INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection and methadone (or buprenorphine) monitoring inspection conducted on November 18, 19, 20 2019 by staff from the Department of Drug and Alcohol Programs, Bureau of Quality Assurance for Prevention and Treatment. Based on the findings of the on-site inspection, New Directions Treatment Services 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.
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Observations
The facility failed to obtain an informed and voluntary consent to release information form prior to the disclosure of information in one of eleven patient records reviewed.Patient #2 was admitted on March 27, 2018 and was still active at the time of the inspection. There was a consent form to the funding source signed by the client on March 27, 2018 and expired March 27, 2019. There was evidence of billing from the date of expiration through the date of inspection, with no valid consent to release information form on file.The findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
On November 26th, during weekly Clinical Team Meeting all clinical staff will be reminded to update client Consents to Release Confidential Information annually as required by the regulation. This will be accomplished at the time of the completion of the Client Annual Review. The Clinical Supervisor will be responsible for verifying that all necessary Releases have been updated annually when signing off on the Annual Review. Ongoing compliance will be monitored by the Clinical Supervisor during Individual Clinician Supervision and during random record review. |
709.14(b)(5) LICENSURE Subchapter B.Licensing Procedures.Restriction
709.14. Restriction on license.
(b) The licensee, using Department forms, shall notify the Department within 90 days of the occurrence of any of the following conditions:
(5) Change in authorized maximum capacity.
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Observations
The facility failed to notify the Department, within 90 days, of an increase in the patient capacity for the narcotic treatment program. According to the facility's submitted Staffing Requirements Facility Summary Report and a review of the patient listings provided by the facility, there were 582 patients receiving treatment services on the day of the inspection. The facility's licensed capacity is 560 patients.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
On 11/21/2019, the Facility Director notified the Department of the change in capacity for the Narcotic Treatment Program. On 12/02/2019, the Facility Director submitted a request for approval of an increase in authorized capacity to meet the current census as well as the projected increased demand for services. Ongoing compliance with the requirement will be monitored by regular review of client census and notification of the Department within 90 days of any census increase that would exceed authorized maximum capacity.
In the event that the request for an increase in capacity is not approved, the facility will refer Suboxone clients to other providers in the area to meet the approved capacity of 560. Going forward, the facility would refer all Suboxone patients to other providers in the community in order to reserve all openings for methadone patients |