INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on March 16 - 17, 2022 by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, Fayette Treatment Center, LLC d/b/a Greene Treatment Center 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/training records, the facility failed to document HIV/AIDS and TB/STD training in one of one personnel record.
Employee # 5 was hired February 18, 2021 for the position of counselor. No documentation of HIV/AIDS and TB/STD training was provided for employee # 5.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Project Director will have all current counselors in need of HIV/AIDS and TB/STD training completed by 5/1/2022.
This issue will no longer be a non compliance issue for the facility as the training will be completed on site following the specific DDAP training curriculum for these particular trainings.
Clinical Supervisor is responsible for checking the trainings completed for all counselors at 90 days period and annually.
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709.22 (c) LICENSURE Governing Body
§ 709.22. Governing body.
(c) If a facility is publicly funded, the governing body shall make available to the public an annual report which includes, but is not limited to, a statement disclosing the names of officers, directors and principal shareholders, when applicable.
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Observations
Based on a review of administrative materials, the facility is publicly funded and failed to provide documentation that an annual report was made available to the public for January 1, 2019 through December 31, 2019 and January 1, 2020 through December 31, 2020.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Project Director will publish the annual report of the organization on the organization new Facebook page by 5/1/2022. The Project Director will ensure this task is completed annually. |
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 and staff interviews, the facility exceeded the limitations imposed at 4 Pa. Code 255.5 when documenting the specific information to be disclosed to the funding entity on the consent to release information form in one of ten records.
Client # 8 was admitted April 20, 2020 and discharged August 9, 2021. A consent for probation dated July 19, 2021 indicated the drug test of client # 8 would be released. Staff confirmed the drug test results were disclosed to the probation office.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Project Director will train all staff members on how to complete consents for entities such as probation and what can be released per 4Pa. Code 255.5. The Clinical Supervisor will complete random chart audits to ensure that releases are documented correctly and only the documentation allowed by 4 Pa Code 255.5 is being released. The facility will be in compliance by April 30, 2022. |
715.17(b) LICENSURE Medication control
(b) A narcotic treatment program shall develop policies and procedures regarding verbal medication orders, including the issuing and receiving of orders, identifying circumstances when orders are appropriate and documenting orders, in accordance with applicable Federal and State statutes and regulations.
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Observations
Based on a review of patient records, the Certified Registered Nurse Practitioner (CRNP) was issuing verbal orders and writing orders for methadone in violation of Federal and State statutes and regulations. The narcotic treatment program failed to provide documentation the required approval was obtained from Federal and State authorities for a mid-level practitioner to issue orders for methadone.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The facility developed policy and procedure regarding verbal medication orders, including the issuing and receiving of orders, identifying circumstances when orders are appropriate and documenting orders, in accordance with applicable Federal and State statutes and regulations.
This policy will be in compliance by 4/11/2022. Medical Director and nursing staff was provided with education regarding this issue.
Medical Director is the only staff member permitted to write orders.
Medical Director is responsible for random client records review to check on the orders written.
The facility applied also for exception on SAMSHA for NP to be able to write orders for dose changes, take home medication and intakes on 3/17/22. |
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 and dosing observation on March 17, 2022 from 9:20 AM - 9:50 AM, the Certified Registered Nurse Practitioner (CRNP) issued verbal orders and written orders for methadone dose changes without approval from Federal and State authorities in five of ten records. The narcotic treatment physician is the only practitioner authorized to determine methadone dosage orders and dosage changes.
Patient # 2 was admitted November 24, 2021. During intake, the CRNP issued a verbal order for weekly take home medication.
Patient # 3 was admitted October 7, 2021. The CRNP issued the following verbal orders:
October 9, 2021 - increase to 35 mg
October 13, 2021 - increase to 45 mg
October 14, 2021 - increase to 50 mg
October 16, 2021 - increase to 60 mg
November 4, 2021 - increase to 70 mg
Patient # 4 was admitted November 24, 2021. During intake, the CRNP issued a verbal order for weekly take home medication.
Patient # 5 was admitted May 3, 2021. During dosing observation on March 17, 2022, the patient asked the CRNP for an increase in methadone. The CRNP wrote an order for an increase to 60 mg due to signs and symptoms of withdrawal and immediately gave the new dosage to the patient.
Patient # 6 was admitted March 9, 2022. During dosing observation on March 17, 2022, the patient asked the LPN for an increase in methadone. The CRNP gave a verbal order for a dose increase to the LPN. The LPN immediately gave the new dosage of 50 mg to the patient.
In addition, the narcotic treatment physician failed to document the proper dosage level was determined for a patient by writing standing orders.
