bar
Pennsylvania Department of Health
Inspection Results

bar

Surveys don't appear on this website until at least 41 days have elapsed since the exit date of the survey.

LIBERATION WAY, LLC
1035 VIRGINIA DRIVE
Suite 120 & Suite 130
FORT WASHINGTON, PA 19034

Inspection Results   Overview    Definitions       Surveys   Additional Services   Search

Survey conducted on 12/13/2017

INITIAL COMMENTS
 
This report is a result of an on-site complaint investigation conducted on November 16, 2017 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site complaint investigation, Liberation Way, LLC was found not to be in compliance with the applicable chapters of 28 PA Code which pertain to the facility.
 
Plan of Correction

705.23 (3)  LICENSURE Counseling or activity areas and office space

705.23. Counseling or activity areas and office space. The nonresidential facility shall: (3) Ensure privacy so that counseling sessions cannot be seen or heard outside the counseling room. Counseling room walls shall extend from the floor to the ceiling.
Observations
DDAP observed a client receiving their medication and medication counseling with the door open to the nurse's office. There was a line outside of the office for individuals waiting to be seen and all could hear the conversations between the client and nurses.Additionally, in suite 130 group sessions could be seen and heard. One group session took place in a large area with no doors, staff and clients could be seen walking in and out during that group session. finally, DDAP staff were in an office that was beside another group room and that group session could also be heard.
 
Plan of Correction
Plan of Correction:

Nursing staff have been provided verbal and written instructions by their direct supervisor that only one client at a time is allowed in the medication room. The Medication Control Policy (709.32) has been amended to reflect this directive. The door to the nurses' office is to remain closed at all times and a hydraulic hinge has been installed (on Friday, March 16, 2018) to ensure automatic closing. The Nursing Supervisor/Compliance Officer is performing spot audits several times weekly to ensure compliance with this directive. Supervisor will maintain ongoing audit log.



All Groups are now held in private, closed group rooms. Compliance is monitored by random spot checks by Clinical Director/Project Director.

Sound machines have been purchased for all offices as of 3/1/2018. Clinical Director/Program Director will perform spot checks to ensure all staff utilize this protocol. Supervisor will maintain ongoing audit log. Completion Date:

03/23/2018

Status:

Submitted

Date:


709.22 (b) (3)  LICENSURE Governing Body

709.22. Governing body. (b) The duties of the governing body include, but are not limited to, the following: (3) Documenting the project ' s organizational structure.
Observations
During an interview with employees #2 and #4, both were unable to identify who was the Facility Director. The Licensing Specialist Supervisor informed them of who was listed as the Facility Director. Additionally, Employees #3 and #4 were unaware of their official titles; which is evidence that there is no clear documentation of project's organizational structure as it relates to this facility.
 
Plan of Correction
Human Resources and the Communications Department have updated the Organizational Flow Chart to reflect the titles used by the Commonwealth.



New identification badges were made and distributed by April 2,2018 depicting correct titles.



Clinical Director? Project Director at all sites.



Clinical Director ? Facility Director at Bala Cynwyd site.



Nursing Supervisor/Compliance Officer- Fort Washington ?Facility Director at Fort Washington site.



Clinical Supervisor Yardley ? Facility Director at Yardley site.





This information will be updated in internal Policy and Procedure Manual.



All current staff will be given a copy the Organizational Flowchart. The Flowchart will be posted in staff areas at each site. The facility will forward documentation verifying the qualifications for the individuals assigned to these positions by 4/30/2018.


709.24 (a) (1)  MEMO 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: (1) Definition of the target population toward whom facility services are directed.
Observations
Employees #2 and #4 were unable to verbally explain or provide a written plan for the facility ' s standard procedure(s) for referring clients between the project's three facilities.
 
Plan of Correction
Policy 709.21, Program Services/Continuum of Care, addresses treatment and rehabilitation management. Staff has been made aware of where to locate the Policy and Procedure manual verbally and by email.



