INITIAL COMMENTS
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This report is a result of an onsite licensure renewal and methadone monitoring inspection. The inspection was conducted on October 21-22, 2015 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the onsite inspection, Discovery House CU- Inc. 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 the inspection:
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Plan of Correction
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704.11(c)(2) LICENSURE CPR CERTIFICATION
704.11. Staff development program.
(c) General training requirements.
(2) CPR certification and first aid training shall be provided to a sufficient number of staff persons, so that at least one person trained in these skills is onsite during the project's hours of operation.
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Observations
Based on a review of the CPR eradication documentation, the facility failed to provide CPR certification and First Aid training so that at least one person trained in these skills was onsite during the project's hours of operation.
The findings include:
The CPR cards were reviewed during the inspection which was conducted on October 21-22, 2015. There was no documentation that a sufficient number of staff persons trained in CPR were onsite during the project's hours of operation All of the staff had documentation of a completed CPR certification that had been taken as an online course. There was no documentation that the CPR certification course included hands on instruction.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Program Director will have a training with the medical staff regarding the importance of having onsite CPR training that includes hands on instruction. There will be a meeting scheduled as soon as possible to make sure there is enough staff to cover the project hours. The Program Director will ensure there is enough personal to cover the project hours of operation. The Program Director will ensure this is completed annually. |
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 a review of patient records, the facility failed to document that the narcotic treatment physician determined the patient's initial and subsequent dose and schedule and communicated it to the person responsible for the administration of medication.
The findings include:
Ten patient records were reviewed on October 21-22, 2015. One of the patient records reviewed, patient #10, was found to have take home privileges rescinded; however, there was no corresponding order from the narcotic treatment physician.
Patient #10 was admitted on August 15, 2013 and discharged at the time of her death, on October 7, 2015. The patient was hospitalized for several days in June 2015. Upon returning from the hospital, her privileges were rescinded and she began medicating daily. Daily dosing was continued up until the time of her death. There is no order from the narcotic treatment physician that the patient's privileges were rescinded.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
A training was held on 10/28/2015,with the medical director to explain the importance of the medical director placing medical orders in the computer for each patient incident.The Program Director will do sporadic checks to make sure there are orders in the computer for each patient. |