INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on January 2, 2025, by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, Clem-Mar House Inc 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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709.28 (c) LICENSURE Confidentiality
§ 709.28. Confidentiality.
(c) The project shall obtain an informed and voluntary consent from the client for the disclosure of information contained in the client record.
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Observations
Based on a review of client records, the facility failed to obtain a consent to release information form prior to releasing information in one out of seven records reviewed. There was no consent to release information form for the emergency contact listed on AMA letter.
Client #4 was admitted on March 15, 2024 and discharged AMA on April 25, 2024. There was a note in the client record that an individual was contacted by the facility to make them aware the client had left. The facility had a letter stating the individual could be contacted if there was an AMA discharge, however there was no signed release of information form in the client record. The letter did not contain all of the requirements for release of information form.
These findings were reviewed with the facility staff during the licensing process.
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Plan of Correction
Upon inspection, the AMA form stated "EMERGENCY CONTACT INFORMATION
The following contact information is strictly intended for the safety and concern of the client and would only be used in the event of a hindrance of the clients physical or mental health as well as in compliance with Act 41 of 2021. Act 41 requires that inpatient drug and alcohol treatment facilities must immediately notify an emergency contact if a patient leaves the facility against medical advice, provided the patient has not revoked consent to notify the emergency contact on file.
Notification shall occur immediately and in no event later than 12 hours of a patient leaving against medical advice.
Name:
________________________________________Relationship to Client: ______________
Address: _____________________________________________________________________________
Phone #: _____________________________________________________________________________
*I acknowledge that when I leave the facility AMA, my Emergency Contact stated on my release will be notified of my departure from the facility. Information provided will only be within the scope of the release.
Clients Address: _____________________________________________________________________________
Clients Phone #: ________________________________________
A staff meeting was held on 01/02/2025 to review this finding. The AMA form was amended on this date, removing the section "name and phone number" that was intended for information gathering. It remains, as stated on the AMA document, that clients acknowledge "that when I leave the facility AMA, my Emergency Contact stated on my release will be notified of my departure from the facility. Information provided will only be within the scope of the release." Confidentiality and Act 41 was reviewed on 01/02/2025 as well as the new AMA form. The Project Director will ensure that the proper documentation is used and that only the emergency contacted as stated on the resident's release is contacted in compliance with Act 41.
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709.28 (c) (4) LICENSURE Confidentiality
§ 709.28. Confidentiality.
(c) The project shall obtain an informed and voluntary consent from the client for the disclosure of information contained in the client record. The consent must be in writing and include, but not be limited to:
(4) Dated signature of client or guardian as provided for under 42 CFR 2.14(a) and (b) and 2.15 (relating to minor patients; and incompetent and deceased patients).
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Observations
Based on a review of client records, the facility failed to obtain an informed and voluntary consent from the client for the disclosure of information contained in the client record that included the dated signature of the client in one out of seven records reviewed.
Client #4 was admitted on March 15, 2024 and discharged on April 25, 2024. An informed and voluntary consent for a treatment provider was in the client record that only had a written note " verbal consent. " There was no dated signature of the client on the form.
This finding was reviewed with the facility staff during the licensing process.
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Plan of Correction
A staff meeting was held on 01/02/2025, reviewing the findings of the inspection held on the same day. 42 CRF and confidentiality was reviewed during this meeting. All staff will be required to complete the DDAP training "Substance Use Disorder Confidentiality - On Demand" by 03/01/2025 as a refresher on confidentiality laws and regulations. The Clinical Team Lead and Project Director will continue monthly QA of active charts to ensure compliance with 709.28. |
709.32 (c) (6) LICENSURE Medication control
§ 709.32. Medication control.
(6) Medication errors and drug reactions shall be recorded in the client record. This may be the medical record if a separate medical record is maintained for all clients.
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Observations
Based on a review of medication administration records provided by the facility, the facility failed to document medication errors in the client record in four out of seven records reviewed.
Client #1 was admitted on July 10, 2024, and was still active at the time of the inspection. Client #1 was prescribed Topiramate 25mg one tablet two times daily on July 12, 2024. There was no documentation of the medication being administered two times a day or the reason not administered on July 14, 2024, and October 1-31, 2024. There was a prescription for Buprenorphine/Naloxone 2mg/0.5 1 capsule two times daily on July 12, 2024. There was no documentation of the medication being administered two times a day or the reason not administered on July 14-18, 2024. There was a prescription for a Nicotine patch 21mg to wear daily on July 12, 2024. There was no documentation of the medication being administered or the reason not administered on August 4-31, 2024. There was a prescription for Quetiapine 150 mg one tab at bedtime on July 12, 2024, and there was no documentation of the medication being administered or the reason not administered on September 17, 2024.
Client #2 was admitted on August 30, 2024, and was still active at the time of the inspection. Client #2 was prescribed Amlodipine 10 mg 1 tab in the AM on September 1, 2024. There was no documentation of the medication being administered or the reason not administered on September 2-3, 5, 8, 10-14,17-18, 21, 28-29, 2024. There was a prescription for Quetiapine 150 mg at bedtime on September 1, 2024. There was no documentation of the medication being administered or the reason not administered on September 9, 14-15, 21-22, 24-26, 28, 29 2024 and October 19 and 21, 2024. There was a prescription for Propanol 20 mg 1 tab three times daily on September 1, 2024. There was no documentation of the medication being administered three times daily or the reason not administered on September 1-30, 2024, October 1-8, 10, 12-16, 19-31, 2024.