By 4/9/2018, a training for all staff will be developed by the Clinical Director/Project Director, called Standard Procedures for Admission, Transfer, and Discharge. This training will include but not limited to:

Organizational Structure

ASAM Criteria and Treatment Planning

Discharge Criteria

Level of Care Criteria

Admissions

Transfers

Discharges

As soon as possible but no later than 4/13/2018, the Clinical Director/Project Director will facilitate this training with all current staff at each treatment site. There will be a sign in with staff's name, credentials and original signature that they received this training.

This Training will be mandated for all New Hires as well as part of Annual Review process for all staff.

s

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.
Observations
Employee #4 was unable to verbally explain or produce written documents regarding the facility's adoption of a written plan for the management of treatment/rehabilitation services for clients. The facilities referral and discharge processes were unclear. Activities described by the clinical supervisor regarding referrals were in reality transfers between the project's three facilities. DDAP staff interviewed clients and it appeared that some of the clients thought the "detox" house (unregulated by DDAP) was a part of their treatment at the facility. They explained a direct correlation between what house they lived in, weekly food allowance, and the facility's program. It was viewed as one program. When DDAP staff asked employee #1 about the housing the clients referred to, they stated the housing has no connection to the facility or it's services.
 
Plan of Correction
Policy 709.21, Program Services/Continuum of Care, addresses treatment and rehabilitation management. Staff has been made aware of where to locate the Policy and Procedure manual verbally and by email.



By 4/9/2018, a training for all staff will be developed by the Clinical Director/Project Director, called Standard Procedures for Admission, Transfer, and Discharge. This training will include but not limited to:

Organizational Structure

ASAM Criteria and Treatment Planning

Discharge Criteria

Level of Care Criteria

Admissions

Transfers

Discharges

As soon as possible but no later than 4/13/2018, the Clinical Director/Project Director will facilitate this training with all current staff at each treatment site. There will be a sign in with staff's name, credentials and original signature that they received this training.

This Training will be mandated for all New Hires as well as part of Annual Review process for all staff.

***

An orientation packet will be developed by 4/13/2018 for clients which will include an explanation of the Supportive Housing Program. All staff will be training to facilitate this training, to ensure staff understanding of the Supportive Housing Program. As soon as possible but no later than 4/13/2018, all current clients will receive the orientation. Clients will sign a consent in the medical record that they received and understand the orientation.

Clinical Director/Program Director and Nursing Supervisor/Compliance Officer/Facility Director will perform random interviews with clients every two weeks to ensure understanding of the voluntary Supportive Housing Program. Supervisors will maintain ongoing audit log.


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
Each client chart had a release of information forms that were not in complaince with 255.5. This appeared to be a standard form for the project.
 
Plan of Correction
The facility will comply with 42 CFR Part 2, 4 Pa. Code 255 in its entirety, inclusive of 4 Pa. Code 255.5(b) and 4 Pa. Code 255.7, and 28 Pa. code 709.28. Release of Private Healthcare Information will be updated within the Electronic Medical Record to reflect 4 Pa. Code 255.5 Disclosure of Client-oriented information inclusive of 255.5(b), 255.7 and 28 Pa. Code 709.28 and 42 CFR Part 2. All staff will be trained on the regulations of 42 CFR Part 2, 4 Pa. Code 255, in its entirety, inclusive of 4 Pa. Code 255.5(b) and 4 Pa. Code 255.7, and 28 Pa. Code 709.28 and will sign a sign-off sheet indicating that they received the training by May 9,2018.

Any forms that do not comply with 42 CFR Part 2, 28 Pa. Code 709.28 and 4 Pa. Code 255.5(b) will be voided out and new consent to release information forms that do comply will be obtained from each client and included in their record by May 5,2018.

The statement that the client relieves the facility or anyone else of liability in the release of information form will be removed from the release of information form by April 27,2018.