The following standing order for methadone was written by the physician for any patient that has missed a dose: "If a patient misses: 1 day - give full dose, 2 days - give dose then return to full dose level next day, 3 days - give dose then return to full dose level next day, 4 days - give dose then increase 10 mg/d (day) until full dose level, 5 to 7 days - must see MD or designee or obtain verbal orders, and a patient must provide a U/A (urinalysis) screen. If a dose is 55 mgs or lower, give 30 mgs as a dose. If a dose is less than 30 mgs, give last lowest dose received."
These standing orders required the nursing staff to determine if the dosage change was appropriate for a patient. The physician is the only practitioner authorized to determine the proper dosage level for a patient.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The facility implemented policy that states that each medication order and dosage change shall be written and signed by the narcotic treatment physician.
There are no current standing orders in place.
Medical Director and nursing staff received training on this issue.
The facility will be in compliance by 4/11/22.
Nurse Practitioner will conduct chart reviews monthly and she will observe dosing on random occasions, at least 2 times per month.
The facility applied for SAMSHA exception on 3/17/22 in order for NP to make any dose changes, write take home orders and admission orders. |
715.20(1) LICENSURE Patient transfers
A narcotic treatment program shall develop written transfer policies and procedures which shall require that the narcotic treatment program transfer a patient to another narcotic treatment program for continued maintenance, detoxification or another treatment activity within 7 days of the request of the patient.
(1) The transferring narcotic treatment program shall transfer patient files which include admission date, medical and psychosocial summaries, dosage level, urinalysis reports or summary, exception requests, and current status of the patient, and shall contain the written consent of the patient.
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Observations
Based on a review of patient records, the facility failed to document the transfer of the required patient files to the receiving narcotic treatment program in one of one patient record.
Patient # 7 was admitted June 5, 2020 and discharged October 4, 2021.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The facility has written transfer policies and procedures which shall require that the narcotic treatment program transfer a patient to another narcotic treatment program for continued maintenance, detoxification or another treatment activity within 7 days of the request of the patient.
Staff members who faxed the records for patients who are transferring to other facilities must inform all staff members of the transfer and scan in the electronic medical record the verification of documents sent along with fax confirmation that the information was received.
Project Director provided training to all staff members on 4/7/2022.
The facility will be in compliance starting 4/11/22.
Based on a review of patient records, the facility failed to document the transfer of the required patient files to the receiving narcotic treatment program in one of one patient record. |
715.20(4) LICENSURE Patient transfers
A narcotic treatment program shall develop written transfer policies and procedures which shall require that the narcotic treatment program transfer a patient to another narcotic treatment program for continued maintenance, detoxification or another treatment activity within 7 days of the request of the patient.
(4) The receiving narcotic treatment program shall document in writing that it notified the transferring narcotic treatment program of the admission of the patient and the date of the initial dose given to the patient by the receiving narcotic treatment program.
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Observations
Based on a review of patient records, the facility failed to document in writing that it notified the transferring narcotic treatment program of the admission of the patient and the date of the initial dose given to the patient in two of two records.
Patient # 2 was admitted November 24, 2021.
Patient # 4 was admitted November 24, 2021.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The facility has written transfer policies and procedures which shall require that the narcotic treatment program transfer a patient to another narcotic treatment program for continued maintenance, detoxification or another treatment activity within 7 days of the request of the patient.
Nursing staff received training in regards to documenting in the patient electronic medical record that she notified the transferring narcotic treatment program of the admission of the patient and the date of the initial dose given to the patient by the receiving narcotic treatment program.
Training was provided by Project Director on 3/22/22 to all nursing staff, including NP. The organization will be in compliance starting 4/11/22.Nurse Practitioner is responsible of checking nursing notes and transfer orders on weekly basis. |
715.23(b)(5) LICENSURE Patient records
(b) Each patient file shall include the following information:
(5) The results of all annual physical examinations given by the narcotic treatment program which includes an annual reevaluation by the narcotic treatment physician.
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Observations
Based on a review of patient records, the facility failed to document the results of all annual physical examinations by the narcotic treatment physician in one of four records.
Patient # 1 was admitted July 31, 2019. The 2021 annual physical was not documented until August 27, 2021.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Project Director provided training to staff on couple occasions regarding this regulations: 3/24/22 and 4/7/22.
Nursing started to schedule patients for their annual physical examinations at least one week prior to due date, and write no show or cancellation notes in case patient did not keep the appointment.
Patients who have take home status and do not show up for the appointment will have their take home medication on hold until completion of the appointment.
On monthly basis nurse lead will provide project director with list of annual physical exams due and list of annual physical exams completed.
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