INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on May 9-10, 2017 by staff from the Division of Drug and Alcohol Program Licensure. The inspection was also conducted for the approval to use Methadone in the treatment of narcotic addiction. Based on the findings of the on-site inspection, Horsham Clinic 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(d)(2) LICENSURE Annual Training Requirements
704.11. Staff development program.
(d) Training requirements for project directors and facility directors.
(2) A project director and facility director shall complete at least 12 clock hours of training annually in areas such as:
(i) Fiscal policy.
(ii) Administration.
(iii) Program planning.
(iv) Quality assurance.
(v) Grantsmanship.
(vi) Program licensure.
(vii) Personnel management.
(viii) Confidentiality.
(ix) Ethics.
(x) Substance abuse trends.
(xi) Developmental psychology.
(xii) Interaction of addiction and mental illness.
(xiii) Cultural awareness.
(xiv) Sexual harassment.
(xv) Relapse prevention.
(xvi) Disease of addiction.
(xvii) Principles of Alcoholics Anonymous and Narcotics Anonymous.
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Observations
One personnel record was reviewed for the project director position on May 9, 2017. The facility failed to document at least 12 hours of annual training for employee record # 1.
Employee # 1 was hired by the project on 7/11/94, and then assumed the project director position on 7/15/13. The facility's last complete training year of June 1, 2015 - May 31, 2016 was reviewed. Documentation in the employee's record indicated that the employee completed 1.75 hours of annual training for the reviewed training year.
This finding was reviewed with facility staff during the licensing inspection.
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Plan of Correction
The Director of Staff Development will re-educate clinical staff of the training hours requirement via memo by July 1. Horsham Clinic will purchase and create individual accounts for Clinical staff with CEUs online by 7/31/2017. The Director of Staff Development will track and manage the CEU account to ensure that all Clinical Staff fulfill their training hours. |
709.28 (d) LICENSURE Confidentiality
§ 709.28. Confidentiality.
(d) A copy of a client consent shall be offered to the client and a copy maintained in the client record.
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Observations
Eight client records were reviewed on May 9-10, 2017. The facility failed to document verification that the client was offered a copy of a consent to release information for client records # 1, 4, 6, and 7.
Client # 1 was admitted into treatment on 5/5/17 and was still active in treatment. A consent to release information to another treatment provider, signed and dated on 5/8/17, was documented in the client's record. Verification that the client was offered a copy of the consent form was not documented in the client's record.
Client # 4 was admitted into treatment on 12/22/16 and was discharged on 12/28/16. A consent to release information to another treatment provider, signed and dated on 12/27/16, was documented in the client's record. Verification that the client was offered a copy of the consent form was not documented in the client's record.
Client # 6 was admitted into treatment on 1/11/17 and was discharged on 2/10/17. A consent to release to information to another treatment provider, signed and dated on 2/1/17, was documented in the client's record. Verification that the client was offered a copy of the consent form was not documented in the client's record. The client's record also contained a consent to release information to a county courthouse, signed and dated on 2/3/17. Verification that the client was offered a copy of this consent form was not documented in the client's record.
Client # 7 was admitted into treatment on 11/18/16 and was discharged on 12/14/16. A consent to release information to a relative, signed and dated on 11/18/16, was documented in the client's record. Verification that the client was offered a copy of the consent form was not documented in the client's record.
These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
The Director of Social Work will re-educate Social Workers of the completion requirements for Releases of Information via a staff meeting by 7/1/17. The Director of Quality Improvement will modify the form and highlight in bold the verification section by 7/15/17. The form will be distributed to all respective staff and the Director of Social Work will randomly audit 15 charts per week to ensure verification section is complete. Results of audits will be shared and reviewed by the Performance Improvement Committee on a monthly basis. |
709.34 (a) (4) LICENSURE Reporting of unusual incidents
§ 709.34. Reporting of unusual incidents.
(a) The project shall develop and implement policies and procedures to respond to the following unusual incidents:
(4) Significant disruption of services due to disaster such as fire, storm, flood or other occurrence which closes the facility for more than 1 day.
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Observations
The facility's administrative records were reviewed on May 9-10, 2017. The facility failed to develop policies and procedures to respond to the following unusual incidents:
(4)Significant disruption of services due to disaster such as fire, storm, flood or other occurrence which closes the facility for more than 1 day.
(6)Event at the facility requiring the presence of police, fire or ambulance personnel.
(8)Outbreak of a contagious disease requiring Centers for Disease Control (CDC) notification.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
The Risk Manager will revise the Healthcare Peer Review Reporting policy by 6/30/2017. The Policy will be reviewed and approved by the Leadership team by 7/1/17. The Risk Manager will upload the policy to PolicyStat (Horsham's web based policy system) and make available to all staff by 7/1/2017. |
709.34 (c) (1) LICENSURE Reporting of unusual incidents
§ 709.34. Reporting of unusual incidents.