709.29 (a)  LICENSURE Retention of client records

709.29. Retention of client records. (a) Client records, regardless of format, shall be readily accessible for a minimum of 4 years following the discharge of a client.
Observations
Upon request, employees #2 and #7 were unable to provide discharge dates and summaries for any of the clients who were no longer enrolled in services at the facility. It appeared some clients were never officially discharged from the facility ' s outpatient program but rather transferred to another outpatient program within the project. There were numerous clients that transferred between the project's three facilities on multiple occasions. Discharge information should be available in the client's record for every client that is no longer enrolled at the facility because the facility opened less than a year ago.
 
Plan of Correction
Policy 709.21, Program Services/Continuum of Care, addresses treatment and rehabilitation management. Staff has been made aware of where to locate the Policy and Procedure manual verbally and by email.



By 4/9/2018, a training for all staff will be developed by the Clinical Director/Project Director, called Standard Procedures for Admission, Transfer, and Discharge. This training will include but not limited to:

Organizational Structure

ASAM Criteria and Treatment Planning

Discharge Criteria

Level of Care Criteria

Admissions

Transfers

Discharges

As soon as possible but no later than 4/13/2018, the Clinical Director/Project Director will facilitate this training with all current staff at each treatment site. There will be a sign in with staff's name, credentials and original signature that they received this training.

This Training will be mandated for all New Hires as well as part of Annual Review process for all staff.

***

Since 12/13/2017, all clients are now officially discharged from each program site and readmitted with a new chart to the next site. Relevant documentation is completed in the medical record at the releasing and receiving site to document 1) reason for the site change and 2) updates to the client's consent forms, biopsychosocial profile and mental status.

Counseling staff are trained and expected to complete all discharge summaries within 48 business hours of discharge. The Clinical Supervisors/Facility Directors at each site are expected to meet with counselors on a weekly basis for documented supervision. Clinical Director/Program Director will perform supervisions every two weeks with supervisors to ensure compliance with supervision standards.


709.30 (1)  LICENSURE Client rights

709.30. Client rights. The project shall develop written policies and procedures on client rights and document written acknowledgement by clients that they have been notified of those rights. (1) A client receiving care or treatment under section 7 of the act (71 P. S. 1690.107) shall retain civil rights and liberties except as provided by statute. No client may be deprived of a civil right solely by reason of treatment.
Observations
During an interview with employees #5 and #6 (employees in charge of patient urine collection and paperwork associated with it), DDAP staff learned the technicians and clients were unaware of client rights as it relates urinalyses. This is because some client rights are located with a dialogue box that appears on the technician's computer after the urine collection. When the technicians were questioned about the content in the dialogue box, they were unaware of all the information. DDAP staff informed them it contained information regarding client rights and responsibilities. Additionally, DDAP employees witnessed a client complaining because the nurses were refusing to dose/administer his prescription Suboxone to him. The facility is licensed to provide outpatient and partial hospitalization services and prohibited from taking possession of the clients controlled substances (suboxone) that was prescribed by the client's DATA waived doctor and dispense it back to the clients (21 U.S.C. 825(c)). Clients were unaware the medication belonged to them and they could take possession of their medication at any time. The nursing staff stated they were unaware it was illegal to take the client's Suboxone that was prescribed by a DATA 2000 waived doctor and dispense or administer it to them.
 
Plan of Correction
By 4/13/2018, all staff responsible for collection of urine drug testing received training of the updated consent process (Urine Drug Testing: Consent to Testing and Use of Results). The facility will forward a copy of the document to DDAP.



Clients will date and initial next to their name that they received and understand this consent prior to each urine analysis. This will be kept in a locked safe when not in use to protect PHI. Chemical Dependency Technicians are responsible for compliance and have been trained as of 4/13/2018 to complete and initial the form.



This Training will be mandated for all New Hires as well as part of Annual Review process for relevant staff.

***

As of 12/14/2017 Liberation Way no longer takes control of client's narcotic prescriptions. As of 3/23/2017 all client's personal prescriptions are sent with clients back to their respective residence after reconciliation.



