INITIAL COMMENTS
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This report is a result of an on-site complaint investigation conducted November 4-8, 2021 by staff from the Bureau of Program Licensure. Based on the findings of the onsite complaint investigation, Hanover Treatment Services was found not to be in compliance with the applicable chapters of 28 PA Code which pertain to the facility.
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Plan of Correction
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709.24 (a) (3) LICENSURE Treatment/rehabilitation management.
§ 709.24. Treatment/rehabilitation management.
(a) The governing body shall adopt a written plan for the coordination of client treatment and rehabilitation services which includes, but is not limited to:
(3) Written procedures for the management of treatment/rehabilitation services for clients.
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Observations
Based on staff interviews, a review of the client's chart and the facility's policies and procedures manual, the facility failed to follow their written procedures for the management of treatment services for clients. The facility policy indicates that nursing staff will conduct a thorough assessment on an impaired patient and complete an Impaired Patient Form. On June 25, 2021, this was not done.
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Plan of Correction
709.24 Plan of Correction: Patient 23384 did not display any signs of impairment upon entering the building or at the dosing window upon medicating. Some impairment was noted by a nurse after the patient was medicated. Patient's THBs were held for safety reasons. Patient was transported to facility by a family member and was returned safely to her family member for transport from the facility with a recommendation to seek medical assistance.
Executive Director re-trained medical staff on 12/1/21 to ensure understanding of existing policies regarding management of treatment services for impaired patients. During this re-training, Executive Director informed medical staff that they are to ensure that an impaired patient assessment is completed on any patient if there is a question regarding impairment.
Medical staff will directly contact Executive Director and Medical Director when there is a question of impairment and Executive Director and Medical Director will advise medical staff to complete and document the impaired assessment, to ensure that staff follow the policies regarding impaired patients. Executive Director will ensure a completion of an audit of the patient in questions chart to ensure that the impaired assessment was completed and documented in the patients electronic health record.
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715.6(c) LICENSURE Physician Staffing
(c) A narcotic treatment physician shall be otherwise available for consultation and verbal medication orders at all times when a narcotic treatment program is open and a narcotic treatment physician is not present.
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Observations
Based on staff interviews and a review of the client chart and facility policy, the facility did not follow their protocol of nursing staff contacting the NTP physician to determine the next course of action when a patient presents as impaired.The NTP physician was not onsite on June 25, 2021 and the nurse did not consult with him as per policy regarding a patient that presented as impaired.
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Plan of Correction
715.6 Plan of Correction: Executive Director provided training and re-education to staff on 12/1/21 on existing policies regarding when to consult with a narcotic treatment physician. During the re-training, medical and clinical staff were directed by the Executive Director to contact the NTP regarding any impaired or thought to be impaired patient. Medical staff were informed to share the results of the impaired assessment with the NTP and document the results and consultation with the NTP in the patient's electronic health record. Documentation of the consultation will ensure that the patient's chart clearly shows the directives provided by the NTP. |