INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection and complaint investigations conducted on May 8th - 10th, 2019 of Wilkes-Barre Treatment LLC dba Clearbrook Treatment Centers by staff from the Department of Drug and Alcohol Programs, Bureau of Quality Assurance for Prevention and Treatment, Program Licensure Division. Based on the findings of the on-site inspection, Wilkes-Barre Treatment LLC dba Clearbrook Treatment Centers 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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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 records and the facility's Staffing Requirement Facility Summary Report (SRFSR) form, the facility failed to ensure that employee #14 received the minimum of six hours of HIV/AIDS training and at least four hours of TB/STD and other health related topics within the regulatory time frame. Employe #14 was hired as a residential tech on April 5, 2017 and was due to have the communicable disease trainings no later than April 5, 2019. There was no documentation in the personnel file of the completion of the HIV/AIDS training and the TB/STD training as of the date of the inspection.The findings were discussed with facility staff during the licensing process.
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Plan of Correction
On 5/20/19 our newly hired HR Coordinator was made aware of the licensing finding re: employee #14 who has not had the required HIV-STD-TB training within the mandated time frame. HR Coordinator will monitor and track all new employees to ensure that the HIV-STD-TB training is completed within the time frame mandated for the positions of counselor and counselor assistant, and all other positions. Employee #14 will be scheduled to obtain the minimum of six hours of HIV/AIDS training and at least four hours of TB/STD as soon as the training can be approved and scheduled, but at least by 6-30-19. |
705.10 (c) (4) LICENSURE Fire safety.
705.10. Fire safety.
(c) Fire extinguisher. The residential facility shall:
(4) Instruct all staff in the use of the fire extinguishers upon staff employment. This instruction shall be documented by the facility.
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Observations
Based on a review of personnel records, the facility failed to ensure that employee #2 was instructed on the use of fire extinguishers upon transfering to the facility. Employee #2 was hired on December 13, 2017 and promoted to a position within this facility on February 25, 2019. There was no documentation in the personnel file of the completion of the fire extinguisher training. The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
On 5/20/19 the Director of Facility Services met with employee #2 re: the need for him to complete the required Fire Safety/Fire Extinguisher training. The designated facility services employee will provide the necessary training to employee #2 by 5/30/19. HR coordinator will maintain a tracking system for all new employees to ensure that the required fire extinguisher training occurs within the mandated time frame. In addition, HR will alert the Director of Facility Services or designee of all new hires and their hire date. |
705.10 (d) (3) LICENSURE Fire safety.
705.10. Fire safety.
(d) Fire drills. The residential facility shall:
(3) Ensure that all personnel on all shifts are trained to perform assigned tasks during emergencies.
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Observations
Based on a review of personnel records, the facility failed to ensure that employee #2 was instructed on the emergency safety upon transfering to the facility. Employee #2 was hired on December 13, 2017 and promoted to a position within this facility on February 25, 2019. There was no documentation in the personnel file of the completion of the emergency training. The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
On 5/20/19 the Director of Facility Services met with employee #2 re: the need for him to complete the required emergency training. The designated facility services employee provided the necessary training to employee #2 on 5/30/19. Documentation was signed to verify this training occurred. HR coordinator will establish and maintain tracking system for all new employees to ensure that the required emergency training is accomplished within the mandated time frame. HR will alert the Director of Facility Services or designee of all new hires and their hire date. |
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.
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Observations
Based on a review of client records, the facility failed to keep disclosures of client identifying information within the limits established by 4 Pa. Code 255.5(b) for releases of information in client record #'s 8, 10 and 11. Client #8 was admitted on October 29, 2018 and discharged on November 21, 2018. A consent to release form was signed and dated on October 29, 2018 to "Trinity Health Systems". The purpose listed on the release included "billing-collections-insurance-finance". The consent allowed for release of medical history & physical, including medications, psychosocial data and assessment, discharge summary and aftercare plan.Client #10 was admitted on April 13, 2018 and discharged on April 20, 2018. A consent to release form was signed and dated on April 13, 2018 to a billing agency that allowed for release of medical history and physical, including medications, psychosocial data and assessment, discharge summary and aftercare plan. Client #11 was admitted on May 16, 2018 and discharged on May 17, 2018. A consent to release form was signed and dated on May 16, 2018 to a billing agency that allowed for release of medical history and physical, including medications, psychosocial data and assessment, discharge summary and aftercare plan.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
On 5/13/19 Compliance Director met with Case Management staff to review the licensing specialist's findings specific to Consents. Case Management staff was instructed not to include "Billing" and "Case Management" together in the "Purpose" section of the same Consent. As of 5/15/19 chart monitoring activities by compliance staff will ensure that each Consent entered in KIPU EMR does not exceed the limits of 4 Pa. Code 255.5(b). |
709.30 (2) 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.
(2) The project may not discriminate in the provision of services on the basis of age, race, creed, sex, ethnicity, color, national origin, marital status, sexual orientation, handicap or religion.
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Observations
Based on a review of 14 client records, the facility's client rights policy failed to include documentation of all the required client rights, including that facility staff may not discriminate based on ethnicity and marital status. As part of every client's record, the client had signed the incomplete policy in regards to basis of discrimination. These findings were reviewed with facility staff during the licensing process. A plan of correction was developed and implemented, including all current clients signing a corrected policy, before the inspection was completed.