All Nursing staff have been informed that Liberation Way does not hold any client's personal prescriptions as of 3/23/2018.

.




709.31 (b)  LICENSURE Data collection system

709.31. Data collection system. (b) The recordkeeping system must allow for the identification of clients' admissions and discharges within a specific time period.
Observations
Employees #3 and #4 were unable to readily provide discharge dates for clients. It was noted that many of the clients were transferred throughout the project (some multiple times).
 
Plan of Correction
Policy 709.21, Program Services/Continuum of Care, addresses treatment and rehabilitation management. Staff has been made aware of where to locate the Policy and Procedure manual verbally and by email.



By 4/9/2018, a training for all staff will be developed by the Clinical Director/Project Director, called Standard Procedures for Admission, Transfer, and Discharge. This training will include but not limited to:

Organizational Structure

ASAM Criteria and Treatment Planning

Discharge Criteria

Level of Care Criteria

Admissions

Transfers

Discharges

As soon as possible but no later than 4/13/2018, the Clinical Director/Project Director will facilitate this training with all current staff at each treatment site. There will be a sign in with staff's name, credentials and original signature that they received this training.

This Training will be mandated for all New Hires as well as part of Annual Review process for all staff.

***

Since 12/13/2017, all clients are now officially discharged from each program site and readmitted with a new chart to the next site. Relevant documentation is completed in the medical record at the releasing and receiving site to document 1) reason for the site change and 2) updates to the client's consent forms, biopsychosocial profile and mental status.

***

Counseling staff are trained and expected to complete all discharge summaries within 48 business hours of discharge. The clinical supervisors at each site are expected to meet with counselors on a weekly basis for documented supervision. Clinical Director/Program Director will perform supervisions twice a week with supervisors to ensure compliance with supervision standards.


709.32 (c) (1)  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.
Observations
Upon interviews with the facility's medical staff and review of medication documentation there was no evidence the facility has implemented policies and procedures regarding all various stored medications administered to clients. There was no written acknowledgement from clients that they received their medication. There was no tracking logs regarding the administration of medication. The medication inventory was inconsistent and missing signatures where applicable
 
Plan of Correction
As of 3/23/2018 all prescriptions are sent with the clients to their respective residence. Policy 709.32 Medication Control has been updated regarding medication administration and medication reconciliation procedures. No personal patient medication will be stored at any of the clinical sites. As of 3/26/2018, a new comprehensive form has been introduced to address the inventory of controlled substances. The policies and forms with be sent in writing to all current staff then reviewed on an individual basis with the Nursing Supervisor. A signature was obtained from all nurses that the policy and procedure is understood on March 30th, 2018. All new nurses will be trained in these procedures during orientation. Daily narcotic counts will be audited weekly by the Nursing Supervisor. Monthly safe/vault inventory will be performed by the Nursing Supervisor and a nurse on staff.


709.32 (c) (2)  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: (2) Drug storage areas including, but not limited to, the secure storage of controlled substances and other abusable drugs in accordance with State and Federal regulations and program requirements.
Observations
Upon inspection of the nurse's office where medication is stored, there was methadone from the facility's stock and clients prescribed Suboxone housed in a cabinet with other medications. Per federal regulations, methadone is to be stored in a locked safe.
 
Plan of Correction
As of 12/14/2018, we have stopped holding client's narcotic prescriptions. Stock Methadone and Suboxone are housed in the large floor safe.

As of 3/19/2018, a double-locking steel narcotic cabinet/safe was installed in the medication room, intended to house smaller amounts of controlled substances. The DEA approved use of the cabinet during business hours on 4/4/18. The Nursing Supervisor/Compliance Officer/Facility Director is performing spot audits 5 days a week to ensure compliance. In the absence of the Nursing Supervisor, logs will be maintained by the full-time nurse. Nursing staff were educated of the procedure on 4/2/2018 and will be required to sign off by 4/12/2018 Nursing Supervisor will maintain ongoing audit log.


