INITIAL COMMENTS
|
This report is a result of an on-site licensure renewal inspection conducted on January 19-20, 2021 by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, Pennsylvania Care Llc, dba Miners Medical 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:
|
Plan of Correction
|
704.6(c) LICENSURE Core Curriculum - Supervisor Training
704.6. Qualifications for the position of clinical supervisor.
(c) Clinical supervisors and lead counselors who have not functioned for 2 years as supervisors in the provision of clinical services shall complete a core curriculum in clinical supervision. Training not provided by the Department shall receive prior approval from the Department.
|
Observations
Based on a review of seventeen personnel records, the facility failed to ensure that clinical supervisors and lead counselors who have not functioned for 2 years as supervisors in the provision of clinical services shall complete a core curriculum in clinical supervision.Employee #3 hired on August 4, 2019 as the clinical supervisor did not function for 2 years as a supervisor in the provision of clinical services and has not completed the core curriculum clinical supervisor training. These findings were discussed with facility staff during the inspection process.
|
Plan of Correction
The facility failed to comply with regulation 704.6 (c) requiring Clinical Supervisors and Lead Counselors to complete a core curriculum in clinical supervision. The Clinical Supervisor and Lead Counselor will monitor the Department of Drug and Alcohol Training Management System in order to schedule and complete training requirements. The Facility Director will monitor completion of training to ensure the program remains compliant. |
709.28 (a) (1) LICENSURE Confidentiality
§ 709.28. Confidentiality.
(a) A written procedure shall be developed by the project director which shall comply with 4 Pa. Code § 255.5 (relating to projects and coordinating bodies: disclosure of client-oriented information). The procedure must include, but not be limited to:
(1) Confidentiality of client identity and records. Procedures must include a description of how the project plans to address security and release of electronic and paper records and identification of the person responsible for maintenance of client records.
|
Observations
Based on an observed medication administration the facility failed to maintain confidentiality of all client identities as clients were observed throwing away take home bottles without blacking out each name and dose into a trash can by each dosing window that could be viewed by the next client or any individual who approach the window.It was also observed that an outside cleaning agency came into the building and emptied the same trash can with take home bottles. These findings were discussed with facility staff during the inspection process.
|
Plan of Correction
The facility failed to comply with 709.28(a) (1) relating to Confidentiality to maintain security of client identity. The medical team will enforce the blacking out of any identifying information from take home bottles to ensure that the client's confidentiality is being protected. The Medical Director and Facility Director will monitor medical team to ensure duties assigned are conducted properly. |
709.28 (c) (1) 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:
(1) Name of the person, agency or organization to whom disclosure is made.
|
Observations
Based on a review of eight client records, the facility failed to ensure that all consent to release forms contained the name of the person, agency or organization to whom the disclosure is made. Client #2 was admitted on September 30, 2020 and was still active at the time of inspection. A consent to release form was signed and dated on January 13, 2021 that failed to include the name of the person, agency or organization in which the release was form. These findings were discussed with facility staff during the inspection process.
|
Plan of Correction
The facility failed to comply with 709.28(c) (1) related to Confidentiality to maintain proper documentation completion. Based on these findings, the staff will be retrained on the proper way to complete releases and how these releases are used to protect the client's confidentiality. These trainings have begun and conducted on a weekly basis during group staff supervision. We will continue to have these trainings over the next three months and lead counselor along with the clinical supervisors will review the charts to assure the releases are improving and will continue to be completed properly in the future. |
709.28 (c) (2) 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:
(2) Specific information disclosed.
|
Observations
Based on the review of eight client records, the facility failed to include specific information disclosed in one client record. Additionally, one client record had consent to release forms that allowed for the release of information outside of 255.5. Client #4 was admitted on January 17, 2017 and discharged on November 5, 2020. A consent to release form to an outside provider signed and dated on October 29, 2020 failed to include specific information to be released. Client #5 was admitted on November 19, 2018 and still active at the time of inspection. A consent to release form to a government agency was signed and dated on April 19, 2019 that is valid until discharge allowing for the release of admission summary, dose history/current dose, labs and discharge summary. These findings were discussed with facility staff during the inspection process.
|
Plan of Correction
The facility failed to comply with 709.28(c) (3) related to Confidentiality to maintain proper documentation completion. Failed to include specific information and information outside 255.5. Based on these findings, the staff will be retrained on the proper way to complete releases and how these releases are used to protect the client's confidentiality. These trainings have begun and conducted on a weekly basis during group staff supervision. We will continue to have these trainings over the next three months and lead counselor along with the clinical supervisors will review the charts to assure the releases are improving and will continue to be completed properly in the future. |
709.28 (c) (3) 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:
(3) Purpose of disclosure.
|
Observations
Based on a review of eight client records, the facility failed to ensure that all client records contained the purpose of disclosure. Client #4 was admitted on January 17, 2017 and discharged on November 5, 2020. A consent to release form to an outside provider signed and dated on October 29, 2020 failed to contain the purpose of disclosure. These findings were discussed with facility staff during the inspection process.
