INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on February 10. 2020 through February 11, 2020 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, Rehab After Work, 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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709.32 (b) LICENSURE Medication control
§ 709.32. Medication control.
(b) Verbal orders for medication can be given only by a physician or other medical professional authorized by State and Federal law to prescribe medication and verbal orders may be received only by another physician or medical professional authorized by State and Federal law to receive verbal orders. When a verbal or telephone order is given, it has to be authenticated in writing by a physician or other medical professional authorized by State and Federal law to prescribe medication. In detoxification levels of care, written authentication shall occur no later than 24 hours from the time the order was given. Otherwise, written authentication shall occur within 3 business days from the time the order was given.
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Observations
The facility failed to include, within their medication policy, a procedure for handling verbal and/or telephone orders given by the physician.
The findings were discussed with facility staff during the licensing process.
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Plan of Correction
709.32 (b) LICENSURE
Medical policies and procedures have been updated to include the statement, "Verbal orders will not be given". Medical policies and procedures will be reviewed annually by the medical director, assistant vice president of operations, clinical director and regional quality manager to ensure that policies capture medication control regulations. Policies and procedures manual was updated as of February 13th, 2020 and has been updated on the internal intranet that houses the policies and procedures manual.
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709.32 (c) (3) (i) - (v) LICENSURE Medication control
§ 709.32. Medication control.
(3) Inspection of storage areas that ensures compliance with State and Federal laws and program policy. The policy must include, but not be limited to:
(i) What is to be verified through the inspection, who inspects, how often, but not less than quarterly, and in what manner it is to be recorded.
(ii) Disinfectants and drugs for external use are stored separately from oral and injectable drugs.
(iii) Drugs requiring special conditions for storage to insure stability are properly stored.
(iv) Outdated drugs are removed.
(v) Copies of drug-related regulations are available in appropriate areas.
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Observations
The facility failed to include, within their medication policy, a procedure for how disinfectants and drugs for external use would be stored separately from oral and injectable drugs.
The findings were discussed with facility staff during the licensing process.
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Plan of Correction
709.32 (c) (3) (i) - (v) LICENSURE
Medical policies and procedures have been updated to include the statement, "Disinfectants and drugs for external use are stored separately from oral or injectable drugs". Medical policies and procedures will be reviewed annually by the medical director, assistant vice president of operations, clinical director and regional quality manager to ensure that policies capture medication control regulations. Policies and procedures manual was updated as of February 13th, 2020 and has been updated on the internal intranet that houses the policies and procedures manual.
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709.82(d)(1) LICENSURE Treatment and rehabilitation services
709.82. Treatment and rehabilitation services.
(d) Counseling shall be provided to a client on a regular and scheduled basis. The following services shall be included and documented:
(1) Individual counseling, at least twice weekly.
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Observations
The facility failed to provide individual counseling sessions at least two times a week in seven of seven partial hospitalization level of care client record reviewed.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
709.82(d)(1) Treatment and rehabilitation services
Clinical Supervisor will conduct a training to review the regulations on treatment and rehabilitation services 709.82(d)(1). Clinical Supervisor will review regulations and policies regarding individual counseling being provided in partial hospitalization level of care during a weekly staff meeting on March 5, 2020. Clinical Supervisor will perform weekly chart audits for two active clients for PHP level of care for 4 weeks to ensure two individual counseling sessions are provided each week. Following that the sessions are being completed for a month, Clinical Supervisor will audit two active and one discharged PHP client charts monthly.
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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:
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Observations
The facility failed to have a complete client record in three of seven outpatient level of care client records reviewed.
Client #11 was admitted into the outpatient level of care on April 26, 2018 and was discharged August 15, 2018. The facility failed to document follow-up information.
Client #12 was admitted into the outpatient level of care on March 28, 2018 and was discharged September 7, 2018. The facility failed to document follow-up information.
Client #14 was admitted on February 13, 2019 and was discharged April 16, 2019. The facility failed to document follow-up information.
These findings were discussed with facility staff during the licensing process.
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Plan of Correction
709.93(a) Client records
Clinical Supervisor will conduct a training to review the regulations on client records 709.93(a) during weekly staff meeting on March 5, 2020. This training will review discharge documentation and follow up documentation. Clinical Supervisor will conduct 2 discharged client chart audits per clinician one time per month to review the client records discharges and follow up information to ensure the clinicians are in compliance with this policy. After 3 months, Clinical Supervisor will review one discharge client per clinician per month. The Clinical Supervisor will continue these charts audits each month to ensure that clinicians are in compliance with the state regulations.
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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 a change in activity to the partial hospitalization program.
During a review of client records, it was discovered that the facility was administering a narcotic treatment agent to clients in the partial hospitalization level of care. However, the facility is only licensed to administer a narcotic treatment agent to clients in the outpatient level of care and they do not have, nor have they applied for, Department approval for the use of a narcotic agent in the partial hospitalization level of care at the time of the inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The intent to request the addition of the Partial Hospitalization Program Other Chemotherapy drug and alcohol facility program for Suboxone to the license was submitted on February 13, 2020. Clinical Director and Regional Quality Manager for Rehab After Work will complete an annual review of all open licenses with the state to ensure that license capture services being provided.
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