INITIAL COMMENTS
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This report is a result of an on-site licensure renewal and buprenorphine monitoring inspection conducted on July 30-August 1, 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, Retreat at Lancaster County PA, LLC 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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709.23 LICENSURE Project Director
§ 709.23. Project director.
Project directors shall prepare, annually update and sign a written manual delineating project policies and procedures.
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Observations
Based on a review of the facility's policy and procedure manual on July 30, 2019, the project director failed to annually update and sign the written manual. The manual was last signed on January 1, 2018.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Chief Clinical Officer will review policies annually and will sign off accordingly. The PI Officer will schedule this on the calendar each year as a reminder. The CCO will review this has taken place each year to ensure compliance. |
709.28 (b) LICENSURE Confidentiality
§ 709.28. Confidentiality.
(b) The project shall secure hard copy client records within locked storage containers. Electronic records must be stored on secure, password protected data bases.
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Observations
Based on an observation of medication administration on August 1, 2019, the facility failed to ensure that all electronic patient records were secured with no ability of unauthorized persons gaining access to such records. It was observed that a nurse left his/her station with a client's medical record open on the computer screen. The facility's policy and procedure, Confidentiality CORP A-5 states "Computers will be locked and individually password protected at all times when a nurse is away from the computer".
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Nursing Director will conduct a training with all nurses to inform that all computers are locked and password protected at all times away from the computer. Nursing Director will conduct monthly walk-thru at each nursing station to ensure this is in compliance. The CCO will ensure this is occurring via monthly meetings with the nursing director. This training will be completed by August 29, 2019. |
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
Based on the review of fourteen client records on July 30-August 1, 2019, the facility failed to document an informed and voluntary consent to release information prior to the disclosure of information in client records #3 and 4.
Client #3 was admitted on July 29, 2019 and was still active at the time of the inspection. The client's record did not include a signed consent to release information form for the funding source for billing purposes. The record did not contain a consent to the funding source for case management services. Since funding source billing is not privy to all parts of the record, a separate informed consent limiting only items permitted under 4 Pa. Code 255.5, needs to be signed by the client. During an interview with the facility director, acknowledgement was made that the form should have been in the file, as billing would have begun upon admission.
Client #4 was admitted on April 27, 2019 and discharged on May 27, 2019. A contact log in the client's record showed staff made contact with an aftercare facility on May 9, 2019; however, there was no proper consent to release information form signed by the client prior to disclosure.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
By Sept 1, 2019, all clinical and support staff will be trained and informed that all consents must be active and properly completed before any call is made or any billing has taken place. Signed consent to release information to the funding source will be obtained during the intake process for every active patient admitted to Retreat. Clinical Supervisor will conduct the training. The Chief Clinical Officer will conduct monthly chart reviews to ensure compliance with this matter. |
709.28 (c) (2) 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 must be in writing and include, but not be limited to:
(2) Specific information disclosed.
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Observations
Based on the review of fourteen client records on July 30-August 1, 2019, the project failed to keep disclosures of client identifying information within the limits established by 4 Pa. Code 255.5(b) for releases of information in client record #'s 1, 2, 4, 5, 6, 7, 8, 9, 11, 12, 13 and 14.
Client #1 was admitted on July 27, 2019 and was still active at the time of the inspection. A consent to release form was signed and dated on July 27, 2019 to the funding source allowed for the release of discharge summary, aftercare treatment plan, referral source, history and physical, diagnosis, consultations, face sheet, and lab reports EKG.
Client #2 was admitted on July 26, 2019 and was still active at the time of the inspection. A consent to release form was signed and dated on July 26, 2019 to the employer allowed for the release of discharge summary, aftercare treatment plan, referral source, history and physical, diagnosis, consultations, face sheet, and lab reports EKG.
Client #4 was admitted on April 27, 2019 and discharged on May 27, 2019. A consent to release form was signed and dated on April 27, 2019 to the funding source allowed for the release of discharge summary, aftercare treatment plan, referral source, history and physical, diagnosis, consultations, face sheet, and lab reports EKG.
Client #5 was admitted on May 1, 2019 and discharged on May 3, 2019. A consent to release form was signed and dated on May 1, 2019 to the funding source allowed for the release of discharge summary, aftercare treatment plan, referral source, history and physical, diagnosis, consultations, face sheet, and lab reports EKG.
Client #6 was admitted on May 5, 2019 and discharged on May 27, 2019. A consent to release form was signed and dated on May 5, 2019 to the funding source allowed for the release of discharge summary, aftercare treatment plan, referral source, history and physical, diagnosis, consultations, face sheet, and lab reports EKG.