|
Plan of Correction
The facility failed to comply with 709.28(c) (3) related to Confidentiality to maintain proper documentation completion. Failed to include purpose of disclosure. Based on these findings, the staff will be retrained on the proper way to complete releases and how these releases are used to protect the client's confidentiality. These trainings have begun and conducted on a weekly basis during group staff supervision. We will continue to have these trainings over the next three months and lead counselor along with the clinical supervisors will review the charts to assure the releases are improving and will continue to be completed properly in the future. |
709.28 (c) (6) 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:
(6) Date, event or condition upon which the consent will expire.
|
Observations
Based on a review of eight client records, the facility failed to ensure that consent to release forms contained the date, event or condition upon which the consent will expire in one client record. Client #4 was admitted on January 17, 2017 and discharged on November 5, 2020. A consent to release form to an outside provider signed and dated on October 29, 2020 failed to include the date, event or condition upon which the consent will expireThese findings were discussed with facility staff during the inspection process.
|
Plan of Correction
The facility failed to comply with 709.28(c) (6) related to Confidentiality to maintain proper documentation completion. Failed to include date, event or condition upon which consent will expire. Based on these findings, the staff will be retrained on the proper way to complete releases and how these releases are used to protect the client's confidentiality. These trainings have begun and conducted on a weekly basis during group staff supervision. We will continue to have these trainings over the next three months and lead counselor along with the clinical supervisors will review the charts to assure the releases are improving and will continue to be completed properly in the future. |
709.31 (a) LICENSURE Data collection system
§ 709.31. Data collection system.
(a) A data collection and recordkeeping system shall be developed that allows for the efficient retrieval of data needed to measure the project ' s performance in relationship to its stated goals and objectives.
|
Observations
Based on an inspection conducted on January 19-20th, the facility failed to allow for the efficient retrieval of data needed to measure the project ' s performance in relationship to its stated goals and objectives. The facility would not allow access to view records on the EMR but instead printed out each record which resulted in data missing from each printed record.These findings were reviewed with the facility during the licensing inspection.
|
Plan of Correction
The facility failed to comply with 709.31(a) Data Collection System for inspector to access electronic medical records. The facility will implement inspector access to electronic medical records to review during licensing inspection. |
715.17(c)(1)(i-vi)) LICENSURE Medication control
(c) A narcotic treatment program shall develop and implement written policies and procedures regarding the medications used by patients which shall include, at a minimum:
(1) Administration of medication.
(i) A narcotic treatment physician shall determine the patient 's initial and subsequent dose and schedule. The physician shall communicate the initial and subsequent dose and schedule to the person responsible for the administration of medication. Each medication order and dosage change shall be written and signed by the narcotic treatment physician.
(ii) An agent shall be administered or dispensed only by a practitioner licensed under the appropriate Federal and State laws to dispense agents to patients.
(iii) Only authorized staff and patients who are receiving medication shall be permitted in the dispensing area.
(iv) There shall be only one patient permitted at a dispensing station at any given time.
(v) Each patient shall be observed when ingesting the agent.
(vi) Administering and dispensing shall be conducted in a manner that protects the patient from disruption or annoyance from other individuals.
|
Observations
Based on an observation of medication administration during the physical plant inspection, the facility failed to ensure six patients ingested the agent following administration. The findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
The facility failed to comply with 715.17(c) (1) (i-vi) Medication Control to ensure ingestion of administered medication. The Medical Director and Facility Director will provide additional education to medical team on proper dosing procedures to ensure ingestion are monitored. The Medical Director and Facility Director will monitor medical team to ensure duties assigned are conducted properly. |
709.92(b) LICENSURE Treatment and rehabilitation services
709.92. Treatment and rehabilitation services.
(b) Treatment and rehabilitation plans shall be reviewed and updated at least every 60 days.
|
Observations
Based on a review of client records, the facility failed to ensure that treatment plan updated were completed every 60 days for client record # 6, 7, and 8.Client #6 was admitted on May 16, 2011 and was still active at the time of the inspection. A treatment plan updated was completed July 22, 2020 and the next updated was due by September 22, 2020; however, was not completed until January 13, 2021. Client #7 was admitted on June 11, 2019 and was discharged on July 13, 2020. A treatment plan update was completed on February 13, 2020 and an update was to be completed no later than April 13, 2020; however, there was no update completed until June 15, 2020. Client #8 was admitted on October 22, 2018 and was discharged on December 24, 2020. A treatment plan update was completed on July 30, 2020 and an update was to be completed no later than September 30, 2020; however, no update was completed until October 9, 2020.These findings were discussed with facility staff during the inspection process.
|
Plan of Correction
The facility failed to comply with 709.92(b) Treatment and Rehabilitation Services to complete treatment plan at the specific due date. Based on these findings each counselor has found a way to track when their services are due. Each counselor has a spreadsheet with their caseload, this spreadsheet includes formulas to calculate the upcoming due dates of treatment plans as well as case consults and ASAMS. During each counselors individual supervision this spreadsheet is reviewed to assure all services are completed. This has begun as of February 1, 2021 and will continue on an ongoing basis. The Clinical Supervisors will assure the services are complete going forward during supervision. |