INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on April 10 - 11, 2014 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Allied Addiction Recovery, LLC 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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709.33(a) LICENSURE Notification of Termination
709.33. Notification of termination.
(a) Project staff shall notify the client, in writing, of a decision to involuntarily terminate the client's treatment at the project. The notice shall include the reason for termination.
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Observations
Based on a review of client records, the facility failed to notify the client, in writing, of a decision to involuntarily terminate the client's treatment at the project, in one of two client records.
The findings include:
Ten client records were reviewed on April 10 - 11, 2014. Two records pertained to clients that were involuntarily terminated from treatment at the project. The facility failed to notify the client, in writing, of a decision to involuntarily terminate the client's treatment at the project, in client record # 6.
Client # 6 was admitted into treatment on October 20, 2013 and was involuntarily terminated from treatment on January 5, 2014. There was no documentation that client # 6 was notified, in writing, of a decision to involuntarily terminate the client's treatment at the project, as of April 11, 2014.
The office manager confirmed the findings on April 11, 2014.
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Plan of Correction
All staff were informed by the Facility Director via email of the need to include a copy of the written notice in the charts on 4/11/14. The Office Manager will ensure that a copy of the involuntary termination letter is included in the file when they complete the follow up portion of the discharge/termination form. |
715.15(b) LICENSURE Medication dosage
(b) The narcotic treatment physician shall determine the proper dosage level for a patient, except as otherwise provided in this section. If the narcotic treatment physician determining the initial dose is not the narcotic treatment physician who conducted the patient examination, the narcotic treatment physician shall consult with the narcotic treatment physician who performed the examination before determining the patient 's initial dose and schedule.
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Observations
Based on a review of patient records, the facility's physician failed to adhere to the dosing protocol listed on the medication by ordering that single dose Suboxone film be halved in one of eight patient records. The medication packaging identifies this as a single dose medication.
The findings include:
The physician prescribed Suboxone 8 mg/2 mg SL film, 2 1/2 films daily for patient # 5 on February 2 and February 16, 2014.
Suboxone film is not formulated to be cut into smaller doses. Prescriptions need to be for the manufactured quantities of 12 mg/3 mg, 8 mg/2 mg, 4 mg/1 mg or 2 mg/.5 mg doses.
The project/facility director was interviewed throughout the licensing inspection and confirmed the findings on April 11. 2014.
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Plan of Correction
On 4/11/14 the pharmaceutical company was contacted by Facility Director regarding the cutting of films for decreased dosages. They reported that although it is a common practice, that no clinical trials have been conducted to authorize the cutting of films. They will be sending information regarding FDA approved dosages to our facility. Staff was informed by the Facility Director via email and the Medical Assistants/Administrative staff will review prescriptions prior to leaving the facility to ensure they follow FDA regulations and the Office Manager will review prescriptions weekly. |
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
Based on a review of patient records, the facility failed to provide each patient an average of 2.5 hours of psychotherapy per month during the patient's first 2 years of treatment in two of eight patient records.
The findings include:
Ten patient records were reviewed on April 10 - 11, 2014. Eight records were reviewed for documentation of an average of 2.5 hours of psychotherapy per month. The facility failed to provide each patient with an average of 2.5 hours of psychotherapy per month during the patient's first 2 years of treatment in patient records # 1 and 2.
Patient # 1 was admitted into treatment and prescribed Suboxone on September 1, 2013. Patient # 1 was provided the following number of hours of psychotherapy: 1 hour in October 2013, 1.5 hours in November 2013, 1/2 hour in December 2013, 0 hours in January 2014, 2 hours in February 2014 and 1 hour in March 2014. The facility failed to provide an average of 2.5 hours of psychotherapy per month.
Patient # 2 was admitted into treatment and prescribed Suboxone on September 8, 2013. Patient # 2 was provided the following number of hours of psychotherapy: 1/2 hour in November 2013, 1 hour in December 2013, 2 hours in January 2014, 1 hour in February 2014 and 1/2 hour in March 2014. The facility failed to provide an average of 2.5 hours of psychotherapy per month.
The findings were confirmed by the project/facility director on April 11, 2014.
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Plan of Correction
Clinical staff was informed by the Facility Director via email on 4/11/14 to ensure that clients are attending 2.5 hours of psychotherapy per month. Bimonthly clients will either participate in one 1.5 hour group and one 1 hour individual per month, two 1.25 individual sessions per month or individualized services equaling 2.5 hours per month according to clinical need. The Clinical Director will monitor compliance during Case Consultations and Treatment Plan Update meetings with Clinical staff. |
709.94(g) LICENSURE Project management services
709.94. Project management services.
(g) Outpatient projects which receive reimbursement under the medical assistance program shall have a current, signed provider agreement with the Department of Public Welfare and comply with 55 Pa. Code Part III (relating to Medical Assistance Manual).
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Observations
Based on a review of client records, the facility failed to comply with 55 Pa. Code Part III (relating to the Medical Assistance Manual) in one of one client records.
The findings include:
Ten client records were reviewed on April 10 - 11, 2014. One client record pertained to a client receiving Medical Assistance benefits and required documentation of a physician's dated signature on the level of care assessment, psychosocial evaluation, treatment and rehabilitation plans, diagnosis and treatment plan updates. The regulation at 55 Pa. Code Part III chapter 1223.52 section (a) subsection 6 (i) - (ii) specifies that "within 15 days following intake, the clinic's supervisory physician shall review and verify each patient's level of care assessment, psychosocial evaluation and initial treatment plan prior to the provision of any treatment beyond the 15th day following intake. The clinic's supervisory physician shall verify the patient's diagnosis. The clinic's supervisory physician shall sign and date the patient's level of care assessment, psychosocial evaluation, treatment plan and diagnosis in the patient's record. Sixty days following the date of the initial treatment plan and at the end of every 60-day period during the duration of treatment, the clinic's supervisory physician shall review and update each patient's treatment plan. Each review and update shall be dated, documented and signed in the patient's record by the clinic's supervisory physician."
The facility failed to comply with 55 Pa. Code Part II (relating to the Medical Assistance Manual) in client record # 6.
Client # 6 was admitted into treatment on October 20, 2013 and discharged on January 5, 2014. Client # 6 was receiving Medical Assistance benefits. A physician was required to sign and date the patient's level of care assessment, psychosocial evaluation, treatment plan, treatment plan updates and diagnosis. The level of care assessment, diagnosis, psychosocial evaluation and initial treatment plan were completed on October 20, 2013 and did not include a physician's dated signature as of April 11, 2014. The treatment plan was updated on November 20, 2013 and did not include a physician's dated signature as of April 11, 2014.
The findings were confirmed by the project/facility director and office manager on April 11, 2014.
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Plan of Correction
On 4/11/14, the Office Manager added physician signature lines to all required documents and informed the physicians of the requirement that the physician sign off on the required documents for clients who are receiving medical assistance. All staff were informed by the Facility Director via email of the requirement. The Office Manager and Clinical Director will monitor compliance weekly during chart reviews. |