INITIAL COMMENTS
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This report is a result of an on-site licensure renewal and a methadone buprenorphine monitoring inspection conducted on December 16-18, 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, UPMC McKeesport Hospital 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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704.11(c)(1) LICENSURE Mandatory Communicable Disease Training
704.11. Staff development program.
(c) General training requirements.
(1) Staff persons and volunteers shall receive a minimum of 6 hours of HIV/AIDS and at least 4 hours of tuberculosis, sexually transmitted diseases and other health related topics training using a Department approved curriculum. Counselors and counselor assistants shall complete the training within the first year of employment. All other staff shall complete the training within the first 2 years of employment.
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Observations
Based on a review of personnel records and the facility's Staffing Requirement Facility Summary Report (SRFSR) form on December 16-18, 2019, the facility failed to ensure that employee #6 received the minimum of at least four hours of TB/STD and other health related topics training within the regulatory timeframe.
Employee #6 was hired as a direct support professional on September 17, 2017 and was due to have the communicable disease trainings no later than September 17, 2019. There was no documentation in the personnel file of the completion of the TB/STD training as of the date of the inspection.
The findings were discussed with facility staff during the licensing process.
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Plan of Correction
1. UPMC Mckeesport Hospital Addiction Medicine Services will assure that all employees receive the minimum of at least four hours of TB/STD and other health related topics training within the regulatory timeframe.
2. The program Manager will be responsible for monitoring that all staff required to have the said trainings acquire so within the regulatory time frame of 2 years post hire date.
3. Compliance, Employee #6 is scheduled for the said DDAP training TB/ STD for 2/2/2020. |
715.11 LICENSURE Confidentiality of patient records
A narcotic treatment program shall physically secure and maintain the confidentiality of all patient records in accordance with 42 CFR 2.22 (relating to notice to patients of Federal confidentiality requirements) and § 709.28 (relating to confidentiality).
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Observations
Based on a review of client records on December 16-18, 2019, the facility 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 #2.
Client #2 was admitted on September 13, 2019 and discharged on September 26, 2019. A consent to release information form, signed and dated on September 13, 2019 to a funding source, permitted the release of "other" information without specifying what information was included in "other".
The findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
1. As a narcotic treatment program UPMC Mckeesport Hospital Addiction Medicine Services shall physically secure and maintain the confidentiality of all patient records in accordance with 42 CFR 2.22 (relating to notice to patients of Federal confidentiality requirements) and § 709.28 (relating to confidentiality).
2. In reference to releases of information in client record #2. Going forward UPMC Mckeesport Hospital Addiction Medicine Services will assure that all staff is trained as to the appropriate completion and expectations as to the completion of releases of information. Staff to sign as to their competence of the completion of patient releases of information.
3.All staff to be trained as a new hire competency and a yearly competency to be managed by the program manager.
Current staff has been reeducated as to the competencies associated with the completion of a release of information form.
Also an admission checklist has been created and initiated immediately 1/1/2020 to assure that specific documents required for charting by state and county regulatory agencies are completed and become a part of the patients permanent chart. This process is audited by the Health Unit Clerk daily. |
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
Based on the review of client records on December 16-18, 2019, the facility failed to obtain an informed, voluntary, written consent to treat before administering an agent in client record #1.
Client #1 was admitted on June 4, 2019 and discharged on June 10, 2019. There was no documentation of a consent to treat for methadone detoxification treatment in the client's record.
The findings were reviewed with facility staff during the licensing inspection.
This is a repeat citation from the inspection on October 30, 2018.
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Plan of Correction
UPMC Mckeesport Hospital Addiction Medicine Services will assure that as a narcotic treatment program an informed, voluntary, written consent before an agent may be administered to the patient for either maintenance or detoxification treatment.
1.An admission checklist has been created to assure that specific documents required for charting by state and county regulatory agencies are completed and become a part of the patients permanent chart. 2.This process is audited by the Health Unit Clerk daily.
3. Process initiated immediately 1/1/2020. All staff has been informed of the documentations and the checklist process. |