Client #7 was admitted on July 9, 2019 and discharged on July 15, 2019. Consent to release forms were signed and dated on July 9, 2019 to the funding source and the employer which allowed for the release of discharge summary, aftercare treatment plan, referral source, history and physical, diagnosis, consultations, face sheet, and lab reports EKG.
Client #8 was admitted on July 5, 2019 and was still active at the time of the inspection. Consent to release forms were signed and dated on July 5, 2019 to the funding source and employer which allowed for the release of discharge summary, aftercare treatment plan, referral source, history and physical, diagnosis, consultations, face sheet, and lab reports EKG.
Client #9 was admitted on July 13, 2019 and discharged on August 1, 2019. A consent to release form was signed and dated on July 13, 2019 to the funding source allowed for the release of discharge summary, aftercare treatment plan, referral source, history and physical, diagnosis, consultations, face sheet, and lab reports EKG.
Client #11 was admitted on July 14, 2019 and was still active at the time of the inspection. A consent to release form was signed and dated on June 19, 2019 to the funding source allowed for the release of discharge summary, aftercare treatment plan, referral source, history and physical, diagnosis, consultations, face sheet, and lab reports EKG.
Client #12 was admitted on May 28, 2019 and discharged on June 13, 2019. A consent to release form was signed and dated on May 28, 2019 to the funding source allowed for the release of discharge summary, aftercare treatment plan, referral source, history and physical, diagnosis, consultations, face sheet, and lab reports EKG.
Client #13 was admitted on March 19, 2019 and discharged on April 11, 2019. A consent to release form was signed and dated on March 19, 2019 to the funding source allowed for the release of discharge summary, aftercare treatment plan, referral source, history and physical, diagnosis, consultations, face sheet, and lab reports EKG.
Client #14 was admitted on June 18, 2019 and discharged on June 7, 2019. A consent to release form was signed and dated on June 18, 2019 to the funding source allowed for the release of discharge summary, aftercare treatment plan, referral source, history and physical, diagnosis, consultations, face sheet, and lab reports EKG.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
By August 30, 2019, the Clinical Supervisor will train and inform all clinical and support staff that consents must be in align with the 4 PA Code 255.5 code. Consent forms will be modified accordingly. Chief Clinical Officer will conduct monthly chart reviews to ensure compliance. Clinical Supervisor will conduct weekly chart reviews to ensure compliance. |
709.32 (c) (1) (i) - (ii) LICENSURE Medication control
§ 709.32. Medication control.
(c) The project shall have and implement a written policy and procedures regarding all medications used by clients which shall include, but not be limited to:
(1) Administration of medication, including the documentation of the administration of medication:
(i) By individuals permitted to administer by Pennsylvania law.
(ii) When self administered by the client.
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Observations
Based on a physical plant inspection on July 31 and August 1, 2019, the facility failed to adhere to their policy and procedures regarding administration of medication in the following manners:
(1) Facility failed to administer medications in a private setting on July 31, 2019. During the physical plant inspection, the rehabilitation nurse's area door was observed to be propped open. A patient was observed to be sitting approximately four feet into the nurse's area, which is adjacent to a waiting area. The patient was receiving medications and speaking to a nurse regarding questions about the medication. Other patients were observed to be sitting in the waiting area. The conversation could be overhead in the waiting area. The facility's policy and procedures, Confidentiality CORP A-5, states "Privacy curtains will be used when more than one patient is being treated at the nurse's station". Policy and procedures, Medication Administration Methods CORP C-5, states "Oral Drug Administration" "See Lippincott: Oral Drug Administration". The Lippincott Procedures-Oral drug administration, which was provided by the facility to the licensing specialist, under the Implementation section states "Provide privacy".
(2) Facility failed to secure client identifying information. During observation of medication administration on August 1, 2019, it was observed that nurses wrote down each patient's first and last name along with their medications on a sheet of paper. The list was an accumulation of the nurse's patients during that medication administration time frame, with each new patient's information being added under the previous client's information. In one instance, it was observed the nurse left the sheet of paper in plain sight next to a patient when the nurse left the area. In a second observation, the nurse placed the sheet of paper between her and a patient where the patient had view of previous patient's information. Both patients had clear visibility of patient identifying information along with their medications. The facility's policy and procedure manual, Confidentiality CORP A-5, states "restrict disclosure and use of patient identifying information by using patient's first name and last initial".
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
By August 30, 2019, the Director of Nursing will train and inform all nursing and support staff that all identifying patient information must be locked at all times when not in use. Additionally, nursing staff will be trained to understand that the door must be closed to nursing station and med rooms at all time when not in use. When using paper forms for medication administration, nurses will only include patient's first name and last initial on the form, to protect patient identifying information. To ensure compliance, Director of Nursing will conduct weekly walk-thru to ensure compliance. The Chief Clinical Officer will meet with Nursing Director monthly to ensure compliance. |
709.32 (c) (2) LICENSURE Medication control
§ 709.32. Medication control.
