INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on June 5-7, 2018 by staff from the Division of Drug and Alcohol Program Licensure, with the inspection also conducted for the approval to use Methadone and Buprenorphine in the treatment of narcotic addiction. Based on the findings of the on-site inspection, Recovery Center of America at Devon 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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704.9(c) LICENSURE Supervised Period
704.9. Supervision of counselor assistant.
(c) Supervised period.
(1) A counselor assistant with a Master's Degree as set forth in 704.8 (a)(1) (relating to qualifications for the position of counselor assistant) may counsel clients only under the close supervision of a trained counselor or clinical supervisor for at least the first 3 months of employment.
(2) A counselor assistant with a Bachelor's Degree as set forth in 704.8 (a)(2) may counsel clients only under the close supervision of a trained counselor or clinical supervisor for at least the first 6 months of employment.
(3) A registered nurse as set forth in 704.8 (a)(3) may counsel clients only under the close supervision of a trained counselor or clinical supervisor for at least the first 6 months of employment.
(4) A counselor assistant with an Associate Degree as set forth in 704.8 (a)(4) may counsel clients only under the close supervision of a trained counselor or clinical supervisor for at least the first 9 months of employment.
(5) A counselor assistant with a high school diploma or GED equivalent as set forth in 704.8 (a)(5) may counsel clients only under the direct observation of a trained counselor or clinical supervisor for the first 3 months of employment. For the next 9 months, the counselor assistant may counsel clients only under the close supervision of a lead counselor or a clinical supervisor.
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Observations
Two personnel records were reviewed for the counselor assistant position on June 5, 2018. The facility failed to document the provision of direct observation for employee records # 16 and 17.
Employee # 16 was hired on 4/9/18 as a Bachelor's degree level counselor assistant. The employee was then promoted to the counselor position on 5/27/18. The employee required direct observation and close supervision while employed in the counselor assistant position. Weekly supervision notes were reviewed for the period of 4/16/18 - 5/21/18. The facility failed to demonstrate that weekly close supervision included 1 hour of direct observation per week.
Employee # 17 was hired on 3/19/18 as a Bachelor's degree level counselor assistant. The employee was then promoted to the counselor position on 5/27/18. The employee required direct observation and close supervision while employed in the counselor assistant position. Weekly supervision notes were reviewed for the period of 3/23/18 - 5/25/18. The facility failed to demonstrate that weekly close supervision included 1 hour of direct observation per week.
These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
At the time of survey, clinical leadership team discussed the counselor assistant requirement and identified the need to document specific direct observation on a one hour per week basis. Clinical supervisors now, as of 6/7/18, document a specific session or group where direct observation occurred. The clinical supervisors now write the date of the observation, the initials of the patient with whom the counselor assistant was being observed, and the details of the supervision session into the supervision notes. Clinical Director will monitor the clinical supervision notes taken by Clinical Supervisors for Counselors Assistants at least quarterly. Clinical Director will give feedback on clinical supervision notes and check that notes are written in the form of direct observation. |
705.10 (d) (4) LICENSURE Fire safety.
705.10. Fire safety.
(d) Fire drills. The residential facility shall:
(4) Maintain a written fire drill record including the date, time, the amount of time it took for evacuation, the exit route used, the number of persons in the facility at the time of the drill, problems encountered and whether the fire alarm or smoke detector was operative.
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Observations
Fire drill records were reviewed during the licensing renewal inspection, conducted on June 5-7, 2018. Fire drill records were reviewed for the period of September 2017 - May 2018. Fire drill logs did not specify the amount of time it took for the evacuation, the exit route used, and/or the number of people in the facility during fire drills conducted during the following months: September 2017, October 2017, November, 2017, December 2017, January 2018, February 2018, March 2018, April 2018, and May 2018.
These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
As of 6/7/18, the facilities manager has changed the format of the fire drill log template used to document all fire drills and fire drill evacuations. The facilities technicians have also been trained on how to properly fill out this form so that the following data points are collected: 1) total amount of time it took to evacuate 2) the exit route or routes used to evacuate and the 3) total number of people in the facility that were evacuated. Facilities Manager will monitor fire drill log on at least a quarterly basis to maintain compliance with these data points. |
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
Seventeen client records were reviewed on June 5-7, 2018. The facility failed to document an informed and voluntary consent to release information to an insurance company, the treatment funding source, for client records # 1 - 17.
This finding was reviewed with facility staff during the licensing inspection.
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Plan of Correction
As of 6/7/18, all staff, particularly admissions coordinators, have been trained to have patient sign the voluntary consent to release information to the insurance company funding treatment. Director of Admissions will monitor staff adherence with this requirement. Compliance in this area will also be monitored by QA Manager during monthly chart audits. |
709.82(d)(1) LICENSURE Treatment and rehabilitation services
709.82. Treatment and rehabilitation services.
(d) Counseling shall be provided to a client on a regular and scheduled basis. The following services shall be included and documented:
(1) Individual counseling, at least twice weekly.
