INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection and methadone/buprenorphine monitoring conducted on March 9, 2022 through March 10, 2022 by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, Avenues Recovery Medical Center at Valley Forge 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, the facility failed to ensure that all staff persons received a minimum of 6 hours of HIV/AIDS training and/or at least 4 hours of TB/STD and other health related topics training within the regulatory timeframe in six of twenty-one personnel records reviewed.
Employee #16 was hired as a patient care worker on November 13, 2019 and was due to have both communicable disease trainings completed no later than November 13, 2021. The HIV/AIDS training and the TB/STD training were not completed at the time of the inspection.
Employee #17 was hired as a patient care worker on September 11, 2019 and was due to have both communicable disease trainings completed no later than September 11, 2021. The HIV/AIDS training was not completed at the time of the inspection.
Employee #18 was hired as a mental health worker on September 9, 2019 and was due to have both communicable disease trainings completed no later than September 9, 2021. The HIV/AIDS training and the TB/STD training were not completed at the time of the inspection.
Employee #19 was hired as a patient care worker on February 12, 2020 and was due to have both communicable disease trainings completed no later than February 12, 2022. The HIV/AIDS training and the TB/STD training were not completed at the time of the inspection.
Employee #20 was hired as a unit coordinator on September 9, 2019 and was due to have both communicable disease trainings completed no later than September 9, 2021. The HIV/AIDS training was not completed at the time of the inspection.
Employee #21 was hired as a recovery assistant on October 9, 2019 and was due to have both communicable disease trainings completed no later than October 9, 2021. The HIV/AIDS training and the TB/STD training were not completed at the time of the inspection.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
- Employee #16 will be enrolled in the HIV/AIDS training that is scheduled for 6/22/2022-6/23/2022 and completed the TB/STD training 3/7/2022.
- Employee #17 will be enrolled in the HIV/AIDS training that is scheduled for 6/22/2022-6/23/2022.
-Employee #18 will be enrolled in the HIV/AIDS training that is scheduled for 6/22/2022-6/23/2022 and completed the TB/STD training on 3/7/2022.
- Employee #19 will be enrolled in the HIV/AIDS training that is scheduled for 6/22/2022-6/23/2022 and completed the TB/STD training on 11/21/2021.
-Employee #20 will be enrolled in the HIV/AIDS training that is scheduled for 6/22/2022-6/23/2022.
- Employee #21 will be enrolled in the HIV/AIDS training that is scheduled for 6/22/2022-6/23/2022 and TB/STD training scheduled on 8/25/2022.
- Nurse Executive is responsible for ensuring patient care workers, mental health workers, unit coordinators, and recovery assistants attend these mandatory communicable disease trainings within two years of employment. The Nurse Executive will ensure each employee is enrolled in the above trainings.
- The Director of Counseling is responsible for ensuring counselors and counselor assistants attend these mandatory communicable disease trainings within one year of employment.
- The Medical Director will consult with Nursing Administration to develop both the 6 hour HIV/AIDS and 4 hour TB/STD trainings, incorporating appropriate DDAP requirements into curriculum, within 6 months. These trainings will be incorporated into the new employee onboarding process.
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705.6 (7) LICENSURE Bathrooms.
705.6. Bathrooms.
The residential facility shall:
(7) Maintain each bathroom in a functional, clean and sanitary manner at all times.
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Observations
Based on a physical plant inspection, the facility failed to maintain each bathroom in a functional, clean and sanitary manner at all times.
On March 10, 2022, at approximately 12:45 PM, the bathroom in room 223 had what appeared to be mold on the ceiling and an upper part of the wall and there was a fire suppression system pipe with a significant amount of rust on it. Additionally, the bathroom in room 331 had wall tiles missing from around the shower/tub area.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
- The black substance on the ceiling & upper part of the wall was cleaned and easily removed in room 223.
- Rust from Fire Suppression System Pipe in room 223 has been removed. Pipe has been cleaned & repainted.
- The tiles have been replaced in the bathroom of 331.
- The Director of Plant Maintenance is responsible for cleaning, repairs and renovations.
In addition:
- Housekeeping staff will report any housekeeping and/or plant maintenance issues as needed to the Director of Plant Maintenance. Housekeeping staff will be educated by Director of Plant Maintenance on identifying issues of concern by April 15, 2022. The Director of Plant Maintenance will then submit an electronic ticket for anything reported and assign the task to a maintenance employee.
- Environmental rounds will be completed quarterly by PI Coordinator and include, at a minimum, the Director of Plant Maintenance & Executive Director or designee, to ensure cleaning and renovation concerns are identified and repaired.
- The PI Coordinator will ensure corrective action above is implemented.
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705.10 (d) (4) LICENSURE Fire safety.