Client #4 was admitted on March 15, 2024 and discharged on April 25, 2024. Client #4 was prescribed NAC 1 cap at 12:30 p.m. and 9:30 p.m. on March 15, 2024. There is no documentation of the medication being administered at the required times or the reason not administered on March 16-18, 20, 22-25, 30-31 2024, and April 1-30, 2024. There was a prescription for a Nicotine patch 21 mg to wear daily on March 15, 2024. There was no documentation of the medication being administered or the reason not administered on March 16, 18, 20-31, 2024.
Client #5 was admitted on April 1, 2024, and discharged on July 29, 2024. Client #5 was prescribed Bupropion 300 mg 1 tab in the A.M. on April 1, 2024. There is no documentation of the medication being administered or the reason not administered on April 23-28, 2024, and May 1-31. There was a prescription for Clobetasol 15mg two times a day. There was no documentation of the medication being administered or the reason not administered on June 1-30, 2024, and July 2-28, 2024. There was a prescription for Acitretin 25 mg 1 in the A.M.. There was no documentation of the of the medication being administered or the reason not administered on June 7-8, 14-15, 2024. There was a prescription for Buprenorphine/Naloxone 8-2mg 1 per day. There is no documentation of the medication being administered or the reason not administered June 3, 7-10, 12-13, 2024. There was an additional prescription for Bupropion 300 mg 1 tab in the A.M.. There is no documentation of the medication being administered or the reason not administered on July 23-29, 2024.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
A staff meeting was held on 01/02/2025 to review the findings of our DDAP inspection held on the same date. During this meeting, our policy on medication relating to 709.32 was reviewed. The policy states the following procedure for monitoring the client's self-administration of approved medication will be adhered to by Clem-Mar House staff:
1. At their designated times, each client will report to the medication room. Residents are handed their medication, one at a time, and instructed how many pills to take. Staff verifies that the appropriate amount was administered by the client before consumption. The client then replaces the cap on the bottle and returns bottle or bubble pack to the staff member who puts it in the medicine cabinet. The Medication log is then initial by staff and resident. This procedure is done for each medication at each designated time.
2. One staff member on duty, per shift, is authorized to remove medication from the medication cabinet.
3. Medication Logs are to be completed each medication pass and may not contain blank spaces. When a resident leaves, the log is dated with their date of discharge and blank spaces are crossed out, with staff initials.
As stated in the aforementioned policy, all medication adherence is documented at each med pass. If a client misses or refuses to take their medication, it will be documented in their chart additionally with a case consult completed by their primary counselor effective immediately.
The Project Director and Head Resident Manager will complete weekly inspections of the medication logs to ensure compliance.
The Project Director and Clinical Team Lead will complete monthly QA of charts to ensure compliance with documentation.
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709.34 (c) (4) 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:
(4) Event at the facility requiring the presence of police, fire or ambulance personnel.
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Observations
Based on a review of administrative documents, the facility failed to inform the Department of an unusual incident within the required three business days following an unusual incident.
It was discovered that the facility had an unusual incident occur on September 30, 2024, which required the presence of fire personnel. The facility did not report the incident to the Department within the regulatory three business day timeframe.
This finding was reviewed with project and facility staff during the licensing process.
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Plan of Correction
During a staff meeting held on 01/02/2025, the facilities policy was reviewed. The policy states that 709.34 Reporting of Unusual Incidents
All Unusual Incidents must be reported, documented, investigated, and a corrective action plan to prevent similar incidents must be included in the written report. Reports must be filed on the correct incident report form and submitted to staff member in charge and the Clinical Director within 24 hours of any/all reportable incidents. Some incidents are reportable to the Department of Health.
In-services on incident to be reported, proper completion of Incident Report Forms, and proper procedure for notifying DDAP will be held bi-annually, or more frequently if required. The Clinical Director will be responsible for coordinating and providing in-services to all staff and to assuring this policy is strictly adhered to.
Specific Incidents to be Reported to The Department of Drug and Alcohol Programs:
1. Physical Assault or Sexual assault by staff or resident.
2. Selling or use of illicit drugs on the premise
3. Significant disruption of services results in closure of the facility for more than one scheduled day of operation.
4. An incident requiring the services of a fire department or law enforcement agency.
5. Outbreak of a contagious disease or food poisoning among residents the requires CDC notification.
Procedure to be Followed in Filing an Unusual Incident Report
The facility should notify The Department of Drug and Alcohol Programs within 24 hours via Event Reporting System (ERS.) at PA Department of Health Step by step instructions can be found at Event Reporting System Provider Manual.
Following the Project Director's investigation and recommendations, a copy of the incident report must be filed in the Incident Report Log which is kept in the Project Director's office.
A facility incident report is also completed for the above events. This is then reviewed by the Facility Director and a corrective action plan in developed if needed. This is then monitored for continued to corrective action. The facility should notify others, including all appropriate officials, of an unusual incident, maintaining client confidentiality.
When an unusual incident affects the physical or emotional well-being of a client, staff should ensure that the client is safe from further injury, receives medical and clinical attention as soon as possible, is sensitive to the emotional needs of the client, and arranges for specialized counseling, if appropriate.
Upon the presence of emergency personnel, the Clinical Team Lead and Project Director are contacted immediately and will ensure the completion of an electronically submitted unusual incident repot. |