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Observations
Two client records were reviewed for the partial hospitalization activity on June 6, 2018. The facility failed to ensure that individual counseling services were provided at least twice weekly for client records # 8 and 9.
Client # 8 was admitted into treatment on 2/22/18 and was discharged on 4/2/18. Documentation in the client's record indicated that the client attended individual counseling sessions on 2/22/18 and 4/2/18.
Client # 9 was admitted into treatment on 2/9/18 and was discharged on 3/21/18. The client did not receive individual counseling services during their treatment. Documentation in the client's record indicated that the client failed to attend a scheduled individual counseling session on 3/5/18. However, the client's record did not contain specific documentation of additional scheduled individual counseling sessions that the client failed to attend.
These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
The outpatient clinical director and outpatient therapists have addressed the requirement to document and provide individual sessions to all PHP clients. Outpatient therapists have been retrained to document when a patient did not attend an individual session. The outpatient admissions coordinator is also helping to track missed appointments and monitor charts to make sure that missed individual sessions are documented. Outpatient therapists now include in their notes: 1) patient's absence from scheduled session 2) session reschedule attempts. |
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
Six client records were reviewed for the use of Buprenorphine in the inpatient detoxification and inpatient rehabilitation treatment activities on June 6-7, 2018. For client record # 14, the facility failed to provide sufficient physician documentation of evidence of a 1-year history of addiction.
Client # 14 was admitted into inpatient detoxification treatment 5/17/18 and was then transferred into inpatient rehabilitation treatment on 5/22/18. The client was still active in treatment at the time of the inspection. The initial dose of Buprenorphine was administered to the client on 5/18/18, while in detox treatment, and the client continued to receive Buprenorphine upon transferring to inpatient rehabilitation treatment. At the time of the inspection, Buprenorphine was most recently administered to the client on 6/7/18. Documentation of the client's current dependence on a narcotic drug was noted on the record of a medical assessment conducted by the physician on 5/17/18. However, this record did not contain physician documentation of a 1-year history of addiction.
This finding was reviewed with facility staff during the licensing inspection.
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Plan of Correction
Medical director, psychiatric nurse practitioner, and nurse practitioners have been trained by QA Manager to document the following information in the medical record: 1) That the medical director has made a face to face determination that the patient has a physiological dependence on a narcotic drug 2) dependence for at least one year prior to admittance for maintenance treatment 3) any previous narcotic treatment attempts. To track compliance of this requirement, monthly chart audits are conducted by medical department reviewed by the QA manager. |
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
Six client records were reviewed for the use of Buprenorphine in the inpatient detoxification and inpatient rehabilitation treatment activities on June 6-7, 2018. For client record # 15, the facility failed to document that the female patient had been fully informed of the possible risk to an unborn child from continued use of illicit drugs and from use of, or withdrawal from, a narcotic drug administered in treatment.
Client # 15 was admitted into inpatient detoxification treatment on 11/10/17 and was transferred into inpatient rehabilitation treatment on 11/17/17. The initial dose of Buprenorphine was administered to the client on 11/11/17.
This finding was reviewed with facility staff during the licensing inspection.
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Plan of Correction
This documentation requirement was reviewed by QA manager and director of nursing on 6/7/18. It was identified that female patients are educated about the risks to an unborn child from drug use on the 'Consent to Treat With Approved Narcotic' form. Medical staff review these risks with female patients before administering narcotic drug treatment. Medical department is monitoring that these consent forms are completed for all patients treated with narcotic drugs. To track compliance of this requirement, monthly chart audits are conducted by medical department reviewed by the QA manager. |
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
Six client records were reviewed for the use of Buprenorphine in the inpatient detoxification and inpatient rehabilitation treatment activities on June 6-7, 2018. The facility failed to obtain an informed, voluntary, written consent prior to the administration of Buprenorphine for client records # 14 and 15.
Client # 14 was admitted into inpatient detoxification treatment 5/17/18 and was then transferred into inpatient rehabilitation treatment on 5/22/18. The client was still active in treatment at the time of the inspection. The initial dose of Buprenorphine was administered to the client on 5/18/18
Client # 15 was admitted into inpatient detoxification treatment on 11/10/17 and was transferred into inpatient rehabilitation treatment on 11/17/17. The initial dose of Buprenorphine was administered to the client on 11/11/17.
These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
Plan of Correction: The documentation requirement was reviewed by QA manager and director of nursing on 6/7/18. The Medical department completes a 'Consent to Treat With Approved Narcotic' form for patients treated with narcotic drugs. Medical department is monitoring that these consent forms are completed for all patients treated with narcotic drugs. To track compliance of this requirement, monthly chart audits are conducted by medical department reviewed by the QA manager. |