INITIAL COMMENTS
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This report is a result of an on-site complaint investigation conducted on March 12, 2024 by staff from the Bureau of Program Licensure. Based on the findings of the on-site complaint investigation, Clear Day Treatment of Westmoreland was found not to be in compliance with the applicable chapters of 28 PA Code which pertain to the facility.
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Plan of Correction
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709.24 (a) (3) LICENSURE Treatment/rehabilitation management.
§ 709.24. Treatment/rehabilitation management.
(a) The governing body shall adopt a written plan for the coordination of client treatment and rehabilitation services which includes, but is not limited to:
(3) Written procedures for the management of treatment/rehabilitation services for clients.
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Observations
Based on a review of client records and the Documentation of Services Provided policy, the facility failed to adhere to its written procedures for the management of treatment/rehabilitation services for clients.Per the Documentation of Services Provided policy, nursing notes to be completed to document any nursing services provided including, but not limited to: medication adherence, missed doses, refusals or concerns and medical monitoring.Client #9 was admitted on January 9, 2024, and discharged on February 26, 2024. The client was prescribed a medication and the prescription stated that one tablet was to be taken once daily. The medication administration records showed that the medication was not given as prescribed on January 21 - February 10, 2024, and February 12 - February 25, 2024. Documentation of nursing notes for the missed doses of medication was missing from the client record.These findings were reviewed with facility staff during the investigation process.
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Plan of Correction
The Documentation of Services Provided policy was reviewed through individual training sessions for nursing staff regarding key documentation requirements. To ensure ongoing compliance with the policy, the Lead Counselor and Facility Director will continue to complete weekly chart audits. |
709.32 (b) LICENSURE Medication control
§ 709.32. Medication control.
(b) Verbal orders for medication can be given only by a physician or other medical professional authorized by State and Federal law to prescribe medication and verbal orders may be received only by another physician or medical professional authorized by State and Federal law to receive verbal orders. When a verbal or telephone order is given, it has to be authenticated in writing by a physician or other medical professional authorized by State and Federal law to prescribe medication. In detoxification levels of care, written authentication shall occur no later than 24 hours from the time the order was given. Otherwise, written authentication shall occur within 3 business days from the time the order was given.
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Observations
Based on a review of client records, the facility failed to document that verbal medication orders were received by a medical professional authorized by State and Federal law. In addition, the facility failed to document written authentication of the verbal orders within three business days from the time the verbal order was given.Client #4 was admitted on December 26, 2023, and discharged on January 17, 2024. A verbal order was issued by a medical doctor on January 15, 2024. This verbal order was received by a medical assistant, who is not considered an authorized medical professional by State and Federal law. In addition, there was no written authentication of the verbal order within three business days, as required by regulation.Client #5 was admitted on December 19, 2023, and discharged on January 27, 2024. A verbal order was issued by a medical doctor on January 26, 2024. This verbal order was received by a recovery tech / medical tech, who is not considered an authorized medical professional by State and Federal law. In addition, there was no written authentication of the verbal order within three business days, as required by regulation.Client #9 was admitted on January 9, 2024, and discharged on February 26, 2024. A verbal order was issued by a medical doctor on January 20, 2024. This verbal order was received by a medical assistant, who is not considered an authorized medical professional by State and Federal law. In addition, there as no written authentication of the verbal order within three business days, as required by regulation.These findings were reviewed with facility staff during the investigation process.
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Plan of Correction
Clear Day has updated their Medication Control Plan including the utilization of Verbal orders. Staff will conduct training sessions on May 1 2024. These sessions will cover the proper procedures for giving and receiving verbal medication orders, that verbal orders can only be received by Nursing staff, emphasizing the necessity of timely written authentication from the Physician. Additionally weekly chart audits will be conducted by the Nursing Supervisor, Lead Counselor and Facility Director to ensure ongoing compliance. |
709.32 (c) LICENSURE Medication control
§ 709.32. Medication control.