709.32 (c) (3)  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.
Observations
Medical staff were unable to produce documentation that inspections of the medication storage area was conducted in a consistent manner. There were missing signatures on several of the forms. Dates were inconsistent. Additionally, there were no copies of drug-related regulations available in nursing area.
 
Plan of Correction
Inspection of the Medication Storage Areas are now being performed on a quarterly basis by the Advanced Nurse Practitioner. The last was performed in February 25, 2018 and documented on an audit sheet that is currently filed in the medication room.

A copy of the DEA Best Practices manual has been placed in the nurses' office as of 3/24/2018. A laminated list of websites where state and federal regulations can be accessed has been posted in several staff areas.

Policy 709.32 Medication Control was updated and reviewed with all nurses on staff as of March 30th, 2018 and signatures were obtained. All new nursing staff will be trained during orientation.

As of 4/20/2018, a copy of state and federal drug-related regulations have been posted in the medication room, nurses' station.


709.32 (c) (4)  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.
Observations
There was no documentation or clear documented procedures regarding the removal of drugs from the facility's safe or cabinet that contained client's medication. Additionally, there was no record of the client's specific dosing.
 
Plan of Correction
As of 4/13/2018 The policy and procedure regarding the accountability, documentation and administration of narcotics have been updated in Medication Control Policy 709.32 to reflect both DDAP and DEA regulations. All logs for the safe and cabinet have been updated to ensure accountability of all narcotics and all narcotics signed out for administration will reflect client specific dosing. All current nursing staff will be trained in the updated procedures and logs and this training will be documented on a sign in sheet prior to the nurse being permitted to handle controlled substances at the facility. By Friday 3/27/2018 a client specific medication administration record will be created for each client and housed in a binder at the nurses station for the current month. At the end of the month, it will be transferred to the individual client record. New hires will be trained during orientation.

715.1(a)(b)  LICENSURE General Provisions

(a) An entity within this Commonwealth which uses agents for maintenance or detoxification of persons shall obtain the approval of the Department to operate a narcotic treatment program. (b) The Department's approval of a narcotic treatment program shall be contingent upon the narcotic treatment program's compliance with the standards and conditions in this part. In addition, the program shall comply with applicable Federal laws and regulations.
Observations
The facility is only approved for NTP detoxification activities; however, they are conducting maintenance activities via the administration of Suboxone prescribed to clients by their DATA 2000 waived doctor. The facility services clients on an out-patient basis and is taking possession of the clients controlled substances (suboxone) that was prescribed by the client's DATA waived doctor and dispensing it back to the clients (21 U.S.C. 825(c)). DDAP staff witnessed a client complaining that the medical staff would not dose him. DDAP asked the medical staff why they were refusing to dose this client with his prescription medication, and the medical staff member stated it was because the client was late without good-cause. The medical staff did, however, dose the individual with his prescribe Suboxone (this was prior to DDAP speaking with medical staff regarding this issue). When a client has controlled substances that has been dispensed to the him/her, the controlled substances should remain with him/her. Further, the client has no authority to distribute to others the controlled substances that he or she has legally obtained. Such activity constitutes unlawful distribution by the ultimate user and unlawful possession by the person who receives these controlled substances, which are violations of Title 21, United States Code, Sections 841(a)(1) and 844 (21 U.S.C. 841(a)(1) and 844).Additionally, the facility failed to notify local law enforcement and DDAP of an incident that occurred on July 31, 2017. In a review of a letter to the Drug Enforcement Agency (DEA) a nurse took a bottle of methadone (46 10 mg tablets) off site to the client ' s sober living residence to start the client ' s taper. The nurse brought the methadone in a locked box. During dose, the client distracted the nurse and took the bottle of methadone and distribute the methadone to other residents of the sober living facility. All was recorded on the sober livings 24-hour surveillance camera. Finally, the facility failed to obtain a license and CLIA from the PA Department of Health, Bureau of Labs to conduct urine screening/testing. Employee # 2 was aware the facility needed this license and certification and stated they were in the process of applying.
 
