INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on November 9-10, 2015 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, St. Joseph Institute 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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705.10 (a) (1) (iv) LICENSURE Fire safety.
705.10. Fire safety.
(a) Exits.
(1) The residential facility shall:
(iv) Clearly indicate exits by the use of signs.
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Observations
Based on observation during a physical plant inspection, the facility failed to ensure that all exits were clearly indicated by the use of signs.
The findings include:
A physical plant inspection was conducted on November 12, 2015 at approximately 11:15 AM.
The facility failed to ensure that exit signage was posted at both the front and rear exits in the Admission Building.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Exit signage was installed above the two doors in the Admissions building. |
705.10 (c) (3) LICENSURE Fire safety.
705.10. Fire safety.
(c) Fire extinguisher. The residential facility shall:
(3) Ensure fire extinguishers are inspected and approved annually by the local fire department or fire extinguisher company. The date of the inspection shall be indicated on the extinguisher or inspection tag. If a fire extinguisher is found to be inoperable, it shall be replaced or repaired within 48 hours of the time it was found to be inoperable.
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Observations
Based on observation during a physical plant inspection, the facility failed to ensure that all fire extinguishers were inspected and approved annually.
The findings include:
A physical plant inspection was conducted on November 12, 2015 at approximately 11:15 AM.
The facility failed to ensure that the fire extinguisher mounted on the wall in room 2 and room 3 in Appalachian Lodge was inspected and approved by either the local fire department or a fire extinguisher company.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The two new fire extinguishers have been inspected by the qualified vendor and tagged as approved. The General Manager, who is also the Institute?s safety officer, will ensure that all new fire extinguishers are inspected and tagged before being installed. All fire extinguishers will continue to be inspected on an annual basis by the certified safety company. |
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. The consent shall be in writing and include, but not be limited to:
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Observations
Based on a review of client records, the facility exceeded the limitations imposed in 4 Pa. Code, Subsection 255.5(b) as it pertains to the information authorized to be released per the the informed and voluntary to release information forms in six of six client records reviewed.
The findings include:
Limitations imposed at 4 Pa. Code, Subsection 255.5(b) specify that the release of information to probation officers and insurance companies shall be restricted to whether the client is or is not in treatment, the prognosis of the client, the nature of the project, a brief description of the progress of the client, and a short statement as to whether the client has relapsed and the frequency of such relapse.
Six client records requiring informed and voluntary consent to release information forms were reviewed on 11/9/15 and 11/10/15. The facility failed to ensure that the informed and voluntary consent to release information forms only authorized the release of information as per the restrictions within 4 Pa. Code, Subsection 255.5(b) in client records # 1, 2, 3, 4, 5, and 6.
Client # 1 was admitted into treatment on 11/2/15 and was still active at the time of the inspection. The client's consent to release information to the client's probation officer, dated 11/5/15, authorized the release of the client's medical information, specified on the consent form with use of the generalized term Medical. The same consent form also authorized the release of the client's discharge summary/aftercare recommendations. Additionally, the client's consent to release information to an insurance company, dated 11/2/15, authorized the release of the client's medical information, specified on the consent form with the use of the generalized term Medical. The same consent form also authorized the release of the client's discharge summary/after recommendations.
Client # 2 was admitted into treatment on 10/12/15 and was still active at the time of the inspection. The client's consent to release information to an insurance company, dated 10/12/15, authorized the release of the client's medical information, specified on the consent form with the use of the generalized term Medical. The same consent form also authorized the release of the client's discharge summary/after recommendations.
Client # 3 was admitted into treatment on 10/14/15 and was still active at the time of the inspection. The client's consent to release information to an insurance company, dated 10/1415, authorized the release of the client's medical information, specified on the consent form with the use of the generalized term Medical. The same consent form also authorized the release of the client's discharge summary/after recommendations.
Client # 4 was admitted into treatment on 7/29/15 and was discharged on 8/28/15. The client's consent to release information to an insurance company, dated 7/29/15, authorized the release of the client's medical information, specified on the consent form with the use of the generalized term Medical. The same consent form also authorized the release of the client's discharge summary/after recommendations.
Client # 5 was admitted into treatment on 2/6/15 and was discharged on 3/8/15. The client's consent to release information to an insurance company, dated 2/6/15, authorized the release of the client's medical information, specified on the consent form with the use of the generalized term Medical. The same consent form also authorized the release of the client's discharge summary/after recommendations.
Client # 6 was admitted into treatment on 3/12/15 and was discharged on 4/11/15. The client's consent to release information to an insurance company, dated 3/12/15, authorized the release of the client's medical information, specified on the consent form with the use of the generalized term Medical. The same consent form also authorized the release of the client's discharge summary/after recommendations.
These findings were reviewed with facility staff during the licensing process.
This is a repeat citation for the facility. The facility had been cited for non-compliance of this standard in the previous licensing renewal inspection, completed on 10/29/14.
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Plan of Correction
The Clinical Supervisor will continue to ensure that all clinical and admissions staff understand the confidentiality limitations imposed by 4 PA Code, Subsection 255.5. As per current policy, all new staff will be trained on the understanding of this policy at the time of hire and this training will be repeated for all staff not less than twice each year. Training will be provided by the President or Clinical Supervisor. All clinical and admissions staff will have copies of the ?Interpretive Guidelines? prepared by the Department on this issue. Quarterly audits of the UR records will continue to be conducted by the Clinical Supervisor to ensure that staff is complying with the guidelines, especially as they pertain to the release of information to insurance companies and probation officers. Language will be added to the electronic medical record (EMR) which states that the disclosure of medical information is limited by law. |
715.12(1-5) LICENSURE Informed patient consent
A narcotic treatment program shall obtain an informed, voluntary, written consent before an agent may be administered to the patient for either maintenance or detoxification treatment. The following shall appear on the patient consent form:
(1) That methadone and LAAM are narcotic drugs which can be harmful if taken without medical supervision.
