for Disease Control (CDC) notification.
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Observations
During a licensing inspection conducted on January 14, 2020, the project failed to develop and implement policies and procedures to respond to an unusual incident involving the outbreak of a contagious disease requiring Centers for Disease Control (CDC) notification.
These findings were reviewed with the project staff during the licensing process.
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Plan of Correction
The Merakey policy addressing 709.34 has been developed with specific procedures to be implemented to respond to an unusual incident involving the outbreak of a contagious disease requiring Centers for Disease Control notification. According to the policy, the Program Director or designee will fax a report within 48 hours utilizing the State DDAP Unusual Incident Report. The Drug and Alcohol staff will receive the policy directly on February 28th at which time the policy will be in effect followed by a training on how to implement the specific facets of the policy on March 5th. Each staff member will again receive the information in supervision. The Program Director and the Clinical Supervisor will be responsible to ensure this deficiency does not re-occur |
709.34 (b) (1) LICENSURE Reporting of unusual incidents
§ 709.34. Reporting of unusual incidents.
(b) Policies and procedures must include the following:
(1) Documentation of the unusual incident.
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Observations
During a licensing inspection conducted on January 14, 2020, the project's policy and procedure manual did not provide policies and procedures on documenting unusual incidents.
These findings were reviewed with project staff during the licensing process.
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Plan of Correction
The Merakey policy addressing 709.34 has been developed with specific procedures to be implemented to document unusual incidents. According to the policy, the Program Director or designee will fax a report within 48 hours utilizing the State DDAP Unusual Incident Report. The Drug and Alcohol staff will receive the policy directly on February 28th at which time the policy will be in effect followed by a training on how to implement the specific facets of the policy on March 5th. Each staff member will again receive the information in supervision. The Program Director and the Clinical Supervisor will be responsible to ensure this deficiency does not re-occur. |
709.34 (b) (2) LICENSURE Reporting of unusual incidents
§ 709.34. Reporting of unusual incidents.
(b) Policies and procedures must include the following:
(2) Prompt review and identification of the causes directly or indirectly responsible for the unusual incident.
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Observations
During a licensing inspection conducted on January 14, 2020, the project's policy and procedure manual did not provide a policy and procedure to include the prompt review and identification of the cause directly or indirectly responsible for the unusual incident.
These findings were reviewed with project staff during the licensing process.
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Plan of Correction
The Merakey policy addressing 709.34 has been developed with specific procedures to be implemented to include the prompt review and identification of the cause or causes directly or indirectly responsible for the unusual incident. According to the policy, the Program Director or designee will fax a report within 48 hours utilizing the State DDAP Unusual Incident Report. The Program Director with the support of the Quality Improvement Specialist will assist the program in designing performance improvement plans as related to incident management and to evaluate the data and analyze the incidents and areas for improvement. The Program Director will keep incident binders with all documented information and POC's. The Drug and Alcohol staff will receive the policy directly on February 28th at which time the policy will be in effect followed by a training on how to implement the specific facets of the policy on March 5th. Each staff member will again receive the information in supervision. The Program Director and the Clinical Supervisor will be responsible to ensure this deficiency does not re-occur. |
709.34 (b) (3) LICENSURE Reporting of unusual incidents
§ 709.34. Reporting of unusual incidents.
(b) Policies and procedures must include the following:
(3) Implementation of a timely and appropriate corrective action plan, when indicated.
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Observations
During a licensing inspection conducted on January 14, 2020, the project's policy and procedure manual did not provide a policy and procedure to include the implementation of a timely and appropriate corrective action plan for an unusual incident, when indicated.
These findings were reviewed with project staff during the licensing process.
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Plan of Correction
The Merakey policy addressing 709.34 has been developed with specific procedures to be implemented to address the timely and appropriate corrective action plan for an unusual incident plan when indicated. According to the policy, the Program Director or designee will fax a report within 48 hours utilizing the State DDAP Unusual Incident Report. The Program Director with the support of the Quality Improvement Specialist will assist the program in designing performance improvement plans as related to incident management and to evaluate the data and analyze the incidents and areas for improvement. The Program Director will review the COA plan if needed to ensure that it is working effectively. The Program Director will keep incident binders on site that will include all COA's and follow up documentation. The Drug and Alcohol staff will receive the policy directly on February 28th at which time the policy will be in effect followed by a training on how to implement the specific facets of the policy on March 5th. Each staff member will again receive the information in supervision. The Program Director and the Clinical Supervisor will be responsible to ensure this deficiency does not re-occur. |
709.34 (b) (4) LICENSURE Reporting of unusual incidents
§ 709.34. Reporting of unusual incidents.
