INITIAL COMMENTS
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This report is a result of an on-site inspection conducted for licensing renewal, as well as for the approval to use a narcotic agent, specifically Buprenorphine, in the treatment of narcotic addiction. The inspection was conducted on December 13-15, 2016 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, St. Joseph Institute, LLC 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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705.7 (b) (5) LICENSURE Food service.
705.7. Food service.
(b) A residential facility may operate a central food preparation area to provide food services to multiple facilities or locations. A residential facility that operates an onsite food preparation area or a central food preparation area shall:
(5) Keep cold food at or below 40F, hot food at or above 140F, and frozen food at or below 0F.
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Observations
A physical plant inspection was conducted on December 14, 2016, between 1:00-2:00 pm. The facility failed to ensure that a walk-in freezer, used for the central food preparation area. was kept at or below a temperature of 0 Fahrenheit.
At the time of the physical plant inspection, the temperature of the walk-in freezer was at 2 Weekly temperature logs for the time period of October 2 - December 14, 2016 indicated that the temperature of the walk-in freezer was regularly over 0 Fahrenheit.
This finding was reviewed with facility staff during the licensing inspection.
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Plan of Correction
The walk-in freezer temperature will be maintained at or below 0 degrees. Repairs to the unit will be done if needed to maintain this temperature. The Kitchen Supervisor will monitor the temperature logs and report to Maintenance Supervisor and Executive Director if the unit is not working properly. |
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
Nine client records were reviewed on December 13-15, 2016. 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 client records # 2, 4, 5, 6, and 8. In addition, the facility failed to document a consent to release where consent was required in client record # 7.
Limitations imposed at 4 Pa. Code, Subsection 255.5(b) specify that the release of information to 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.
Client # 2 was admitted into treatment on 12/11/16 and was still active in treatment. A consent to release information to an insurance company, the treatment funding source, was documented in the client's record. This consent form, signed and dated on 12/12/16, authorized the release of the client's medical information, specified on the consent form with use of the terminology Medical (limited by law). The same consent form also authorized the release of the client's evaluation results and recommendations, discharge summary/aftercare, and discharge summary/aftercare recommendations.
Client # 4 was admitted into treatment on 1/4/16 and was discharged on 2/3/16. A consent to release to an insurance company, the treatment funding source, was documented in the client's record. This consent form, signed and dated on 1/4/16, authorized the release of the client's medical information, specified on the consent form with the use of the terminology Medical (limited by law). The same consent form also authorized the release of the client's discharge summary/aftercare recommendations.
Client # 5 was admitted into treatment on 11/5/16 and was still active in treatment. A consent to release to an insurance company, the treatment funding source, was documented in the client's record. This consent form, signed and dated on 11/5/16, authorized the release of the client's medical information, specified on the consent form with the use of the terminology Medical (limited by law). The same consent form also authorized the release of the client's discharge summary/aftercare recommendations.
Client # 6 was admitted into treatment on 11/30/16 and was still active in treatment. A consent to release to an insurance company, the treatment funding source, was documented in the client's record. This consent form, signed and dated on 11/30/16, authorized the release of the client's medical information, specified on the consent form with the use of the terminology Medical (limited by law). The same consent form also authorized the release of the client's discharge summary/aftercare recommendations.
Client # 7 was admitted into treatment on 2/4/16 and was discharged on 3/5/16. A consent to release information for the client's treatment funding source, an insurance company, was not documented in the client's record.
Client # 8 was admitted into treatment on 5/5/16 and was discharged on 6/6/16. A consent to release to an insurance company, the treatment funding source, was documented in the client's record. This consent form, signed and dated on 5/5/16, authorized the release of the client's medical information, specified on the consent form with the use of the terminology Medical (limited by law). The same consent form also authorized the release of the client's discharge summary/aftercare recommendations.
These findings were reviewed with facility staff during the licensing inspection.
This is a repeat citation, as the facility was cited for non-compliance of this regulation during the previous licensing renewal inspection, completed on November 12, 2015.
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Plan of Correction
Only the 5 points under PA code 255.5 (b) will be released to judges, probation officers, insurance company health or hospital plan or governmental officials. The consent form itself was not changed, but Admission staff, Counselors and Nursing staff will be trained on regulation PA code 255.5 and that only the information permitted to be released to restricted entities as per PA code 255.5 will be checked on the consent. The Compliance Coordinator will implement this corrective action plan. 25 % of charts will be audited by the Admission staff on a monthly basis to monitor compliance related to PA code 255.5 (b). Ongoing compliance will be monitored by the Director of Admissions through the monthly chart audits. Overall compliance will be by the Compliance Coordinator through monitoring of monthly chart audit results. Chart audit outcomes are documented and reported monthly at the Committee of a Whole meeting. The client chart records who were current at the time of site visit, were discharged prior to any correction being made. They are not active clients at this time. |
709.34 (a) (1) LICENSURE Reporting of unusual incidents
§ 709.34. Reporting of unusual incidents.