(2) That methadone and LAAM are addictive medications and may, like other drugs used in medical practices, produce adverse results.
(3) That alternative methods of treatment exist.
(4) That the possible risks and complications of treatment have been explained to the patient.
(5) That methadone is transmitted to the unborn child and will cause physical dependence.
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Observations
The findings include:
Three client records requiring informed, voluntary, written consent to treatment prior to the administration of a narcotic agent were reviewed on 11/9/15 and 11/10/15. The facility failed to document the completion of an informed, voluntary, written consent that includes the required content specified in prior to the administration of the narcotic agent Suboxone in client record # 3.
Client # 3 was admitted into detox treatment on 2/6/15 and was transferred to inpatient rehab treatment on 2/9/15. The client was discharged from treatment on 3/8/15. The client received their initial dose of Suboxone on 2/7/15 at 7:45 am. There was no documentation of an informed, voluntary, written consent for Suboxone treatment in the client's record.
These findings were reviewed with facility staff during the licensing process.
This is a repeat citation for the facility. The facility had been cited for non-compliance of this standard in the previous licensing renewal inspection, completed on 10/29/14.
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Plan of Correction
The Manager of Clinical Services will train new nurses as they are hired and will review with all nursing staff on a quarterly basis the importance of ensuring that residents receiving buprenorphine are properly informed as to the treatment being provided and sign the ?Informed Patient Consent.? An internal audit will be conducted by the Manager of Clinical Services on a quarterly basis to ensure compliance. |
715.14(a) LICENSURE Urine testing
(a) A narcotic treatment program shall complete an initial drug-screening urinalysis for each prospective patient and a random urinalysis at least monthly thereafter.
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Observations
Based on review of the patient records, the facility failed to document a complete drug screen urinalysis prior to the administration of Suboxone, a narcotic agent, in three of three buprenorphine patient records. A complete drug screen includes receiving the results from the CLIA and Department of Health approved laboratory.
The findings include:
Three buprenorphine patient records were reviewed on 11/9/15 and 11/10/15. All six patient records were required to include a complete drug screen urinalysis prior to the administration of Suboxone, a narcotic agent. A complete urine drug screen includes receiving the results from the CLIA and Department of Health approved laboratory. The facility failed to document a complete drug screen urinalysis prior to the administration of Suboxone, a narcotic agent, in three of three patient records.
Client # 1 was admitted into detox treatment on 11/2/15 and was transferred to inpatient rehab treatment on 11/5/15. The client was still active at the time of the inspection. Documentation provided of the initial drug-screen urinalysis was an entry on the electronic nursing assessment dated 11/2/15, which only specified substances with a positive test result. Formal documentation of a complete initial drug-screening urinalysis was not documented or provided.
Client # 2 was admitted into detox treatment on 10/12/15 and was transferred to inpatient rehab treatment on 10/15/15. The client was still active at the time of the inspection. Documentation provided of the initial drug-screen urinalysis was an entry on the electronic nursing assessment dated 10/12/15, which only specified substances with a positive test result. Formal documentation of a complete initial drug-screening urinalysis was not documented or provided.
Client # 3 was admitted into treatment on 2/6/15 and was transferred to inpatient rehab treatment on 2/9/15. The client was discharged from treatment on 3/8/15. Documentation provided of the initial drug-screen urinalysis was an entry on the electronic nursing assessment dated 2/6/15, which only specified substances with a positive test result. Formal documentation of a complete initial drug-screening urinalysis was not documented or provided.
Facility staff have been notified of the findings during the licensing process.
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Plan of Correction
The relevant section of the EMR will be re-programmed to enable the documentation of negative (not just positive) results from drug-screening urinalysis tests. Until this work can be completed by the system vendor, a paper record will be maintained in the resident chart. The Manager of Clinical Services will train all of the nursing staff in the proper process of documentation. New hires will have this process included in the training they receive at the time of hire when they learn to use the EMR. |
715.23(b)(4) LICENSURE Patient records
(b) Each patient file shall include the following information:
(4) The results of an initial intake physical examination.
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Observations
Based on review of the patient records, the facility failed to fully document a complete initial medical examination in three of three buprenorphine patient records. A complete initial medical examination includes the results of a serology test, to be completed within 14 days following client admission.
The findings include:
Three buprenorphine patient records were reviewed on 11/9/15 and 11/10/15. Three patient records required the full documentation of a complete initial medical examination that includes the results of a serology test, completed within 14 days following admission. The facility failed to complete a serology test in client records # 2 and 3.
Client # 2 was admitted into detox treatment on 10/12/15 and was transferred to inpatient rehab treatment on 10/15/15. The client was still active at the time of the inspection. The client's record did not document the results of a complete serology test.
Client # 3 was admitted into treatment on 2/6/15 and was transferred to inpatient rehab treatment on 2/9/15. The client was discharged from treatment on 3/8/15. The client's record did not document the results of a complete serology test.
The facility has been notified of the findings during the licensing process.
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Plan of Correction
All residents receiving buprenorphine during detoxification will have a serology test within 14 days of admission. These results will be documented in the EMR as soon as appropriate programming is completed. Until that time, a paper record will be maintained in the resident's chart. This requirement will also be noted in the relevant Policies and Procedures for detoxification. A contract has been established with a local hospital laboratory to undertake the necessary testing. The Manger of Clinical Services will provide training to existing staff. All new hires will be instructed to follow this procedure as part of their orientation to nursing practice. |