INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection and conducted on June 30, 2015 - July 1, 2015 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection Conewago Pottsville 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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705.24 (3) LICENSURE Bathrooms.
705.24. Bathrooms.
The nonresidential facility shall:
(3) Have hot and cold water under pressure. Hot water temperature may not exceed 120F.
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Observations
Based on an inspection of the physical plant, the facility failed to ensure the hot water temperature did not exceed 120 degrees Fahrenheit.
The findings include:
A physical plant inspection was conducted on July 1, 2015 from approximately 11:30 AM - 1:00 PM. During the physical plant inspection, it was noted that the hot water temperature registered at 130 degrees Fahrenheit in the bathroom in male's detox wing on the first floor.
The findings were reviewed with facility staff during the during the physical plant tour.
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Plan of Correction
The facility maintenance man adjusted the water heater associated with the bathroom in question. He then rechecked the water temperatures in the facility on the day of the inspection 7/1/15 and found the water temperature to be in compliance with the standard at 118 degrees.
The facility maintenance man will monitor compliance with this standard by testing the water temperatures in the facility weekly and document as a component of the fire safety/sanitation report beginning 7/10/15.
The facility director and corporate compliance officer will monitor ongoing compliance by reviewing the weekly fire safety/sanitation reports on a monthly basis beginning 7/30/15.
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715.9(a)(2) 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:
(2) Verify the individual 's identity, including name, address, date of birth, emergency contact and other identifying data.
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Observations
Based on the review of patient records, the facility failed to document verification of the individual's identity, including name, address, date of birth, and other identifying data in two of five patient records.
The findings include:
On June 30, 2015 five patient records were reviewed for compliance with the Buprenorphine waiver, and were required to include verification of the individual's identity. The facility failed to verify the identity of the patient prior to the administration of an agent in two of five patient records, specifically patients #4 and 6.
Patient record # 4 was admitted on March 30, 2015 and was discharged on April 3, 2015. The initial dose of buprenorphine was given to the patient on March 30, 2015. The facility failed to document verification of the individual's identity prior to the first administration.
Patient record # 6 was admitted on April 18, 2015 and was discharged on April 21, 2015. The initial dose of buprenorphine was given to the patient on April 18, 2015. The facility failed to document verification of the individual's identity prior to the first administration.
These findings were reviewed with facility staff during the inspection process.
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Plan of Correction
The facility nursing supervisor revised the agency?s intake form on 7/2/15 to include more detailed information on the client?s identification status and the method of verification and the form was subsequently implemented on 7/5/15 to ensure ongoing compliance.
The facility nursing supervisor will notify the facility director of any clients arriving in the narcotic treatment program without appropriate identification beginning 7/5/15 and contacts with collateral contacts will be made and documented to verify the client?s identification prior to the administration of any narcotic treatment agents.
The corporate compliance officer will monitor monthly to ensure ongoing compliance beginning 7/30/15.
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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.
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Observations
Based on a review of client records, the facility failed to document treatment plans to include the type and frequency of treatment services in three out of ten inpatient client records reviewed.
The findings include:
Ten inpatient client records were reviewed for comprehensive treatment plans, which included the type and frequency of treatment services on July 1, 2015. Three out of ten client records lacked documentation of a treatment plan that included a the type and frequency of treatment services, specifically records # 11, 12, and 14.
The comprehensive treatment plan for client #11 was documented on June 1, 2015; however it did not include the type and frequency of treatment services for client #11.
The comprehensive treatment plan for client #12 was documented on June 17, 2015; however it did not include the type and frequency of treatment services for client #12.
The comprehensive treatment plan for client #14 was documented on April 30, 2015; however it did not include the type and frequency of treatment services for client #14.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The corporate clinical director spoke to the corporate software designer for Firetree in relation to adding a concrete treatment modality on the treatment plans on 7/3/15. The electronic treatment plan will be revised to include a concrete treatment modality by 7/17/15.
All treatment plans of active inpatient clients will be printed out and the hard copy amended with the client?s written permission to include a concrete treatment modality by 7/17/15 to be in compliance with this standard.
The facility lead counselor and the corporate compliance officer will monitor monthly via regular client charts reviews by 7/30/15 to ensure ongoing compliance.
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