(a) The project shall develop and implement policies and procedures to respond to the following unusual incidents:
(1) Physical assault or sexual assault by staff or a client.
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Observations
Administrative records were reviewed on December 13-15, 2016. The policy submitted by the facility for the reporting of unusual incidents failed to specifically address the response to the following unusual incidents:
1) Physical assault or sexual assault by staff or a client.
2) Selling or use of illicit drugs on the premises.
3) Death or serious injury due to trauma, suicide, medication error or unusual circumstances while in residential treatment or, when known by facility, for ambulatory services.
4) Significant disruption of services due to disaster such as fire, storm, flood, or other occurrence which closes the facility for more than 1 day.
5) Theft, burglary, break-in or similar incident at the facility.
6) Event at the facility requiring the presence of police, fire, or ambulance personnel.
7) Fire or structural damage to the facility.
8) Outbreak of a contagious disease requiring Centers for Disease Control (CDC) notification.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
Our policy will be revised to include policies and procedures to respond to the listed unusual incidents under code 709.34 (a) (1-8) with documentation of the unusual incident, review and identification of the causes, implementation of a timely and appropriate corrective action plan, ongoing monitoring of the corrective action plan, and reporting mechanism to ensure that reporting of the unusual incident to an entity is in compliance with State and Federal confidentiality laws. Also, to the extent permitted by State and Federal confidentiality laws, written unusual incident reports will be filed with the Department within 3 days following an unusual incident involving the incidents listed in the regulation (709.34). This corrective action plan and update to the policy will be implemented by the Compliance Coordinator. |
709.34 (c) (4) LICENSURE Reporting of unusual incidents
§ 709.34. Reporting of unusual incidents.
(c) To the extent permitted by State and Federal confidentiality laws, the project shall file a written unusual incident report with the Department within 3 business days following an unusual incident involving:
(4) Event at the facility requiring the presence of police, fire or ambulance personnel.
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Observations
The facility's unusual incident report log was reviewed during the licensing inspection on December 13-15, 2016. The facility failed to report to the Department documented events at the facility that required the presence of police or ambulance personnel on the following dates: 6/3/16, 6/20/16, 7/19/16, 8/6/16, 9/1/16, 9/5/16, 10/7/16, 10/17/16, and 10/28/16.
This finding was reviewed with facility staff during the licensing inspection.
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Plan of Correction
The policy and procedure will be changed to reflect the reporting of the unusual incidents listed in 709.34. Every time emergency personnel (fire, police, and ambulance) are called to campus, The Unusual Incident Report Form will be used to notify the Division within 3 business days following the incident. The Compliance Coordinator will implement this corrective action. She will update the policy and procedure manual. Compliance Coordinator will also train Administration, Nursing, Admission, Recovery Advocate and Counseling Staff on the entire regulation code including all events that are required to be reported to the Department. Due to the citation specifically addressing ambulance calls on campus, the Nursing Supervisor will train all nursing staff on this procedure and monitor that it is done in each situation through supervisory follow-ups. The Compliance Coordinator will also monitor that those specific unusual incidents are reported the Department as well reported internally on St Joseph Incident Reports through daily morning leadership meetings. |
709.84(e) LICENSURE Project management services
709.84. Project management services.
(e) The project shall develop a written client follow-up policy.
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Observations
Administrative records were reviewed on December 13-15, 2016. For Partial Hospitalization activities, the facility failed to provide documentation of a written client follow-up policy.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
The policy for Client Follow-up for Partial Hospitalization activities was labeled with the wrong DDAP code number. The regulation code number will be changed to reflect the correct code. This corrective action plan will be implemented by the Compliance Coordinator. The Compliance Coordinator will review the Policy and Procedure manual to ensure all policies are accurately labeled and will be responsible for the management of the Policy and Procedure manual. |
715.13(b) LICENSURE Patient identification
(b) A narcotic treatment program shall maintain onsite a photograph of each patient which includes the patient 's name and birth date. The narcotic treatment program shall update the photograph every 3 years.
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Observations
Four detoxification client records were reviewed as Buprenorphine client records on December 13-15, 2016. In client record # 2, the facility failed to document a photograph of the client that included the client's name and birth date.
Client # 2 was admitted into detoxification treatment on 12/11/16 and was still active in treatment. Documentation in the client's record indicated that the client received an initial dose of Buprenorphine on 12/13/16. The facility failed to document in the client's record a photograph of the client that included the client's name and birth date.
