INITIAL COMMENTS
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This report is a result of a supervisory review of the written report of the findings of an on-site licensure inspection that was conducted on November 8 and 9, 2012, by staff from the Division of Drug and Alcohol Program Licensure. Based on the supervisory review of findings from 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 supervisory review:
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Plan of Correction
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704.6(e) LICENSURE Supervisory Meetings
704.6. Qualifications for the position of clinical supervisor.
(e) Clinical supervisors are required to participate in documented monthly meetings with their supervisors to discuss their duties and performance for the first 6 months of employment in that position. Frequency of meetings thereafter shall be based upon the clinical supervisor's skill level.
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Observations
Based on a review of personnel records, the facility failed to document that the clinical supervisor participated in monthly meetings with their supervisor to discuss their duties and performance for the first six months of employment in that position in one of one personnel record.
The findings include:
Twelve personnel records were reviewed on November 8, 2012. One personnel record reviewed was that of the clinical supervisor. This personnel record required the documentation of monthly meetings between the clinical supervisor and their supervisor for the first six months of employment in that position. The facility failed to document monthly supervision meetings in personnel record # 3.
Employee # 3 was hired on June 6, 2011, and was promoted to the position of clinical supervisor on April 11, 2012. Monthly supervision meetings were required to take place from April through October 2012. There was no documentation of monthly supervision meetings in the personnel record of employee # 3.
The findings were reviewed with the facility director and it was confirmed that there was no documentation of monthly supervision meetings.
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Plan of Correction
The facility failed to comply with regulation 704.6(e) requiring clinical supervisors to participate in documented monthly meetings with their supervisors to discuss their duties and performance for the first 6 months of employment in that position. It is the sole responsibility of the facility director to meet with the clinical supervisor a minimum of one time per month and document the discussion, work performance, and areas of focus/improvement. The facility director will begin this practice on January 1, 2013 and continue monthly or as needed for a minimum of six months. |
704.11(c)(1) LICENSURE Mandatory Communicable Disease Training
704.11. Staff development program.
(c) General training requirements.
(1) Staff persons and volunteers shall receive a minimum of 6 hours of HIV/AIDS and at least 4 hours of tuberculosis, sexually transmitted diseases and other health related topics training using a Department approved curriculum. Counselors and counselor assistants shall complete the training within the first year of employment. All other staff shall complete the training within the first 2 years of employment.
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Observations
Based on a review of personnel and training records, the facility failed to provide documentation of TB/STD and HIV/AIDS training in one of one record reviewed.
The findings include:
Twelve personnel records were reviewed on November 8, 2012. One record was required to document four hours of TB/STD training and six hours of HIV/AIDS training within the first year of employment, #11.
Employee #11 was hired on May 28, 2010. This employee was required to obtain four hours of TB/STD training and six hours of HIV/AIDS training with Department approved curriculum by May 28, 2011. The Employee failed to obtain the training as of the date of the inspection.
The findings were reviewed with the facility director, clinical supervisor, quality improvement staff member, and project director. The findings were confirmed.
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Plan of Correction
The facility failed to comply with regulation 704.11( c) (1) mandating that all staff receive a minimum of 6 hours of HIV/AIDS training and at least 4 hours of tuberculosis, sexually transmitted diseases and other health related topics using a Department approved curriculum. It is the responsibility of the clinical supervisor to ensure that all clinical staff has attended approved training sessions as mandated and the responsibility of the facility director to ensure that all staff attend and receive mandated training. January 2012 Miners Medical will be implementing a training tracking form that will be completed monthly by the clinical supervisor and reviewed monthly by the facility director to ensure that all staff are in compliance with mandatory training sessions. A copy of all certificates will be placed in the employees training binder. |
709.30(4) LICENSURE Client Rights
709.30. Client rights.
(4) The client has the right to appeal a decision limiting access to his records to the project director.
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Observations
Based on the review of patient records, the facility policy and procedure manual, and the patient handbook, the facility failed to ensure that patients were informed of their right to appeal a decision limiting access to their records to the project director.
The findings included:
Nine patient records were reviewed on November 8 and 9, 2012. Seven patient records were reviewed for documentation of "client rights." The facility failed to document that the patients were informed of their right to appeal a decision limiting access to their records to the project director in seven of seven records reviewed, # 1, 2, 3, 4, 5, 6 and 7.
