INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on January 7, 2019 to January 10, 2019 by staff from the Department of Drug and Alcohol Programs, Bureau of Quality Assurance for Prevention and Treatment. Based on the findings of the on-site inspection, Penn Foundation, 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 this inspection:
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Plan of Correction
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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
The facility failed to identify, on their fire drill logs, the time of the fire drills conducted for the months of February 2018 through November 2018.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The fire drill logs were updated immediately after the inspection by Program Director to reflect the date, time, and amount of time the drill took for evacuation. This document will be used starting with the February 2019 fire drills. |
709.28 (c) 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.
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Observations
The facility failed to document all of the required elements of a consent to release information form in 1 of 22 client records reviewed.
Client #21 was admitted to the outpatient level of care on November 21, 2017 and was discharged on October 23, 2018. There was a consent to relase information form to an outside individual signed and dated by the client on November 21, 2017; however, the form did not include the purpose of the disclosure. Additionally, there was a consent to release information form to another treatment provider signed and dated by the witness on 11/21/17; however, the form did not include a dated client signature.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
By February 15, 2019 Assessment and Client Registration staff will be re trained by Outpatient program Director on filling out releases of information properly. Both Inpatient and Outpatient Program Directors will review the Confidentiality regulations highlighting the importance of client signatures on releases of information in addition to checking the purpose of the disclosure. |
709.82(d)(1) LICENSURE Treatment and rehabilitation services
709.82. Treatment and rehabilitation services.
(d) Counseling shall be provided to a client on a regular and scheduled basis. The following services shall be included and documented:
(1) Individual counseling, at least twice weekly.
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Observations
The facility failed to provide counseling to a client on a regular and scheduled basis including individual counseling, at least twice a week, in four of four client records reviewed in the partial hospitalization activity.
Client # 13 was admitted on December 19, 2018 and was still an active client at the time of the inspection. Documentation of two individual sessions per week was not completed for the week of December 30, 2018 to January 5, 2019.
Client # 14 was admitted on December 7, 2018 and was still active at the time of the inspection. Documentation of two individual sessions per week was not completed for the weeks of December 16, 2018 to December 22, 2018 and December 30, 2018 to January 5, 2019.
Client # 15 was admitted on November 28, 2018 and was discharged on December 26, 2018. Documentation of two individual sessions per week was not completed for the weeks of December 2, 2018 to December 8, 2018 and December 16, 2018 to December 22, 2018.
Client # 16 was admitted on May 22, 2018 and was discharged on June 12, 2018. Documentation of two individual sessions per week was not completed for the weeks of May 27, 2018 to June 2, 2018 and June 3, 2018 to June 9, 2018.
These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
By February 1, 2019 all Partial Hospitalization staff will review DDAP regulation in individual supervision with their clinical supervisor surrounding individual counseling in the program. Partial Hospitalization staff will begin to meet with clients individually twice weekly immediately. |
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
The facility failed to ensure that the client signed an informed consent to treat prior to the administration of a narcotic agent in one of nine applicable client records.
Client # 9 was admitted on November 28, 2018 to the inpatient nonhospital of care and was active at the time of the inspection. The client's initial dose was on December 29, 2018, but there was no informed consent to treat on file prior to the initial dose.
These findings were reviewed with facility staff during the licensing process
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Plan of Correction
By 1/23/2019, physicians will be re-trained by the medical director in the medical staff meeting. Training will include the requirements for completing buprenorphine informed consent form prior to administering a narcotic agent for clients on buprenorphine for detoxification or maintenance purposes. Compliance will be monitored via quarterly chart audits conducted by the compliance manager. It should be noted that client #9 was admitted into the facility on 12/28/2018. |
709.92(b) LICENSURE Treatment and rehabilitation services
709.92. Treatment and rehabilitation services.
(b) Treatment and rehabilitation plans shall be reviewed and updated at least every 60 days.
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Observations
The facility failed to provide treatment plan updates within the regulatory timeframe in two of six client records reviewed.
Client 18 was admitted on August 14, 2018 and was active at the time of the inspection. A treatment plan update was completed on October 15, 2018 and an update was due no later than December 15, 2018. However, no update was not completed at the time of the inspection.
Client #22 was admitted on April 2, 2018 and was discharged on January 2, 2019. A treatment plan update was completed on October 5, 2018 and an update was due no later than December 5, 2018. However, the update was not completed prior to discharge.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
By February 15, 2019 in both group and individual supervision treatment plans and updates will be reviewed with the staff by the clinical supervisors. Staff are required to update treatment plans every 60 days. Random chart audits will continue to be conducted by the clinical supervisor to ensure this is happening. |