INITIAL COMMENTS
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This report is a result of an on-site provisional license follow-up inspection conducted June 27-28, 2024 by staff from the Department of Drug and Alcohol Programs, Bureau of Program Operations. Based on the findings of the on-site inspection, 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. The following deficiencies were identified during this inspection:
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Plan of Correction
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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 written authentication of the verbal orders within three business days from the time the verbal order was given.Client #1 was admitted on April 23, 2024, and discharged on May 4, 2024. Verbal orders were issued on April 23, 2024. The written authentications of the verbal orders were signed by the facility doctor; however, the doctor did not date the signatures.Client # 2 was admitted on May 14, 2024, and discharged on June 2, 2024. A verbal order was issued on May 13, 2024. The written authentication of the verbal order was signed by the facility doctor; however, the doctor did not date the signature.Client # 4 was admitted on May 15, 2024, and discharged on June 5, 2024. Verbal orders were issued on May 22, 2024. The written authentications of the verbal orders were signed by the facility doctor; however, the doctor did not date the signatures.
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Plan of Correction
On 8/7/2024, the facility director, the medical assistant, and an external training agency met to review and make any necessary updates on the Medication Control Plan. On 9/5/2024, a training will be conducted by staff to review the updated Medication Control Plan, specifically verbal medication orders, to ensure that nursing staff continue to be the only staff who are permitted to take verbal orders, and that within three days of the verbal order, the physician includes the appropriate date when he signs authenticates the prescription. Chart audits will continue to be conducted weekly by the nursing supervisor and the facility director. |
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, a review of client records, and the New Medication Control Plan policy, the facility corrected the deficiency from March 12, 2024; however, the facility failed to implement its policy and procedures regarding all medications used by clients. The New Medication Control Plan policy indicates that Medications must be administered according to the route specified in the prescription. A trained medical assistant may administer non-narcotic medications.Client # 1 was admitted on April 23, 2024, and discharged on May 4, 2024. A medication card dated 5/4/24 indicates the medical assistant administered a narcotic medication to this client.Client #6 was admitted on March 21, 2024, and discharged on April 18, 2024. A medication card dated 4/2/24 indicates the medical assistant administered a narcotic medication to this client.Client #7 was admitted on March 21, 2024, and discharged on April 2, 2024. A medication card dated 4/2/24 indicates the medical assistant administered a narcotic medication to this client.
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Plan of Correction
On 8/7/2024, the facility director and the medical assistant met with external training agency to review and update the Medication Control Plan. Since the time that this incident occurred, Clear Day has terminated the medical assistant from who was responsible for this noncompliance with the Medication Control Plan and has hired a medical assistant who has been trained on the appropriate procedures. Staff will conduct training on 9/5/24, to review the updated Medication Control Plan and the importance of adhering to the policies and procedures. Nursing staff are the only staff permitted to administer medications. Medication observation can be done by the medical assistant or med techs only.
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709.32 (c) (1) (i) - (ii) 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:
(1) Administration of medication, including the documentation of the administration of medication:
(i) By individuals permitted to administer by Pennsylvania law.
(ii) When self administered by the client.
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Observations
Based on a review of client records, the facility failed to administer medications by individuals permitted to administer by Pennsylvania law. Furthermore, no documentation was presented that the medical assistant was trained, experienced, and competent to administer medications.Client # 1 was admitted on April 23, 2024, and discharged on May 4, 2024. Documentation dated April 2, 2024, indicates the medical assistant administered medication to this client.Client #6 was admitted on March 21, 2024, and discharged on April 18, 2024. Documentation dated 4/2/24, indicates the medical assistant administered medication to this client.Client #7 was admitted on March 21, 2024, and discharged on April 2, 2024. Documentation dated April 2, 2024, indicates the medical assistant administered medication to this client.
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Plan of Correction
On 8/7/2024, the facility director and the medical assistant met with an external training agency to review and update the Medication Control Plan. The nursing supervisor will conduct training sessions on 9/5/24, to review the necessity of timely documentation by an individual who is permitted to administer the medication. Weekly chart audits will continue to be conducted by the Nursing Supervisor and Facility Director to ensure ongoing compliance. Nursing staff are the only staff permitted to administer medications. Medication observation can be done by the medical assistant or med techs only. |
709.32 (c) (3) (i) - (v) LICENSURE Medication control
§ 709.32. Medication control.
