INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on August 10, 2023, by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, Peniel Drug & Alcohol Treatment Facility 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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709.28 (c) (6) 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:
(6) Date, event or condition upon which the consent will expire.
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Observations
Based on a review of the client records, the facility failed to obtain an informed and voluntary consent from the client for the disclosure of information contained in the client ' s record that included the date, event, or condition upon which the consent will expire in one out of seven records reviewed.Client #4 was admitted on August 27, 2022 and was still active at the time of the inspection. An informed and voluntary consent form to a legal agency dated January 9, 2023, did not document when the consent will expire.This finding was reviewed with the facility staff during the licensing process.
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Plan of Correction
As it relates to 709.28 (c) (6) Confidentiality, client #4, there was an informed and voluntary consent signed for a legal agency but no expiration date was documented.
The corrective action was completed on 8/10/23, the day of the inspection. The Clinical Supervisor met with the clinical staff member whose name was on the specific release form that was missing an expiration date and rehearsed with that staff member the 709.28 (c) (6) regulation of making sure the release form is always documented with an expiration date.
Also on 8/10/23 the Clinical Supervisor met with client #4 and the client signed the new release form which included the expiration date. This new form was placed into the client's file.
Furthermore, to ensure that all clinical staff were correctly informed of this regulation and to ensure that this deficiency does not recur in the future, the Clinical Supervisor has taken the following steps: a) she has sent a memo to all clinical staff to rehearse the 709.28 (c) (6) regulation of making sure all release forms are documented with the expiration date that our clients' sign, and b) she gave to all clinical staff copies of the new release form that includes documentation of the date of expiration and c) she has followed up with each clinical staff member to ensure that they had discarded all copies of the outdated release form.
To ensure the plan of correction is being implemented and to continue to monitor this correction, the Clinical Supervisor will be responsible to periodically review the release forms that are stored in the clients' files to ensure that all signed release forms include the date of expiration.
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709.32 (c) (4) (i) - (ii) 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.
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Observations
Based on a review of client records, the facility failed to provide documentation of medication being provided as prescribed by the physician in two of seven client records. Client #3 was admitted on March 20, 2023 and still active at the time of the inspection. The medication administration record (MAR) documented that client #3 was prescribed one medication daily. On August 4, 2023, the MAR was left blank and there was no documentation indicating if the medication was administered as prescribed. Client #4 was admitted on August 27, 2022 and was still active at the time of the inspection. The medication administration record (MAR) documented that client #4 was prescribed one medication at bedtime. On August 4, 2023, the MAR was left blank and there was no documentation indicating if the medication was administered as prescribed. This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
As it relates to 709.32 (c)(4)(i)-(ii) Medication Control, client #3 and client #4, there were dates in which the clients were to get their medication, but there were no staff initials on the MAR's and no documentation of medication being provided as prescribed by the physician.
The corrective actions for client #3 and client #4 were completed on 8/17/23. To correct this documentation failure and to ensure that this will not recur, the Clinical Supervisor and the Medical Liaison conducted a training on 8/17/23 with those staff members who are authorized to distribute medication to the clients.
The training addressed the failures to correctly document the MAR's by providing the following information: a) a review of the state regulations for Medication Control, b) a review of how and where to document the MAR's when a client receives their prescribed medication, c) a review of how and where to document the MAR's when a client refuses their prescribed medication and d) a review of how and where to initial the MAR's. Following this training, and to ensure that staff have the information readily available to them, the Clinical Supervisor sent a memorandum to the staff who attended the training. The memorandum outlined all of the information that was provided in the training session.
The Medical Liaison is responsible to ensure that this plan of correction is being implemented and followed by conducting a daily (Mon. to Friday) inspection of all MAR's sheets. On Mondays the Medical Liaison's inspection of the MAR's sheets will include three days, (Saturday, Sunday and Monday.) Her inspection will ensure that all MAR's have been correctly and completely documented.
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709.53(a)(11) LICENSURE Follow-up information
709.53. 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:
(11) Follow-up information.
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Observations
Based on a review of client records, the facility failed to follow their policy to document follow up information five days after a client is discharged in one out of three applicable records reviewed. Client #6 was admitted on November 7, 2022 and discharged on January 30, 2023. A Follow up was due no later than February 4, 2023; however, there was no documentation that one was completed. This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
As it relates to 709.53 (a) (11) follow up information and client #6 where there was no follow up information documented or completed.
The corrective action was completed on 8/10/23, the day of the inspection. To ensure the corrective action to this deficiency is being implemented and that this does not recur, the Clinical Supervisor sent a memo to all clinical staff in which she reminded them of the policy for clinical staff to follow up and to document the client file at least 5 days after a client is discharged.
The Clinical Supervisor is responsible to ensure that the plan of correction is being implemented and followed by personally inspecting the client file after the client has left treatment.
The Clinical Supervisor is responsible to ensure that there is a complete client record. The Clinical Supervisor will ensure that five days after the client has been discharged a call is made by either herself or by the counselor and that that information is documented in the client file.
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