INITIAL COMMENTS
|
This report is a result of an on-site licensure renewal inspection conducted on October 5-6, 2016 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Clearbrook Treatment Centers, LLC d/b/a Huntington Creek Recovery Center 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:
|
Plan of Correction
|
705.2 (4) LICENSURE Building exterior and grounds.
705.2. Building exterior and grounds.
The residential facility shall:
(4) Store all trash, garbage and rubbish in noncombustible, covered containers that prevent the penetration of insects and rodents, and remove it, at least once every week.
|
Observations
A physical plant inspection was conducted on October 6, 2016. An uncovered trash receptacle containing waste was observed in the main dining area.
This finding was reviewed with facility staff during the licensing inspection.
|
Plan of Correction
During the physical plant inspection an uncovered trash can was observed in the dining area. The specific course of action to address this deficiency was to place a lid on the trash receptacle. The executive chef replaced the lid on the receptacle on 10/06/16. The executive chef will inspect the dining area on a daily basis in order to ensure that the lid remains on the trash receptacle. The project director will also do periodical spot checks to ensure the facility remains in compliance with this standard. |
709.11-709.18 LICENSURE Subchapter B. Licensing Procedures
Subchapter B. Licensing Procedures
709.11. Application for license.
(a) Persons, partnerships, corporations, or other legal entities intending to provide drug and alcohol treatment services shall apply for a license from the Department. Application shall be made using forms and procedures prescribed by the Department.
(b) The license shall expire 1 year from the date of issuance. Prior to the expiration of the current license, the Department will notify the facility of the date for an annual on-site inspection for renewal of license.
(c) The Department will notify the appropriate SCA of applications for and issuance of a license to any facility or individual within the SCA's area of responsibility.
709.12. Full licensure.
(a) A license to operate the facility will be issued when, after an on-site inspection by an authorized representative of the Department, it has been determined that requirements for licensure under this chapter, have been met.
(b) A license will be issued to the owner of a facility and will indicate the name of the facility, the address, the date of issuance, and the types of activities the facility is authorized to provide.
(c) The current license shall be displayed in a public and conspicuous place in the facility.
709.13. Provisional licensure.
(a) The Department will issue a provisional license, valid for a specific time period of no more than 6 months when the Department finds that a facility:
(1) Has substantially, but not completely, complied with applicable requirements for licensure.
(2) Is complying with a course of correction approved by the Department.
(3) Has existing deficiencies that will not adversely alter the health, welfare or safety of the facility's clients.
(b) Within 15 working days of receipt of the deficiency report, facility staff shall submit a plan to correct deficiencies noted during the site visits.
(c) A provisional license may be renewed no more than three times.
(d) A regular license will be issued upon compliance with this part.
709.14. Restriction on license.
(a) A license applies to the person, the named facility, the premises designated therein and the activities noted, and is not transferable.
(b) The licensee, using Department forms, shall notify the Department within 90 days of the occurrence of any of the following conditions:
(1) Change in ownership.
(2) Change in name of the facility.
(3) Change in location of the facility.
(4) Change in activity/discontinuance of an activity.
(5) Change in authorized maximum capacity.
(6) Closing of facility.
(c) Failure to notify the Department under subsection (b) will result in automatic expiration of the license.
709.15. Right to enter and inspect.
(a) An authorized representative of the Department has the right to enter, visit, and inspect a facility licensed or applying for a license under this chapter.
(b) The authorized Department representative shall have full and free access to the records of the facility and its clients.
(c) The authorized Department representative has the right to interview clients as part of the visitation and inspection process.
709.16. Notification of deficiencies.
(a) The authorized Department representative will leave appropriate Department forms with the facility director to address areas of noncompliance with the standards.
(b) These forms shall be completed and submitted to the Division of Licensing within 15 working days after the site visit.
(c) A license may not be issued until a plan of action has been approved by the Department.
709.17. Refusal or revocation of license.
(a) The Department may revoke or refuse to issue a license for any of the following reasons:
(1) Failure to comply with a directive issued by the Department.
(2) Violation of, or noncompliance with, this chapter.
(3) Failure to comply with a plan of correction approved by the Department, unless the Department approves an extension or modification of the plan of correction.
(4) Gross incompetence, negligence or misconduct in the operation of the facility.
(5) Fraud, deceit, misrepresentation or bribery in obtaining or attempting to obtain a license.
(6) Lending, borrowing or using the license of another facility.
(7) Knowingly aiding or abetting the improper granting of a license.
(8) Mistreating or abusing individuals cared for or treated by the facility.
(9) Continued noncompliance in disregard of this part.
(10) Operating a facility that, by nature of its physical condition, endangers the health and safety of the public.
(b) If the Department proposes to revoke or refuse to issue a license, it will give written notice to the facility by certified mail, stating the following:
(1) The reasons for the proposed action.
(2) The specific time period for the facility to correct deficiencies.
(c) If the facility does not correct the deficiencies within the specified time, the Department will officially notify the licensee that it shall show cause why its license should not be revoked under 1 Pa. Code Subsection 35.14 (relating to orders to show cause), and that it has a right to a hearing authorized by the Department on this question. A request to the Department for a hearing shall be filed, in writing, within 30 days of receipt of the show cause order.
(d) Subsection (c) supplements 1 Pa. Code Subsection 35.14.
709.18. Hearings.
(a) The Department will convene and conduct a show cause hearing for a facility under 1 Pa. Code Subsection 35.37 (relating to answers to orders to show cause) and this chapter.
(b) An administrative hearing held under this section shall be conducted under 1 Pa. Code Part II (relating to general rules of administrative practice and procedure).
(c) The Department may institute appropriate legal proceedings to enforce compliance with this chapter.