(c) The project shall have and implement a written policy and procedures regarding all medications used by clients which shall include, but not be limited to:
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Observations
Based on staff interviews and a review of client records, incident reports, and the Medication Control Plan policy, the facility failed to implement its policy and procedures regarding all medications used by clients. The Medication Control Plan policy indicates that verbal medication orders may be accepted only by a licensed nurse. When a patient misses their prescribed medication time or refuses medication the doctor/nurse practitioner must be contacted. An electronic health record to allow for the electronic signature of authorized staff members. This system records drugs withdrawn indicating the name of the drug dosage, staff persons, amount, time and date. All medication errors such as incorrect dosage, missed medications or discrepancies in the daily medicine count will be documented on the medication incident report. Client #4 was admitted on December 26, 2023, and discharged on January 17, 2024. A verbal order was issued by a medical doctor on January 15, 2024. This verbal order was received by a medical assistant, who is not considered an authorized medical professional by State and Federal law. The client was prescribed a medication and the prescription stated that one tablet was to be taken twice daily. The medication administration records showed that the medication was not given as prescribed on December 27, 2023, January 1 & January 2, 2024. Additionally, client #4 was prescribed a medication and the prescription stated that one tablet was to be taken once daily. The medication administration records showed that the medication was not given on December 30, 2023, January 2 & January 3, 2024. There was no documentation of missed medications on an incident report.Client #5 was admitted on December 19, 2023, and discharged on January 27, 2024. A verbal order was issued by a medical doctor on January 26, 2024. This verbal order was received by a recovery tech / medical tech, who is not considered an authorized medical professional by State and Federal law. Client #9 was admitted on January 9, 2024, and discharged on February 26, 2024. A verbal order was issued by a medical doctor on January 20, 2024. This verbal order was received by a medical assistant, who is not considered an authorized medical professional by State and Federal law. The client was prescribed a medication and the prescription stated that one tablet was to be taken once daily. The medication administration records showed that the medication was not given as prescribed on January 21 - February 10, 2024, and February 12 - February 25, 2024. The client medication administration record provided included documentation of missed medication doses and medication doses not given; however, there was no document of what medications were administered. The medication administration section of the record was found to be blank. There was no documentation of missed medications on an incident report.These findings were reviewed with facility staff during the investigation process.
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Plan of Correction
Clear Day has updated their Medication Control Plan including the utilization of Verbal orders as well as medication errors and missed doses. All medication errors are to be documented on an incident report. Nursing Supervisor will conduct training sessions. These sessions will cover the proper procedures for giving and receiving verbal medication orders, emphasizing the necessity of timely written authentication from the Physician. Additionally weekly chart audits will be conducted by the Nursing Supervisor, Lead Counselor and Facility Director to ensure ongoing compliance. |
709.32 (c) (4) (i) - (ii) LICENSURE Medication control
§ 709.32. Medication control.
(4) Methods for control and accountability of drugs, including, but not limited to:
(i) Who is authorized to remove drug.
(ii) The program ' s system for recording drugs, which includes the name of the drug, the dosage, the staff person, the time and the date.
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Observations
Based on a review of client records, the facility failed to provide documentation of medication being provided as prescribed by a physician.Client #4 was admitted on December 26, 2023, and discharged on January 27, 2024. The client was prescribed a medication and the prescription stated that one tablet was to be taken twice daily. The medication administration records showed that the medication was not given as prescribed on December 27, 2023, January 1 & January 2, 2024. Additionally, client #4 was prescribed a medication and the prescription stated that one tablet was to be taken once daily. The medication administration records showed that the medication was not given on December 30, 2023, January 2 & January 3, 2024.Client #9 was admitted on January 9, 2024, and discharged on February 26, 2024. The client was prescribed a medication and the prescription stated that one tablet was to be taken once daily. The medication administration records showed that the medication was not given as prescribed on January 21 - February 10, 2024, and February 12 - February 25, 2024. These findings were reviewed with facility staff during the investigation process.
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Plan of Correction
Clear Day has updated their Medication Control Plan including the utilization of Verbal orders. Nursing Supervisor will conduct training sessions on 5/1/24. These sessions will cover the proper procedures for observing medication passes to include PRN and scheduled medications, emphasizing the necessity of timely documentation. Additionally weekly chart audits will be conducted by the Nursing Supervisor, Lead Counselor and Facility Director to ensure ongoing compliance. |
709.53(a)(2) LICENSURE Medication records
709.53. Client records.
(a) There shall be a complete client record on an individual which includes information relative to the client's involvement with the project. This shall include, but not be limited to, the following:
(2) Medication records.
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Observations
Based on a review of client records, the facility failed to document a complete client record on an individual which included medication administration records.Client #9 was admitted on January 9, 2024, and discharged on February 26, 2024. The client medication administration record provided included documentation of missed medication doses and medication doses not given; however, there was no document of what medications were administered. The medication administration section of the record was found to be blank.These findings were reviewed with facility staff during the investigation process.
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Plan of Correction
In the event of Electronic Health Record (EHR) system unavailability, Clear Day utilizes paper Medication Administration Records (MARs). The Nursing Supervisor will be responsible for distributing paper MARs to staff. These MARs will accurately document both administered and missed medications, ensuring continuity of care and adherence to protocols. Nursing Supervisor will monitor paper MARs. Additionally, our staff will undergo retraining on 5/1/24 to effectively report incidents related to missed medications, enhancing our documentation practices for comprehensive record-keeping. |