(c) To the extent permitted by State and Federal confidentiality laws, the project shall file a written unusual incident report with the Department within 3 business days following an unusual incident involving:
(1) Physical or sexual assault by staff or a client.
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Observations
The facility's administrative records were reviewed on May 9-10, 2017. Based on a review of the facility's documentation of unusual incidents, the facility failed to file Unusual Incident Reports with the Department for events classified under the following categories identified by the facility:
-Boundary Verbal/Physical Non-Aggressive
-Patient attacked by another patient
-Patient attacked another patient
-Patient attacked by/injured by another
-Patient attacked other
-Patient attacked staff
-Physical confrontation with other patient
-Patient injured, Equipment/Instrument
-Self-inflicted injury
-Sexual misconduct, patient-to-patient
Facility staff confirmed that unusual incidents or events requiring written notification to the Department have not been reported to the Department.
This finding was reviewed with facility staff during the licensing inspection.
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Plan of Correction
The unit Program Coordinator and Nursing Leadership team was re-educated regarding the need to report Unusual Incidents to the Department on 5/11/17. The first report was made to the Department on 5/23/17. Copies of the reports are maintained by the Risk Manager in a binder that is available for onsite review.
The Facility Risk Manager is responsible for oversight of all incident reporting. Incidents are reviewed by Leadership in the daily Flash Meetings. The Facility Risk Manager will ensure that all "Unusual" incidents are reported to the Department. |
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
Five client records were reviewed for the narcotic detoxification activity on May 9-10, 2017. The facility failed to document a complete informed patient consent prior to the administration of a narcotic agent for client records # 1, 2, 3, 4, and 5.
Client # 1 was admitted into detoxification treatment on 5/5/17 and was still active in treatment. The client received an initial dose of methadone on 5/5/17. A consent for new medications documented in the client's record, signed by the client on 5/5/17, identified methadone as a detoxification medication recommended for the client. This patient consent form did not include the following information:
-That methadone is a narcotic drug which can be harmful if taken without medical supervision.
-That methadone is an addictive medication and may, like other drugs used in medical practices, produce adverse results.
Client # 2 was admitted into detoxification treatment on 5/5/17 and was still active in treatment. The client received an initial dose of methadone on 5/6/17. An informed patient consent for the administration of methadone was not documented in the client's record. A consent for new medications documented in the client's record did not identify methadone as a detoxification medication recommended for the client.
Client # 3 was admitted into detoxification treatment on 5/5/17 and was still active in treatment. The client received an initial dose of methadone on 5/7/17. A consent for new medications documented in the client's record, signed by the client on 5/5/17, identified methadone as a detoxification medication recommended for the client. This patient consent form did not include the following information:
-That methadone is a narcotic drug which can be harmful if taken without medical supervision.
-That methadone is an addictive medication and may, like other drugs used in medical practices, produce adverse results.
-That methadone is transmitted to the unborn child and will cause physical dependence.
Client # 4 was admitted into detoxification treatment on 12/22/16 and was discharged on 12/28/16. The client received an initial dose of methadone on 12/22/16. A consent for new medications documented in the client's record, signed by the client on 12/24/16, identified methadone as a detoxification medication recommended for the client. This patient consent form did not include the following information:
-That methadone is a narcotic drug which can be harmful if taken without medical supervision.
-That methadone is an addictive medication and may, like other drugs used in medical practices, produce adverse results.
Client # 5 was admitted into detoxification treatment on 12/13/16, and was transferred to inpatient rehabilitation treatment on 12/18/17. The client was then discharged from treatment on 12/26/16. The client received an initial dose of methadone on 12/14/16. An informed patient consent for the administration of methadone was not documented in the client's record. A consent for new medications documented in the client's record did not identify methadone as a detoxification medication recommended for the client.
These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
Client #1 completed his methadone on the day of the review and was discharged the day after survey (5/11). Therefore a new informed consent was unable to be obtained.
Client #2 completed his methadone and was discharged the day of the survey (5/10)therefore a new informed consent was unable to be obtained.
Client #3 completed her methadone on the day of the survey and was discharged two days later (5/12) therefore a new informed consent was unable to be obtained.
Clients #4 & #5 were not active patients therefore a new informed consent could not be obtained.
The Director of Quality Improvement will revise the Consent for Medications to include: methadone is a narcotic drug which can be harmful if taken without medical supervision, methadone is an addictive medication and may, like other drugs used in medical practices, produce adverse results, and that methadone is transmitted to the unborn child and will cause physical dependence. The form will be reviewed and approved by the Med Executive Committee on 7/19/17. Once approved, the Director of Quality Improvement will distribute the form to all Physicians for immediate use via memo by 7/31/17. All previous forms will be removed from the units and forms drive and shredded by the Unit Secretaries. Medical Records staff will be responsible to monitor patient records to ensure the proper forms are being used and report deficiencies to the PI Committee on a monthly basis. |