705.10. Fire safety.
(d) Fire drills. The residential facility shall:
(4) Maintain a written fire drill record including the date, time, the amount of time it took for evacuation, the exit route used, the number of persons in the facility at the time of the drill, problems encountered and whether the fire alarm or smoke detector was operative.
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Observations
Based on a review of the facility's June 2021 through January 2021 fire drill logs, the facility failed to document the evacuation times for drills conducted during the months of June, August, September, October, November, December 2021, and January 2022. The facility documented that "stand in place" fire drills were completed during these months; however, the facility did not have a Department-approved exception for not completing a full evacuation during all fire drills conducted.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
- The Chief Executive Officer will submit an Exception letter allowing for stand in place drills by May 2022 to DDAP. Until we have a DDAP approved exception letter for stand in place drills, we'll conduct the full evacuation drills & document the evacuation times for the drills, monthly. Fire Safety Officer (Campus Safety Supervisor) is responsible. |
715.9(a)(4) LICENSURE Intake
(a) Prior to administration of an agent, a narcotic treatment program shall screen each individual to determine eligibility for admission. The narcotic treatment program shall:
(4) Have a narcotic treatment physician make a face-to-face determination of whether an individual is currently physiologically dependent upon a narcotic drug and has been physiologically dependent for at least 1 year prior to admission for maintenance treatment. The narcotic treatment physician shall document in the patient 's record the basis for the determination of current dependency and evidence of a 1 year history of addiction.
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Observations
Based on a review of patient records, the facility failed to have a narcotic treatment physician document the determination of whether an individual is currently physiologically dependent and the evidence of a 1-year history of addiction in one of eight applicable patient records reviewed.
Patient #13 was admitted into the non-hospital residential level of care on December 1, 2021 and was discharged on December 21, 2021. There was no documentation in the record of the physician's basis for the determination of current dependency and the evidence of a 1-year history of addiction.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
- The Practitioner, who completed the patient's History and Physical, was re-educated on 3/9/2022 by the Nurse Manager. The Medical Director was made aware on 3/10/2022 and reminded the medical department of the need to document the screening and determination of whether an individual is currently physiologically dependent and evidence of a 1 year history of addiction prior to administration of a narcotic drug in the chart. This was also discussed in the Medical Executive Committee Meeting on 3/31/2022.
- The Documentation of Addiction, as applicable, will be audited nightly by nursing.
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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 patient records, the facility failed to obtain an informed, voluntary, written consent before an agent may be administered to the patient for either maintenance or detoxification treatment in one of eight applicable patient records reviewed.
Patient #3 was admitted into the hospital detoxification level of care on March 6, 2022 and was still active at the time of the inspection. The patient received the initial dose of a narcotic agent on March 6, 2022; however, there was no documentation of the consent to treat with a narcotic agent in the record at the time of the inspection.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
- The Practitioner, who completed the patient's History and Physical, was re-educated on 3/9/2022 by the Nurse Manager. The Medical Director was made aware on 3/10/2022 and reminded the medical department of the need to obtain a narcotic consent when prescribing a narcotic. It was also an item on the MEC agenda on 3/31/2022.
- The nurse who administered the narcotic was re-educated by the Nurse Manager on 3/9/2022 to check for the consent prior to administering a narcotic.
- The Narcotic Consent, as applicable, will be audited nightly by nursing.
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710.23(b) LICENSURE Patient Records
§ 710.23. Patient records.
(b) Patient records shall be kept confidential in accordance with applicable Federal drug and alcohol regulations and the confidentiality requirements in 4 Pa. Code § § 255.4 and 255.5 (relating to UDCS: confidentiality and access to information and projects; and coordinating bodies: disclosure of client-oriented information).
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Observations
Based on a review of patient records, the facility failed to keep consent forms for the disclosures of patient identifying information within the limits established by 4 Pa. Code 255.5 (a) for releases of information in one of six applicable patient records reviewed.
Patient #1 was admitted into the hospital detoxification level of care on March 4, 2022 and was active at the time of the inspection. A release of information form to a parole officer, signed and dated by the patient on March 7, 2022, that allowed for the release of the psychiatric evaluation, discharge summary, lab and ancillary tests, aftercare plans, medication record, HIV-related information, physician history and physical, and the biopsychosocial, all of which exceeded the limits established by 4 Pa. Code 255.5.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
- The staff member, who filled out the consent, was re-educated on 3/11/2022 by the Nurse Executive on the use of the proper consent form for releasing information to the Criminal Justice System such as Judges, Probation or Parole Officer, and to Other Governmental Agencies. The proper consent limits the information released to the 5 specific items as noted in 4 PA Code 255.4 and 255.5.
- Proper consent utilization will be audited by the Health Information Management Committee and presented at the quarterly Health Information Management Committee Meeting for review.
- The patient has already left the facility so we are unable to correct this and secure an appropriate consent form. |