The facility gives the patient a handbook as part of the orientation process. The patient also signs a form entitled "Program Guidelines" that includes the patient rights. The patient rights provided to the patient via the handbook and the form did not include the patient's right to appeal a decision limiting access to their records to the project director.
The findings were reviewed with the facility director, quality improvement staff member and project director and were confirmed.
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Plan of Correction
The facility failed to comply with regulation 709.30 which informs the client that they have the right to appeal a decision limiting access to his records to the project director. The Regional Director and Director of Corporate Compliance and Policy and Procedure will modify the patient handbook to include informing the patient of their right to appeal a decision limiting access to their records to the project director. The Facility Director will ensure that all patients are provided with a new patient handbook by January 2013. |
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.
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Observations
Based on direct observation of the medication area, the facility failed to dispense in a manner that protects the patient from disruption or annoyance from other individuals.
The findings include:
During direct observation of the medication area on November 9, 2012, at about 8 a.m., a patient was receiving medication at the dispensing window. Another patient waiting in line in the waiting area was observed to speak to the patient at the dispensing window. The dispensing nurse did not redirect the patients and continued in the process of dispensing medication to the patient at the window.
The findings were reviewed with the Facility Director. Facility staff are required to provide dosing services to a patient in a setting that is without annoyance or disturbance.
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Plan of Correction
The facility failed to comply with regulation 715.17( c) (i-vi) which states the facility will be administering and dispensing shall be conducted in a manner that protects the patient from disruption or annoyance from other individuals. On December 10th Nursing staff, the administrative assistant, and facility director began reminding patients to have a seat in the chairs provided until they are called to the window to dose. Patients are reminded not to speak to the patient and/or dispensing nurse while they are receiving and/or methadone is being dispensed. On January 2, 2013 a handout will be provided to all patients reminding them of this procedure and the importance of maintaining adherence at all times. |
715.17(c)(2) 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:
(2) Drug storage areas. A narcotic treatment program shall develop and implement written policies and procedures regarding storage of medications and access to the medication storage area. Agents shall be stored in a locked safe that has been approved by the DEA under 21 CFR 1301.72 and 1301.74 (relating to physical security controls; and other security controls).
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Observations
Based on direct observation of the medication area, the facility failed to follow procedures regarding storage of medication and access to the medication storage area.
The findings include:
The facility procedures for the medication dosing and storage areas limit access via a door with key lock and an alarmed safe. During direct observation of the medication area on November 9, 2012, at approximately 8 a.m., the dispensing nurse left medication dosing area and immediately returned. The nurse resumed patient dosing. When the licensing specialist left the dosing area it was observed that the door to the dosing area was unlocked, potentially allowing access to unauthorized individuals. Additionally, the safe was also observed to be unlocked.
The dispensing nurse was located at the dispensing window providing services to a medicating patient at the time of the exit of the observer from the medication storage area.
The findings were reviewed with the Facility Director during the facility tour and the director confirmed the need for review for dispensing area security.
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Plan of Correction
The facility failed to comply with regulation 715.17 by the dosing area door being left unlocked and the safe being left unlocked. It is the responsibility of the dispensing nurse and nursing supervisor to ensure that the dispensing door and safe be kept closed and locked at all times as per the Department regulations and the clinic policy and procedure. The facility director will meet with the nursing supervisor and dispensing nurses to reiterate this policy and procedure on December 31, 2012 and monitor regularly to ensure that the dispensing door and safe is kept locked at all times. |
709.91(b)(3)(i) LICENSURE Intake and admission
709.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(3) Histories, which include the following:
(i) Medical history.
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Observations
Based on the review of patient records, the facility failed to document a medical history in four of seven patient records.
The findings include:
Nine patient records were reviewed on November 8 and 9, 2012. Seven patient records were reviewed for documentation of a medical history. The facility failed to document a medical history in four of seven records reviewed, # 2, 3, 6 and 7.
Patient # 2 was admitted on 2/22/2012. A medical history was not documented at the time of the review.
Patient # 3 was admitted on 7/23/2012. A medical history was not documented at the time of the review.
Patient # 6 was admitted on 10/2/2012. A medical history was not documented at the time of the review.