(c) The project shall have and implement a written policy and procedures regarding all medications used by clients which shall include, but not be limited to:
(2) Drug storage areas including, but not limited to, the secure storage of controlled substances and other abusable drugs in accordance with State and Federal regulations and program requirements.
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Observations
Based on a physical plant inspection on July 31, 2019, the facility failed to securely store medications in accordance with regulations and the facility's policy and procedures. During the inspection, it was observed that medications on the rehabilitation floor nurse's area were not securely locked. The door from the hallway into the nurse's area was propped open. Once in the nurse's area, the door to the medication room, where the medication cart is located, was also propped open. The medication cart was observed to be unlocked. The facility's policy and procedure, Medication Storage LCG-5 states "All medications on-site are to be stored in a locked area, including medications requiring refrigeration".
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
By August 30, 2019, the Nursing Director will train and inform all nursing and support staff the medication door and medication cart must be locked at all times when not in use. Nursing director will conduct weekly walk-thru to ensure compliance. Chief Clinical Officer will meet with nursing director monthly to ensure this is being kept in compliance. |
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
Based on a review of the policy and procedures manual on July 30, 2019, the facility failed to include policy information regarding (ii) disinfectants and drugs for external use to be stored separately from oral and injectable drugs.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Policy has been updated to include that disinfectants will be stored separately from all oral and injectable drugs. The Nursing Director signed off the policy and the chief clinical officer ensured it was complete. |
709.32 (c) (4) (i) - (ii) LICENSURE Medication control
§ 709.32. Medication control.
(4) Methods for control and accountability of drugs, including, but not limited to:
(i) Who is authorized to remove drug.
(ii) The program ' s system for recording drugs, which includes the name of the drug, the dosage, the staff person, the time and the date.
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Observations
Based on an observation of medication administration on August 1, 2019, the facility failed to adhere to their policy and procedures in regards to dispensing of medication. During administration, a nurse failed to follow the steps outlined to properly administer medication to a patient. Policy and procedure, Medication Administration Methods CORP C-5 states "Oral Drug Administration" "See Lippincott: Oral Drug Administration". The Lippincott procedures for oral drug administration, which was provided to the licensing specialist by the facility, includes the following implementation procedures as part of the administration of medication:
(1) compare the drug label to the order in the patient's medical record
(2) visually inspect the drug for signs of loss of integrity.
(3) verify that the drug is being administered at the proper time, in the prescribed dose, and by the correct route to reduce the risk of medication errors
A nurse was observed to leave her nurse's station, enter the medication room, dispense the patient's medication from memory into a medication cup to be given to the patient. The nurse, during the gathering of medication in the medication room, did not review the label on the medications to confirm it was the correct medication, dosage, route and to inspect for signs of loss of integrity.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Director of Nursing will train all nurses via the Lippincott training on medication administration which outlines nurses must confirm the medication being administered by (1)looking at the bottle compare the drug label to the order in the patient's medical record -
(2) visually inspect the drug for signs of loss of integrity.
(3) verify that the drug is being administered at the proper time, in the prescribed dose, and by the correct route to reduce the risk of medication errors
The Lippincott trainings will be logged into the system and nursing director will ensure each nurse has taken the training and passed accordingly. If not, the nurse will be addressed in writing and will re-take the test. The Nursing Director will conduct weekly walk-thru during med admin times to ensure compliance. The Chief Clinical Officer will meet with nursing director monthly to ensure compliance with this matter. Additionally, the CCO will ensure all nurses have taken this Lippincott training by August 30, 2019.
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715.10(f) LICENSURE Pregnant patients
(f) The narcotic treatment program shall ensure that each female patient is fully informed of the possible risk to her or her unborn child from continued use of illicit drugs and from use of, or withdrawal from a narcotic drug administered or dispensed by the program in comprehensive maintenance or detoxification treatment.
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Observations
Based on a review of client records on July 30-August 1, 2019, the facility failed to inform female clients of the possible risk to her or her unborn child from continued use of illicit drugs and from use of, or withdrawal from a drug administered by the program, in two of two female records reviewed.
Client #6 was admitted on May 7, 2019 and discharged on May 27, 2019.
Client #12 was admitted on May 28, 2019 and discharged on June 13, 2019.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
By August 30, the consent form for Buprenorphine will be updated for all females stating the following -
will inform female clients of the possible risk to her or her unborn child from continued use of illicit drugs and from use of, or withdrawal from a drug administered by the program
The Chief Clinical Officer will conduct weekly chart reviews to ensure this consent form is properly signed to ensure compliance. |