Plan of Correction
As of 12/14/2017 - We do not take possession of the client's controlled substances or dispense back to a client his or her controlled substance. As of As of 3/23/2018 we have ceased as directed to administer stock Suboxone to clients for maintenance. No MAT maintenance is provided at any of the Liberation Way facilities.



Regarding the incident on July 31, 2017, going forward any violation of Title 21 United States Code, Sections 941(a) (1) and 844 (21 U.S.C. 841 (a)(1) and 844) will be reported to DDAP and law enforcement. The Facility Director will be responsible to ensure all necessary reporting is done is done in a the designated time frame. The Project Director will be responsible for all reporting in the absence of the Facility Director.



No controlled substances will be taken off site.



The facility now possesses a valid CLIA Waiver to perform urine screening/testing. A copy of the Department of Health, Bureau of Laboratories approval was forwarded to DDAP.



By 4/27/2018, staff will be trained on the regulations and a sign off sheet will be provided.








715.2(a)(b)  LICENSURE Relationship of Federal and State Regulations

(a) A narcotic treatment program shall comply with Federal regulations and requirements governing the administration, dispensing and storage of agents. (b) This chapter is intended to supplement the Federal regulations governing narcotic treatment programs in 21 CFR Chapter II, 1300-1399 (relating to Drug Enforcement Administration, Department of Justice).
Observations
The facility services clients on an out-patient basis and prohibited from taking possession of the clients controlled substances (suboxone) that was prescribed by the client's DATA waived doctor and dispensing it back to the clients (21 U.S.C. 825(c)). Upon inspection of the nurse's office where medication is stored, there was methadone from the facility's stock and clients prescribed Suboxone housed in a cabinet with other medications and not in a safe.
 
Plan of Correction
As of 12/14/2017 - We no longer take possession of the client's controlled substances or dispense back to a client his or her controlled substance. All narcotics used for detoxification purposes are the property stock medication of Liberation Way.

On 4/5/2018 a locking narcotic cabinet was approved by the DEA to store stock narcotics only, during hours of operation. Stock Methadone and Suboxone will be stored in the large inventory safe at all other times.

Policy 709.32 Medication Control has been amended to reflect this procedure and all nursing staff signed off by 3/30/2018. New nursing staff will be trained at orientation.








715.28(c)(1-5)  LICENSURE Unusual incidents

(c) A narcotic treatment program shall file a written Unusual Incident Report with the Department within 48 hours following an unusual incident including the following: (1) Complaints of patient abuse (physical, verbal, sexual and emotional). (2) Death or serious injury due to trauma, suicide, medication error or unusual circumstances. (3) Significant disruption of services due to a disaster such as a fire, storm, flood or other occurrence. (4) Incidents with potential for negative community reaction or which the facility director believes may lead to community concern. (5) Drug related hospitalization of a patient.
Observations
The facility failed to file a written Unusual Incident Report with the Department within 48 hours following incidents with potential for negative community reaction or which the facility director believes may lead to community concern. In a review of a letter to the Drug Enforcement Agency (DEA) a nurse took a bottle of methadone (46 10 mg tablets) off site to the client ' s sober living residence to start the client's taper. The nurse brought the methadone in a locked box. During dose, the client distracted the nurse and took the bottle of methadone and distribute the methadone to other residents of the sober living facility. All was recorded on the sober livings 24-hour surveillance camera.
 
Plan of Correction
Going forward all Unusual Incidents that have the potential for negative community reaction or lead to community concern will be reported within 48 hours to the Department of Drug and Alcohol Programs by either the Project Director or the Facility Director for the respective site. When applicable local law enforcement will also be notified also.