Patient # 7 was admitted on 7/24/2012. A medical history was not documented at the time of the review.
The findings were reviewed with the dispensing nurse, facility director, clinical supervisor, quality improvement staff member, and project director. The findings were confirmed.
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Plan of Correction
The facility failed to comply with regulation 709.91(b)(3)(i) documenting the medical history of all patients admitted to Miners Medical. On December 28, 2012 the facility director will implement the Medical History Form via instructing the Physician on the new form and the procedure of completing one on each individual admitted to Miners Medical. The facility director and nursing supervisor will monitor regularly to ensure that the Medical History Form is being completed and placed in the patient's medical chart. |
709.91(b)(6) LICENSURE Intake and admission
709.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(6) Psychosocial evaluation.
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Observations
Based on the review of patient records, the facility failed to document a comprehensive psychosocial evaluations in five of seven patient records.
The findings include:
Nine patient records were reviewed on November 8 and 9, 2012. Seven patient records were reviewed for documentation of a comprehensive psychosocial evaluation. The facility failed to document a comprehensive psychosocial evaluation in five of seven records reviewed, # 3, 4, 5, 6 and 7.
Patient # 3 was admitted on 7/23/2012. The documented psychosocial evaluation failed to include a clinical assessment of the client's problems/needs, assets/strengths, support systems, coping mechanisms, negative factors affecting treatment, attitude toward treatment and the counselor's conclusions/impressions.
Patient # 4 was admitted on 6/28/2012. The documented psychosocial evaluation failed to include a clinical assessment of the client's problems/needs, assets/strengths, support systems, coping mechanisms, negative factors affecting treatment, attitude toward treatment and the counselor's conclusions/impressions.
Patient # 5 was admitted on 3/29/2012. The documented psychosocial evaluation failed to include a clinical assessment of the client's problems/needs, assets/strengths, coping mechanisms and negative factors affecting treatment.
Patient # 6 was admitted on 10/2/2012. The documented psychosocial evaluation failed to include a clinical assessment of the client's problems/needs, assets/strengths, support systems, coping mechanisms, negative factors affecting treatment, attitude toward treatment and the counselor's conclusions/impressions.
Patient # 7 was admitted on 7/24/2012. The documented psychosocial evaluation failed to include a clinical assessment of the client's problems/needs, assets/strengths, support systems, coping mechanisms, negative factors affecting treatment, attitude toward treatment and the counselor's conclusions/impressions.
The findings were reviewed with the facility director, clinical supervisor, quality improvement staff member, and project director. The findings were confirmed.
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Plan of Correction
The facility failed to comply with regulation 709.91 (b)(6) providing documentation of a Psychosocial Evaluation. On January 4, 2013 the facility director and clinical supervisor will train the staff on completing the Psychosocial Evaluation which has been added to the Bio-Psycho-Social Evaluation. The clinical supervisor and facility director will conduct ongoing chart reviews to ensure that the evaluation is being completed. |
709.93(a)(10) LICENSURE Client records
709.93. 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:
(10) Discharge summary.
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Observations
Based on a review of patient records, the facility failed to document a complete discharge summary that included the patient's reason for treatment, services offered and client's status upon discharge in two of two patient records.
The findings include:
Nine patient records were reviewed on November 8 and 9, 2012. Two records were reviewed for discharge summaries. Both records did not have documented discharge summaries that included all required components, # 8 and 9.
Patient # 8 was admitted on 1/24/2011 and discharged on 10/24/2012. The discharge summary failed to document the patient's reasons for treatment, services offered and the patient's status upon discharge.
Patient # 9 was admitted on 8/24/2011 and discharged on 10/23/2012. The discharge summary failed to document the patient's reasons for treatment, services offered and the patient's status upon discharge.
The findings were reviewed with the facility director, clinical supervisor, quality improvement staff member, and project director. The findings were confirmed.
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Plan of Correction
The facility failed to comply with regulation 709.93 regarding the discharge summary providing the following information: patient's reason for treatment, services offered and client's status upon discharge. On January 4, 2013, the clinical supervisor and the facility director will provide a staff training session in the area of writing a comprehensive discharge summary that includes, but is not limited to, all Department and Facility required information. Ongoing monitoring and supervision will be provided by the clinical supervisor and the facility director. |