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Plan of Correction
On 5/9/19 the Patient Rights form was corrected by compliance staff. This standard has been met by adding the missing elements, "marital status" and "Ethnicity", that were identified during the licensing inspection. This form was then entered into KIPU EMR and each patient currently in treatment signed it and was offered a copy of it. An explanation of the corrections to the form was provided to each of these patients prior to their signing the form. |
715.6(e) LICENSURE Physician Staffing
(e) A physician assistant or certified registered nurse practitioner may perform functions of a narcotic treatment physician in a narcotic treatment program if authorized by Federal, State and local laws and regulations, and if these functions are delegated to the physician assistant or certified registered nurse practitioner by the medical director, and records are properly countersigned by the medical director or a narcotic treatment physician. One-third of all required narcotic treatment physician time shall be provided by a narcotic treatment physician. Time provided by a physician assistant or certified registered nurse practitioner may not exceed two-thirds of the required narcotic treatment physician time.
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Observations
Based on a review of two client records, the facility failed to ensure that the medical director countersigned functions delegated to the physician's assistant in one record. Client #3 was admitted on May 6, 2019 and was still an active client at the time of the inspection. A physical exam was conducted on May 7, 2019 by physician's assistant. There was no documentation in the record of the medical director countersigning the physical exam. The findings were reviewed with facility staff at the time of the inspection.
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Plan of Correction
On 5/23/19 the Director of Nursing informed the physician and PA-C of the following: regardless of the PA-C's Data 2000 approval, the physician must sign off on all H&Ps and medication orders entered onto the EMR by the PA-C. As of 5/22/19 the PA-C will "tag" the physician as a signer for all H&P Exams she enters onto a patient's EMR. This policy and procedure has been integrated into the chart monitoring activities conducted by nursing department. As of 5/23/19 chart monitoring by nursing will ensure that the Medical Director countersigns all H&P Exams conducted by the PA-C.
Our IT Department is currently working with KIPU EMR to modify the physician order form so that the PA-C can alert the physician to cosign the PA-C orders. It is anticipated that this modification may take up to 60 days to accomplish. The physician will sign all h&p's and orders by the PAC.
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715.12(1-5) LICENSURE Informed patient consent
A narcotic treatment program shall obtain an informed, voluntary, written consent before an agent may be administered to the patient for either maintenance or detoxification treatment. The following shall appear on the patient consent form:
(1) That methadone and LAAM are narcotic drugs which can be harmful if taken without medical supervision.
(2) That methadone and LAAM are addictive medications and may, like other drugs used in medical practices, produce adverse results.
(3) That alternative methods of treatment exist.
(4) That the possible risks and complications of treatment have been explained to the patient.
(5) That methadone is transmitted to the unborn child and will cause physical dependence.
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Observations
Based on a review of two client records, the facility failed to document a completed consent with the required information prior to administering detoxification treatment in two records.Client #2 was admitted on May 5, 2019 and was still an active client at the time of the inspection. There was no documented consent in the record. Client #3 was admitted on May 6, 2019 and was still an active client at the time of the inspection. There was no documented consent in the record.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
On 5/23/19 Compliance Director developed and implemented a Patient Consent for Buprenorphine that includes the following items. All patients currently in treatment as of 5/28/19 and all subsequent patients admitted to Clearbrook Treatment Centers will receive and sign the new Consent for Buprenorphine.
I.
(1) Buprenorphine is a narcotic drug which can be harmful if taken without medical supervision;
(2) Buprenorphine is an addictive medication and may, like other drugs used in medical practices, produce adverse results;
(3) That alternative methods of treatment exist;
(4) That the possible risks and complications of treatment have been explained; and
(5) That Buprenorphine may be transmitted to the unborn child and will cause physical dependence.
II.
I authorize Dr. Janerich or the medical resources he may designate, to administer medical treatment which is considered therapeutically necessary.
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715.15(b) LICENSURE Medication dosage
(b) The narcotic treatment physician shall determine the proper dosage level for a patient, except as otherwise provided in this section. If the narcotic treatment physician determining the initial dose is not the narcotic treatment physician who conducted the patient examination, the narcotic treatment physician shall consult with the narcotic treatment physician who performed the examination before determining the patient 's initial dose and schedule.
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Observations
Based on a review of two client records, the facility failed to ensure documentation of a consult between person conducting the physical examination and person prescribing medication for detoxification treatment in one client record. Client #3 was admitted on May 6, 2019 and was still an active client at the time of the inspection. A physical examination was completed on May 7, 2019 by the physician's assistant. The medical director prescribed Suboxone 8-2mg film on May 9, 2019. There is no documentation of a consult between the physician's assistant and medical director before the medication was prescribed. The findings were reviewed with facility staff at the time of the inspection.
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Plan of Correction
By 5/28/19 the following procedure will be implemented.
When the physician determining the initial dose of any agent used for detox is not the individual who conducted the patient's H&P Exam, a consult shall occur between the individual who conducted the patient H&P Exam and the physician prescribing the detox medication. This will be done before determining the patient's initial dose and schedule. The consultation shall be documented in the patient's record.
This policy and procedure has been integrated into the chart monitoring activities conducted by nursing department. As of 5/28/19 chart monitoring by nursing will ensure that the above consultation occurs.
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