709.91(a)(2)  LICENSURE Intake and admission

709.91. Intake and admission. (a) The project director shall develop a written plan providing for intake and admission which includes, but not be limited to: (2) Treatment methodology.
Observations
During the site visit, DDAP staff were unable to determine the facility's treatment methodology. Upon review of client print-out list provided by employee #2, some individuals were enrolled as maintenance and detox clients. The facility transferred several patients to another outpatient facility within the project. When DDAP staff asked employee #1 why these clients were transferred on multiple occasions, the employee stated, facility provides intensive outpatient services and other provides regular outpatient. After further description of services taking place, it appears the facility is only providing partial hospitalization level of care (they are licensed to do) and not outpatient services. DDAP explained to employee #1 this facility is licensed to provide outpatient services regardless of the intensity.
 
Plan of Correction
Starting 4/10/2018, all clients are attending programming according to their Level of Care, for example PHP clients attend for at least 30 hours weekly, outpatient clients attend up to 15 hours weekly. Clients will leave the premises outside of their scheduled programming hours. Normal operating hours for partial hospitalization a are 8:00am-4:30pm, Monday-Saturday weekly. Outpatient sessions can be scheduled within the same time frames of the Partial Hospitalization program's hours.



The Project Director and/or Clinical Supervisor will ensure that this procedure is being followed during daily caseload meetings.



By 4/13/2018, a training occurred for all staff will be developed by the Clinical Director/Project Director, called Standard Procedures for Admission, Transfer, and Discharge. This training will include but not limited to:



Organizational Structure



ASAM Criteria and Treatment Planning



Discharge Criteria



Level of Care Criteria



Admissions



Transfers



Discharges



As of 4/13/2018, the Clinical Director/Project Director will facilitated this training with all current staff at each treatment site. There will be a sign in with staff's name, credentials and original signature that they received this training.



This Training will be mandated for all New Hires as well as part of Annual Review process for all staff.



Clients may be initially directed to or can transition to different sites within Liberation Way as a result of, but not limited to, the following personalized reasons: 1) legal restraints; 2) access to public transportation; 3) access to employment; 4) access to necessary resources; 5) family support/concerns. For example, a client may attend PHP and IOP services in Fort Washington for stabilization and then choose to transition Bala site in Philadelphia area for access to public transportation and employment opportunities.





As of 3/23/2018 the facility has ceased administering Suboxone from stock for maintenance services as directed. All clients currently receiving maintenance services are being treated by a DATA 2000 waived practitioner and receiving prescriptions individually by a DATA 2000 waived practitioner and keep their medication at their respective residence.

709.91(a)(3)  LICENSURE Intake and admission

709.91. Intake and admission. (a) The project director shall develop a written plan providing for intake and admission which includes, but not be limited to: (3) Requirements for completion of treatment.
Observations
There was no evidence of a written plan regarding the requirements for completion of treatment. Employees were unable to provide DDAP with concreate information regarding client discharge but rather transfers between the project's three facilities.
 
Plan of Correction
Client discharge is addressed in policy 205.4.6 Aftercare and Discharge Planning/Criteria. All clinical and medical staff will be provided a copy of the policy and a signature will be required of each recipient that the policy was read and understood by 4/13/2018.




709.93(a)(5)  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: (5) Progress notes.
Observations
Progress notes reviewed in clients #1 and #2 charts, indicates the services stated in the notes were not delivered to the client. Client #1 had duplicate discharge summaries from both terms in treatment.
 
Plan of Correction
On 4/12/2018, a written directive was sent via email to all staff who use the Electronic Medical Record to perform client charting that use of the copy and paste function is strictly prohibited. A response stating confirmation of receipt and understanding of content is required by each employee. The Clinical Director and Nursing Supervisor will ensure compliance by auditing ten random charts monthly.

 
Return to Pennsylvania Department of Health Home Page


Copyright @ 2001 Commonwealth of Pennsylvania. All Rights Reserved.
Commonwealth of PA Privacy Statement