This finding was reviewed with facility staff during the licensing inspection.
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Plan of Correction
For every admit, the Admission staff will obtain a photo ID to ensure proper identification of the client. If unable to obtain a photo ID, a procedure will be put in to action to notify the Department. Admission staff will obtain some other form of identification (birth certificate, SS card) and will have the emergency contact for the admit verify in writing the identity. An exception letter will be submitted to the Department stating that we are requesting an exception to this regulation. This corrective action will be implemented by the Compliance Coordinator. The admissions process policy and procedure will be revised by the Compliance Coordinator to ensure compliance with regulations for patient identification. The Admission Director will train all Admission staff and Nursing staff on this regulation and the procedure of requesting an exception from the Department. Monitoring of compliance will be done through monthly chart audits by Admission and Nursing staff. 25 % of charts will be audited by the Admission and Nursing staff on a monthly basis to monitor compliance. Overall compliance will be by the Compliance Coordinator through monitoring of monthly chart audit results. Chart audit outcomes are documented and reported monthly at the Committee of a Whole meeting. |
715.14(b) LICENSURE Urine testing
(b) A narcotic treatment program shall develop and implement policies and procedures to ensure that urine collected from patients is unadulterated. These policies and procedures shall include random observation which shall be conducted professionally, ethically and in a manner which respects patient privacy.
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Observations
Administrative records were reviewed during the licensing inspection on December 13-15, 2016. The facility failed to develop policies pertaining to urinalysis procedures.
This finding was reviewed with facility staff during the licensing inspection.
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Plan of Correction
A policy will be developed and implemented pertaining to urine testing of residents. This policy will be developed by the Nursing Supervisor and Administrative staff. The nursing Supervisor will review the policy and procedure with all current nurses and any future hires. |
715.14(c) LICENSURE Urine testing
(c) A narcotic treatment program shall develop and implement policies and procedures to minimize misidentification of urine specimens and to ensure that the tested specimens can be traced to the donor.
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Observations
Administrative records were reviewed during the licensing inspection on December 13-15, 2016. The facility failed to develop policies pertaining to urinalysis procedures.
In addition, four detoxification client records were reviewed as Buprenorphine client records during the licensing inspection. For client records # 1, 2, 3, and 4, the facility failed to implement complete urinalysis procedures that minimize the misidentification of urine specimens and ensure that the tested specimens can be traced to the donor. The facility implemented the practice of completing an initial drug-screening urinalysis upon the client's admission into the facility. Documentation of the urinalysis results did not include the date the urinalysis was completed and the name/signature of the staff person administering the urinalysis.
This finding was reviewed with facility staff during the licensing inspection.
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Plan of Correction
The UDS result form will be updated to include lines for nurse signature, the date of testing and the reason for the test. All urine drug screens will be documented on the UDS result form. This corrective action plan as well as the policy update and form update will be implemented by the Compliance Coordinator. The Nursing Supervisor will train all nursing staff on this form and the updated policy. The Nursing Supervisor will monitor that it is being properly completed through monthly audits of 25% of charts. Overall compliance will be by the Compliance Coordinator through monitoring of monthly chart audit results. Chart audit outcomes are documented and reported monthly at the Committee of a Whole meeting. |
715.17(c)(1)(i-vi)) 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:
(1) Administration of medication.
(i) A narcotic treatment physician shall determine the patient 's initial and subsequent dose and schedule. The physician shall communicate the initial and subsequent dose and schedule to the person responsible for the administration of medication. Each medication order and dosage change shall be written and signed by the narcotic treatment physician.
(ii) An agent shall be administered or dispensed only by a practitioner licensed under the appropriate Federal and State laws to dispense agents to patients.
(iii) Only authorized staff and patients who are receiving medication shall be permitted in the dispensing area.
(iv) There shall be only one patient permitted at a dispensing station at any given time.
(v) Each patient shall be observed when ingesting the agent.
(vi) Administering and dispensing shall be conducted in a manner that protects the patient from disruption or annoyance from other individuals.
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Observations
Four client records were reviewed as Buprenorphine client records on December 13-15, 2016. The facility failed to document the physician signature of each verbal order for Buprenorphine in client records # 1, 2, and 3.
Client # 1 was admitted into detoxification treatment on 12/5/16 and was still active in treatment. The initial order physician order documented in the client's record, for the detoxification protocol, was signed and dated by the physician on 12/6/16. The detoxification protocol indicated that the client would be administered a Buprenorphine taper, but did not specify the start date of the taper. A medication administration record documented in the client's record indicated that nursing staff received a verbal order from the physician on 12/6/16, for the client's initial dose of Buprenorphine. The verbal order was not signed by the physician. The client was administered an initial dose of Buprenorphine on 12/7/16, at 0800.