(b) Policies and procedures must include the following:
(4) Ongoing monitoring of the corrective action plan.
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Observations
During a licensing inspection conducted on January 14, 2020, the project's policy and procedure manual did not provide a policy and procedure to include the ongoing monitoring of the corrective action plan for an unusual incident.
These findings were reviewed with project staff during the licensing process.
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Plan of Correction
The Merakey policy addressing 709.34 has been developed with specific procedures to be implemented the on-going monitoring of the corrective action plan. The Program Director with the support of the Quality Improvement Specialist will assist the program in monitoring the Measurable Improvement Plans as related to the incidents reported. The Drug and Alcohol staff will receive the policy directly on February 28th at which time the policy will be in effect followed by a training on how to implement the specific facets of the policy on March 5th. Each staff member will again receive the information in supervision. The Program Director and the Clinical Supervisor will be responsible to ensure this deficiency does not re-occur. |
709.34 (b) (5) LICENSURE Reporting of unusual incidents
§ 709.34. Reporting of unusual incidents.
(b) Policies and procedures must include the following:
(5) Reporting mechanism to ensure that reporting of an unusual incident to an entity is in compliance with State and Federal confidentiality laws.
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Observations
During a licensing inspection conducted on January 14, 2020, the project's policy and procedure manual did not provide a policy and procedure to include the reporting mechanism to ensure that reporting of an unusual incident to an entity is in compliance with State and Federal confidentiality laws.
These findings were reviewed with project staff during the licensing process.
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Plan of Correction
The Merakey policy addressing 709.34 has been developed with specific procedures to include the reporting mechanism to ensure that reporting of an unusual incident to an entity is in compliance with State and Federal confidentiality laws. According to the policy, the Program Director or designee will fax a report within 48 hours utilizing the State DDAP Unusual Incident Report. The Drug and Alcohol staff will receive the policy directly on February 28th at which time the policy will be in effect followed by a training on how to implement the specific facets of the policy on March 5th. Each staff member will again receive the information in supervision. The Program Director and the Clinical Supervisor will be responsible to ensure this deficiency does not re-occur. |
709.34 (c) (4) LICENSURE Reporting of unusual incidents
§ 709.34. Reporting of unusual incidents.
(c) To the extent permitted by State and Federal confidentiality laws, the project shall file a written unusual incident report with the Department within 3 business days following an unusual incident involving:
(4) Event at the facility requiring the presence of police, fire or ambulance personnel.
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Observations
During a review of incident reports on January 14, 2020 the project failed to the extent permitted by State and Federal confidentiality laws, to file a written unusual incident report with the Department within 3 business days following an unusual incident involving an event at the project requiring the presence of police, fire or ambulance personnel.
On July 15, 2019, an event at the facility requiring the presence of ambulance personnel was not filed with the Department within 3 business days.
On July 30, 2019, an event at the facility requiring the presence of police personnel was not filed with the Department within 3 business days.
On August 5, 2019, an event at the facility requiring the presence of ambulance personnel was not filed with the Department within 3 business days.
These findings were reviewed with the project staff during the licensing process.
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Plan of Correction
The Merakey policy addressing 709.34 has been developed with specific procedures to be implemented in order to report to the extent permitted by State and Federal confidentiality laws, to file a written unusual incident report with the Department within three business days following an unusual incident requiring the presence of police, fire, or ambulance personnel at the facility. Drug and Alcohol staff will receive the policy directly on February 28th at which time the policy will be in effect followed by a training on how to implement the specific facets of the policy on March 5th. Each staff member will again receive the information in supervision. The Program Director and the Clinical Supervisor will be responsible to ensure this deficiency does not re-occur. |
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.
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Observations
During a review of four buprenorphine patient records on January 14, 2020, the narcotic treatment program failed to verify in one record reviewed that the individual has reached 18 years of age prior to administration of an agent.
Patient #2 was admitted on May 28, 2019 and was still current at the time of the inspection. The program had no documentation of age prior to administration of the prescribed agent.
These findings were reviewed with program staff during the licensing process.
