INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection and complaint investigation conducted on December 3 - 5, 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 and investigation, St. Joseph Institute, LLC was found not to be in compliance with the applicable chapters of 28 PA Code which pertain to the facility. Based on the findings of the complaint investigation, the allegations made against the facility were partially substantiated. The following deficiencies were identified during this inspection.
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Plan of Correction
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704.12(a)(1)(i) LICENSURE Client/couns ratios
704.12. Full-time equivalent (FTE) maximum client/staff and client/counselor ratios.
(a) General requirements. Projects shall be required to comply with the client/staff and client/counselor ratios in paragraphs (1)-(6) during primary care hours. These ratios refer to the total number of clients being treated including clients with diagnoses other than drug and alcohol addiction served in other facets of the project. Family units may be counted as one client.
(1) Inpatient nonhospital detoxification (residential detoxification).
(i) There shall be one FTE primary care staff person available for every seven clients during primary care hours.
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Observations
The facility failed to maintain a minimum of one FTE (full time equivalent) primary care staff person for every seven clients during primary care hours based on staff interviews, staff schedules and a review of the Staffing Requirements Facility Summary Report form on December 3 - 5, 2019.Primary care hours for the detoxification activity are 24 hours per day, 7 days per week.Based on the census, one primary care staff person was required for the dates listed below. The only staff person listed on the Staffing form was not exclusively assigned to detox, as they were also assigned duties with residential clients. No primary care staff coverage was documented for the following times. November 3, 2019 (census 6) - 12 AM - 6 AM, 9 AM - 12 PM, 5 PM - 9 PMNovember 4, 2019 (census 7) - 12 AM - 6 AMNovember 5, 2019 (census 7) - 8 AM - 9 AMNovember 6, 2019 (census 5) - 12 AM - 6 AMNovember 7, 2019 (census 6) - 6 PM - 9 PMNovember 10, 2019 (census 7) - 12 AM - 6 AM, 9 AM - 12 PM, 5 PM - 9 PMBased on the census, two primary care staff persons were required for the dates listed below. The only staff person listed on the Staffing form was not exclusively assigned to detox, as they were also assigned duties with residential clients. No primary care staff coverage was documented for the following times.November 8, 2019 (census 9) - 12 AM - 6 AMNovember 9, 2019 (census 8) - 12 AM - 6 AM, 9 AM - 1 PMNovember 11, 2019 (census 9) - 12 AM - 6 AMNovember 12, 2019 (census 8) - 8 AM - 9 AMNovember 13, 2019 (census 10) - 12 AM - 6 AMNovember 14, 2019 (census 9) - 12 AM - 6 AMNovember 15, 2019 (census 12) - 12 AM - 6 AMNovember 16, 2019 (census 9) - 12 AM - 6 AMOnly one primary care staff person was documented for the following dates and times. The second staff person listed on the Staffing form was not exclusively assigned to detox, as they were also assigned duties with residential clients. November 8, 2019 (census 9) - 6 AM - 1 PM, 6 PM - 11 PMNovember 9, 2019 (census 8) - 6 AM - 9 AM, 5 PM - 9 PMNovember 11, 2019 (census 9) - 6 AM - 1PM, 6 PM - 9 PMNovember 12, 2019 (census 8) - 9 AM - 1 PM, 6 PM - 10 PMNovember 13, 2019 (census 10) - 6 AM - 1 PM, 6 PM - 10 PMNovember 14, 2019 (census 9) - 6 PM - 10 PMNovember 15, 2019 (census 12) - 6 AM - 1 PM, 5 PM - 10 PMNovember 16, 2019 (census 9) - 6 AM - 1 PM, 6 PM - 10 PMThe findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The facility will increase staffing by hiring primary care staff to ensure the client/staff ratio requirement is met. Hiring primary care staff has begun and will be completed by 2/1/2020. The Director of Nursing will monitor the client census and complete schedules to ensure that the 7:1 ratio is maintained. The Director of Admissions and the Director of Nursing will communicate daily to monitor the status of detox admissions and client detox level of care changes to ensure compliance. |
705.10 (a) (1) (i) LICENSURE Fire safety.
705.10. Fire safety.
(a) Exits.
(1) The residential facility shall:
(i) Ensure that stairways, hallways and exits from rooms and from the residential facility are unobstructed.