Client # 2 was admitted into detoxification treatment on 12/11/16 and was still active in treatment. The initial order physician order documented in the client's record, for the detoxification protocol, was signed and dated by the physician on 12/11/16. The detoxification protocol indicated that the client would be administered a Buprenorphine taper, but did not specify the start date of the taper. A medication administration record documented in the client's record indicated that nursing staff received a verbal order from the physician on 12/13/16, for the client's initial dose of Buprenorphine. The verbal order was not signed by the physician. The client was administered an initial dose of Buprenorphine on 12/13/16, at 1025.
Client # 3 was admitted into detoxification treatment on 1/18/16 and was discharged from treatment on 1/21/16. The initial order physician order documented in the client's record, for the detoxification protocol, was signed and dated by the physician on 12/11/16. The detoxification protocol indicated that the client would be administered a Buprenorphine taper, but did not specify the start date of the taper. A medication administration record documented in the client's record indicated that nursing staff received a verbal order from the physician on 1/19/16, for the client's initial dose of Buprenorphine. The verbal order was not signed by the physician. The client was administered an initial dose of Buprenorphine on 1/19/16, at 0745.
These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
The medication order deficiency will be reviewed with Nursing Staff. They will be trained on the policy of medication administration and the regulations that need to be followed for all physician orders. The Admission order will be edited to state that Buprenorphine will be initiated upon moderate withdrawal symptoms COW Score equal to or greater than 13. The physician will sign all orders. This corrective action plan of training staff and updating the order form will be implemented by the Nursing Supervisor. The Supervisor will review the form change and the policy with nursing staff and monitor to ensure it is being properly completed through monthly audits of 25% of charts. Overall compliance will be by the Compliance Coordinator through monitoring of monthly chart audit results. Chart audit outcomes are documented and reported monthly at the Committee of a Whole meeting. |
715.17(c)(4)(i-viii) 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:
(4) Method for control and accountability of drugs. A narcotic treatment program shall develop and implement written policies and procedures regarding who is authorized to remove drugs from the storage area and the method for accounting for all stored drugs. An agent or other drug prescribed or administered shall be documented on an individual medication record or sheet in a manner sufficient to maintain an accurate accounting of medication at all times and shall include:
(i) The name of the medication.
(ii) The date prescribed.
(iii) The dosage.
(iv) The frequency.
(v) The route of administration.
(vi) The date and time administered.
(vii) The name of the person administering the medication.
(viii) The take-home schedule, if applicable.
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Observations
Four client records were reviewed as Buprenorphine client records on December 13-15, 2016. In client record # 1, the facility failed to maintain an accurate individual medication record that recorded the administration of Buprenorphine.
Client # 1 was admitted into detoxification treatment on 12/5/16 and was then transferred into inpatient rehabilitation treatment on 12/8/16. The client was still active in treatment at the time of the inspection. The Medication Administration Record documented in the client's record, for the administration of Buprenorphine, indicated that the medication record was for the month of November 2016. The facility confirmed that this medication administration record documented Buprenorphine administered in the month of December 2016. On this medication record, the facility documented that the client was administered Buprenorphine on the following dates: 11/7/16, 11/8/16, 11/9/16, 11/10/16, 11/11/16, 11/12/16, and 11/13/16.
This finding was reviewed with facility staff during the licensing inspection.
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Plan of Correction
The Medication Administration Record (MAR) with the wrong month title will be corrected. The Nursing Supervisor will implement this corrective action plan and will train all nursing staff on the importance of documenting the correct date. The Nursing Supervisor will audit 25% of MARs on a monthly basis to ensure proper documentation. Overall compliance will be by the Compliance Coordinator through monitoring of monthly chart audit results. Chart audit outcomes are documented and reported monthly at the Committee of a Whole meeting. |
709.91(a)(1) LICENSURE Intake and admission
709.91. Intake and admission.
(a) The project director shall develop a written plan providing for intake and admission which includes, but not be limited to:
(1) Criteria for admission.
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Observations
Administrative records were reviewed on December 13-15, 2016. For Outpatient activities, the facility failed to provide documentation of a written plan providing for intake and admission which includes, but is not limited to:
1) Criteria for admission
2) Treatment methodology
3) Requirements for completion of treatment
4) Involuntary discharge/termination criteria
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
The policy for Intake and Admission for Outpatient activities is labeled with the wrong DDAP code number. The regulation code number will be changed to reflect the correct code. This corrective action plan will be implemented by the Compliance Coordinator. The Compliance Coordinator will review the Policy and Procedure manual to ensure all policies are accurately labeled and will be responsible for the management of the Policy and Procedure Manual. |