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Plan of Correction
The Register shall obtain a State photo I.D. to determine eligibility for admission by reaching 18 years of age from any client who would like admission to the Suboxone or Vivitrol Program. The I.D.will be scanned into Avatar and copied and placed in the front of chart of the client's chart. The Medical Assistant shall review the chart to confirm that that a copy of the individuals State photo I.D was collected and if not to obtain a copy from the register to add to the chart. If an individual does not have a State Photo I.D, Any valid or expired national federal, state or local issued photo identification cards, A valid or expired passport, a valid or expired student photo ID, which contains the individuals date of birth, a photo identification card issued by another licensed NTP, a valid or expired check cashing photo identification card, a birth certificate and Social Security card, a copy of a photo of the patient and a letter directly from another licensed NTP in which the individual was previously enrolled, a copy of a photo from a medical record with verification of date of birth. A state or federal correctional facility identification card. In the event, individual cannot obtain any of the above listed we may accept any valid or expired photo identification card issued by a national, federal, state or local governmental agency without the patient's DOB in conjunction with a document that contains the patient's DOB (e.g., birth certificate, marriage certificate, a formal signed letter from an agency that provides/provided services to the patient, etc.). We will keep copies of any documents used to verify a patient's identity in the patient's record. With the written consent from the patient, the we may contact the patient's insurer in efforts to verify identification. Information obtained from the insurer must be documented and include the following: Name, DOB, Gender, Race and Ethnicity. The Clinical Supervisor will meet with the Register to explain the new process by February 27th. The Register will be responsible to ensure that this deficiency does not re-occur. |
715.9(a)(2) 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:
(2) Verify the individual 's identity, including name, address, date of birth, emergency contact and other identifying data.
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Observations
During a review of four patient records on January 14, 2020, prior to administration of an agent, the narcotic treatment program failed to verify the individual's identity, including name, address, date of birth, emergency contact and other identifying data in one record reviewed.
Patient #2 was admitted on May 28, 2019 and was still current at the time of the inspection. The program had no documentation of the individual's identity, including name, address, date of birth, emergency contact and other identifying data prior to administering the prescribed agent.
These findings were reviewed with program staff during the licensing process.
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Plan of Correction
The Medical Assistant shall review the chart to confirm that that a copy of the individuals State photo I.D was collected and if not to obtain a copy from the register to add to the chart. The State I.D. will determine eligibility of admission by confirming the individual's identity including name, address, date of birth, emergency contact and other identifying data before being admitting into the Suboxone or Vivitrol program. If an individual does not have a State Photo I.D, Any valid or expired national federal, state or local issued photo identification cards, A valid or expired passport, a valid or expired student photo ID, which contains the individuals date of birth, a photo identification card issued by another licensed NTP, a valid or expired check cashing photo identification card, a birth certificate and Social Security card, a copy of a photo of the patient and a letter directly from another licensed NTP in which the individual was previously enrolled, a copy of a photo from a medical record with verification of date of birth. A state or federal correctional facility identification card. In the event, individual cannot obtain any of the above listed we may accept any valid or expired photo identification card issued by a national, federal, state or local governmental agency without the patient's DOB in conjunction with a document that contains the patient's DOB (e.g., birth certificate, marriage certificate, a formal signed letter from an agency that provides/provided services to the patient, etc.). We will keep copies of any documents used to verify a patient's identity in the patient's record. With the written consent from the patient, the we may contact the patient's insurer in efforts to verify identification. Information obtained from the insurer must be documented and include the following: Name, DOB, Gender, Race and Ethnicity.
Additionally, all completed signed consents including emergency contact will be copied and placed in the front of the Medical Section of the client's file. The Clinical Supervisor will meet with the Register to explain the new process by February 27th. The Resister will be responsible to ensure that this deficiency does not re-occur.
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715.19(1) LICENSURE Psychotherapy services
A narcotic treatment program shall provide individualized psychotherapy services and shall meet the following requirements:
(1) A narcotic treatment program shall provide each patient an average of 2.5 hours of psychotherapy per month during the patient 's first 2 years, 1 hour of which shall be individual psychotherapy. Additional psychotherapy shall be provided as dictated by ongoing assessment of the patient.
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Observations
During a review of four patient records on January 14, 2020, a narcotic treatment program failed to provide one patient reviewed an average of 2.5 hours of psychotherapy per month during the patient 's first 2 years, 1 hour of which shall be individual psychotherapy.
Patient #3 was admitted on January 28, 2019 and was current at the time of the inspection. Patient #3 had no individual therapy documented for the months of October, November and December 2019.
These findings were reviewed with the program staff during the licensing process.
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Plan of Correction
The Clinical Supervisor will meet for a training on March 5th with the Counselors to go over the State Mandate for client psychotherapy which entails each patient receiving an average of 2.5 hours of psychotherapy hours per month during the client's first two years of treatment and one hour of which shall be individual therapy. Also, during individual supervisions, the Clinical Supervisor will go over the counselor's caseload and discuss the DDAP mandate and to ensure the adherence to the mandate by the counselors. The Clinical Supervisor will be responsible for monitoring therapy attendance and discuss strategies for engaging patients who may be at risk of not meeting minimum contact hours in order to ensure this deficiency does not re-occur. |