(3) Inspection of storage areas that ensures compliance with State and Federal laws and program policy. The policy must include, but not be limited to:
(i) What is to be verified through the inspection, who inspects, how often, but not less than quarterly, and in what manner it is to be recorded.
(ii) Disinfectants and drugs for external use are stored separately from oral and injectable drugs.
(iii) Drugs requiring special conditions for storage to insure stability are properly stored.
(iv) Outdated drugs are removed.
(v) Copies of drug-related regulations are available in appropriate areas.
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Observations
Based on a review of client records, and the New Medication Control Plan, the facility failed to follow its policy on the removal of drugs.The New Medication Control Plan indicates only the nursing director, medical director or nursing supervisor are authorized to remove drugs from the drug storage area. This shall be conducted by two of these qualified staff members.Client #1 was admitted on April 23, 2024, and discharged on May 4, 2024. A medication destruction document was signed by the medical assistant on 4/28/24. A medication destruction document was signed by the medical assistant on 5/4/24 with no witness signature. A second medication destruction document, dated 5/4/24, was later uploaded into the client chart containing a witness signature. Client # 6 was admitted on March 21, 2024, and discharged on April 18, 2024. Two Medication destruction documents dated 3/30/24 were signed by the medical assistant with no witness signatures. Another medication destruction document was signed by the medical assistant on 4/2/24. Client # 7 was admitted on March 21, 2024, and discharged on April 2, 2024. A medication destruction document, dated 4/2/24, indicates a narcotic medication was destroyed by the medical assistant with no witness signature.
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Plan of Correction
On 8/7/24, the facility director and the medical assistant met with an external training agency to review and update the Medication Control Plan. Since the time that this incident occurred, Clear Day has terminated the medical assistant responsible for noncompliance with the Medication Control Plan and has hired a medical assistant who has been trained in the appropriate procedures. On 9/5/24, the nursing supervisor will conduct a training with all medical staff to educate them on proper drug removal and review the Medication Control Plan which states the proper procedure for medication destruction. The nursing supervisor will review charts to ensure the nurses are remaining compliant with this procedure. |
709.32 (c) (5) LICENSURE Medication control
§ 709.32. Medication control.
(5) Security of drugs, including, but not limited to, the loss, theft or misuse of drugs.
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Observations
Based on a review of client records, the facility failed to document the security of narcotic medications to limit the loss, theft, or misusage of drugs.Client #3 was admitted on April 4, 2024, and discharged on May 2, 2024. A Narcotic Control Sheet for a medication was dated 4/6-4/19/24. Per the medication administration record, this client continued receiving the narcotic medication twice a day from 4/20-4/30/24. There was no documentation of this medication being administered and counted on a Narcotic Control Sheet after 4/19/24.
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Plan of Correction
On 8/7/24, the facility director and the medical assistant met with an external training agency to review and update the Medication Control Plan. Staff will conduct a training on 9/5/2024 to review the updated Medication Control Plan, emphasizing the importance of utilizing a Narcotic Control Sheet when a narcotic is administered. The Narcotic Control Sheet will reflect the same dates and times as the medication administration record. The nursing supervisor and the medical assistant will audit the medical records for the utilization of narcotic control sheets weekly. |
709.51(b)(5) LICENSURE Physical Examination
709.51. Intake and admission.
(b) Intake procedures shall include documentation of:
(5) Physical examination.
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Observations
Based on a review of client records, the facility failed to document a complete medical history and physical examination.The facility History and Physical Examination policy indicates everyone admitted will be provided a physical examination within 48 hours of admission. A complete history and physical will consist of current vials, current medications, allergies, substance use and treatment history, medical and psychiatric history, pain assessment, nutritional assessment, mental status assessment, review of systems and clinical assessment and diagnosis.Client # 2 was admitted on May 14, 2024, and discharged on June 2, 2024. The medical history, physical findings, and vital signs were not documented on the physical exam dated 5/14/24.
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Plan of Correction
On 8/7/24, the facility director and the medical assistant met with an external training agency to review and update the Medication Control Plan. The nursing supervisor will conduct staff training on 9/5/2024 to review the nursing staff's responsibility to request a consultation from the physician or the physician's assistant for any new patients who are admitted to Clear Day. The physician and physician's assistant will ensure that a complete history and physical examination is completed within 48 hours of a client's admission to 3.5 LOC. All findings will be documented in the client's chart as per policy and procedure. The Director of Nursing and the Facility Director will audit the charts weekly to ensure compliance. |