(d) This section supplements 1 Pa. Code Part II.
|
Observations
A physical plant inspection was conducted on October 6, 2016, at which time, 42 client beds were counted. The facility's authorized maximum client capacity for both inpatient detoxification and inpatient rehabilitation activities combined is 46. The facility confirmed that only 42 beds were available for clients at the time of the inspection.
This finding was reviewed with facility staff during the licensing inspection.
|
Plan of Correction
During facility correction, the reviewer noted there were 42 out of our 46 beds set up for patient use. The plan of correction is for the maintenance manager to clean out room #'s 6 and 8 of Wisdom hallway and set up two beds in each room. The CEO will oversee that the beds are returned to the rooms by 10/26/16. The facility will be in full compliance by 10/26/16 and will have a total of 46 beds that are prepared for patient occupation. |
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.
|
Observations
Five Buprenorphine client records were reviewed on October 5-6, 2016. The facility failed to obtain an informed, voluntary, written consent prior to the administration of Buprenorphine for detoxification treatment in client records # 1, 2, 3, 4, and 5.
Client # 1 was admitted into detoxification treatment on 9/23/16 and was still active in treatment. The client's record documented that the client received an initial dose of 8 mg of Suboxone on 10/4/16.
Client # 2 was admitted into detoxification treatment on 10/4/16 and was still active in treatment. The facility documented that the client received an initial dose of 8 mg of Suboxone on 10/5/16.
Client # 3 was admitted into detoxification treatment on 1/12/16 and was transferred into rehabilitation treatment on 1/18/16. The facility documented that the client received an initial dose of 8 mg of Suboxone on 1/13/16.
Client # 4 was admitted into detoxification treatment on 4/20/16 and was discharged from treatment on 4/26/16. The facility documented that the client received an initial dose of 8 mg of Suboxone on 4/21/16.
Client # 5 was admitted into detoxification treatment on 7/12/16 and was discharged from treatment on 7/17/16. The facility documented that the client received an initial dose of 8 mg of Suboxone on 7/12/16.
These findings were reviewed with facility staff during the licensing inspection.
|
Plan of Correction
During the site inspection, the reviewer noticed that the facility did not obtain an informed, voluntary, written consent prior to the administration of Buprenorphine.
The clinical director, and medical records manager reviewed the standards requiring facilities to acquire informed consent prior to administration of Buprenorphine. The medical records developed a new form entitled "Buprenorphine Informed Consent", which requires the patient, and nurses signature. Nurses on all shifts were trained and educated about providing the proper information to patients prior to taking Buprenorphine, and receiving signed consent from each patient prior to administering the medication. The medical records manager entered the new form in the system on 10/10/2016, and the new procedure for obtaining informed consent started 10/10/2016. The quality assurance manager will monitor case records on a weekly basis to ensure that written informed consent is received from each patient prior to administering the medication. The quality assurance manager will forward reports to the clinical director and CEO for additional monitoring. |
709.52(a)(2) LICENSURE Tx type & frequency
709.52. Treatment and rehabilitation services.
(a) An individual treatment and rehabilitation plan shall be developed with a client. This plan shall include, but not be limited to, written documentation of:
(2) Type and frequency of treatment and rehabilitation services.
|
Observations
Five client records for rehabilitation treatment were reviewed on October 6, 2016. The facility failed to sufficiently document the frequency of treatment services on the comprehensive treatment plans in client records # 6, 7, 8, 9, and 10.
Client # 6 was admitted into detoxification treatment on 2/16/16 and was then transferred into rehabilitation treatment on 2/22/16. The client was discharged from treatment on 3/16/16. The client's individual treatment and rehabilitation plan, dated 2/16/16, indicated the client was to receive individual therapy "2x" and group therapy "2x", but did not specify the period of time in which the sessions were to occur.
Client # 7 was admitted into detoxification treatment on 11/3/15 and was then transferred into rehabilitation treatment on 11/9/15. The client was discharged from treatment on 12/6/15. The client's individual treatment and rehabilitation plan, dated 11/4/15, indicated the client was to receive individual therapy "3x", but did not specify the period of time in which the sessions were to occur.
Client # 8 was admitted into detoxification treatment on 7/24/16 and was then transferred into rehabilitation treatment on 7/29/16. The client was discharged from treatment on 8/16/16. The client's individual treatment and rehabilitation plan, dated 7/25/16, indicated the client was to receive individual therapy "2x" and group therapy "3x", but did not specify the period of time in which sessions were to occur.
Client # 9 was admitted into detoxification treatment on 12/15/15 and was then transferred into rehabilitation treatment on 12/20/15. The client was discharged from treatment on 12/27/15. The client's individual treatment and rehabilitation plan, dated 12/16/15, indicated the client was to receive individual therapy "2x", but did not specify the period of time in which sessions were to occur.
Client # 10 was admitted into detoxification treatment on 12/11/15 and was then transferred into rehabilitation treatment on 12/19/15. The client was discharged from treatment on 12/30/15. The client's individual treatment and rehabilitation plan, dated 12/11/15, indicated the client was to receive individual therapy "2x" and group therapy "2x", but did not specify the period of time in which sessions were to occur.
These findings were reviewed with facility staff during the licensing inspection.
|
Plan of Correction
Medical Records manager will review all 125 treatment plan templates and edit methods to reflect a more specific frequency of treatment services provided by Huntington Creek Recovery Center, (formerly Clearbrook Lodge).
All treatment plan templates will be reviewed and implemented by 10/21/2016. Treatment Plans will be monitored weekly by the (quality assurance manager) to ensure methods and frequencies of treatment are correct and within regulator standards. These reports will be sent out weekly to all therapy staff along with Clinical Director and CEO to be reviewed.
|