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Observations
The facility failed to ensure that exits from bedrooms were unobstructed based on a physical plant inspection conducted on December 3, 2019 at approximately 10:15 AM.The Sycamore building has 6 bedrooms on the second floor that have a key lock on the outside of the bedroom doors. If the doors are locked, there is no way to exit these rooms without someone unlocking the door from the outside. These locks would prevent the exit doors from being operable at all times.The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
On 12/4/2019 the Maintenance Supervisor replaced the 6 bedroom locks in Sycamore with door knobs/locks that can be unlocked and locked from the inside. The Maintenance Supervisor will monitor compliance and ensure that all exits are unobstructed by daily building walk-throughs/inspections. |
715.9(a)(4) LICENSURE Intake
(a) Prior to administration of an agent, a narcotic treatment program shall screen each individual to determine eligibility for admission. The narcotic treatment program shall:
(4) Have a narcotic treatment physician make a face-to-face determination of whether an individual is currently physiologically dependent upon a narcotic drug and has been physiologically dependent for at least 1 year prior to admission for maintenance treatment. The narcotic treatment physician shall document in the patient 's record the basis for the determination of current dependency and evidence of a 1 year history of addiction.
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Observations
The facility's physician failed to document a face to face determination of whether an individual was currently physiologically dependent upon a narcotic drug and the basis for that determination prior to the administration of buprenorphine in four of four patient records reviewed on December 3 - 4, 2019.Patient # 1 was admitted January 15, 2019 and discharged January 19, 2019. The patient was administered buprenorphine on January 17, 2019. Patient # 2 was admitted July 27, 2019 and discharged August 1, 2019. The patient was administered buprenorphine on July 28, 2019. Patient # 3 was admitted September 30, 2019 and discharged October 7, 2019. The patient was administered buprenorphine on October 2, 2019. Patient # 4 was admitted August 5, 2019 and discharged August 10, 2019. The patient was administered buprenorphine on August 6, 2019. The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
A face-to-face consultation form was created by the Director of Nursing and the Compliance Coordinator. It will be implemented on 1/13/2020 to ensure that each client received a face to face with the physician to determine physiological dependence upon a narcotic drug prior to administration of the buprenorphine. Medical and Nursing staff were trained on this form on 1/6/2020. Compliance will be monitored by the Director of Nursing through monthly chart audits. |
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
The facility's physician failed to document a consultation with the physician/physician assistant who performed the patient examination prior to determining the initial dose and schedule of buprenorphine based on four of four patient records reviewed on December 3 - 4, 2019.Patient # 1 was admitted January 15, 2019 and discharged January 19, 2019. Patient # 2 was admitted July 27, 2019 and discharged August 1, 2019. Patient # 3 was admitted September 30, 2019 and discharged October 7, 2019. Patient # 4 was admitted August 5, 2019 and discharged August 10, 2019. The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
A Medical Staff Case Consultation form was created by the Director of Nursing and the Compliance Coordinator. It will be implemented on 1/13/2020 to ensure documentation is completed between the Physician prior to prescribing the initial dose/schedule of the buprenorphine and the physician/physician assistant who performs the H&P. The Director of Nursing trained the Medical and Nursing Staff on the use of this form on 1/6/2020. The Director of Nursing will monitor compliance with this form by monthly audits. |
715.17(c)(3)(i-v) LICENSURE Medication control
(c) A narcotic treatment program shall develop and implement written policies and procedures regarding the medications used by patients which shall include, at a minimum:
(3) Inspection of storage areas. A narcotic treatment program shall inspect all drug storage areas and the dispensing station at least quarterly to ensure that the areas are maintained in compliance with Federal, State and local laws and regulations. A narcotic treatment program shall develop and implement written policies and procedures regarding who performs the inspections, how often, and in what manner the inspections are to be documented. The policies and procedures shall include the following:
(i) Disinfectants and drugs for external use shall be stored separately from oral and injectable drugs.
(ii) Drugs requiring special conditions for storage to insure stability shall be properly stored.
(iii) Outdated and contaminated drugs shall be removed and destroyed according to Federal and State regulations.
(iv) Administration of controlled substances shall be documented.
(v) Controlled substances and other abusable drugs shall be stored in accordance with Federal and State regulations.
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Observations
The facility failed to document quarterly inspections of the medication storage area including whether disinfectants and drugs for external use were stored separate from oral and injectable drugs and whether controlled substances and other abusable drugs were stored in accordance with Federal and State regulations based on a review of the December 2018 - November 2019 medication storage area inspections on December 3, 2019.The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Medication Storage Area Inspection form was updated on 12/27/2019 by the Director of Nursing to include that disinfectants and drugs are stored separate from oral and injectable drugs and to include that controlled substances and other abusable drugs were stored in accordance with regulations. The Director of Nursing trained the Nursing Staff on this updated form on 1/6/2020 and will begin using the form in January 2020 for the monthly inspection. The Director of Nursing will monitor compliance with this form. |