INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on September 11-12, 2019 by staff from the Department of Drug and Alcohol Programs, Bureau of Quality Assurance for Prevention and Treatment, with the inspection also conducted for the approval to use Buprenorphine in the treatment of narcotic addiction. Based on the findings of the on-site inspection, Woman's Institute for Family Health 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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704.3(a) LICENSURE Relapse Policy
704.3. General requirements for projects.
(a) The project shall develop a written policy to address relapse of recovering clinical personnel.
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Observations
The project failed to develop a written policy to address relapse of recovering clinical personnel.
During review of the facility's policy and procedure manual on September 11, 2019, it was found that the facility had no policy to address the relapse of recovering clinical personnel.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Executive Director will develop a written policy to address relapse of recovering clinical personnel. Staff will receive training on this policy through in-service class conducted by the Executive Director, staff will acknowledge receipt of this information through dated signature that will be stored in staff personnel records. The policy will be included in the agency personnel policies and all newly hired staff will receive a copy and date and sign receipt of this policy within 3 days of hire. The policy will be added to Women's Institute for Family Health's policy and procedure manual by 10/8/19 |
709.34 (b) (5) LICENSURE Reporting of unusual incidents
§ 709.34. Reporting of unusual incidents.
(b) Policies and procedures must include the following:
(5) Reporting mechanism to ensure that reporting of an unusual incident to an entity is in compliance with State and Federal confidentiality laws.
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Observations
During a review of the facility's policy and procedure manual on September 11, 2019, the facility failed to have a reporting mechanism to ensure that reporting of an unusual incident to an entity is in compliance with State and Federal confidentiality laws.
The facility's policy and procedure manual had no documentation of a reporting mechanism to ensure that reporting of an unusual incident to an entity is in compliance with State and Federal confidentiality laws.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Executive Director will develop a procedure to include a mechanism to ensure that the facility files reports of unusual incidents that is in compliance with state and federal confidentiality laws. The reporting mechanism will be included in the facility's standard operating procedures manual. The Executive Director will conduct an in-service training for current staff on the purpose of the unusual incident log, the types of incidents that should be reported, how to complete the log and the procedure for documenting and forwarding reports to DDAP as well as proper filing of this information in facility records, the training will include information on state and federal confidentiality laws. Staff will acknowledge attendance to the training through signed and dated signature that will be retained in personnel records. All newly hired staff will receive training on unusual incident reporting within 3 days of hire. The log and procedures will be developed and the training will be completed by 10/8/19 |
709.34 (c) (1) LICENSURE Reporting of unusual incidents
§ 709.34. Reporting of unusual incidents.
(c) To the extent permitted by State and Federal confidentiality laws, the project shall file a written unusual incident report with the Department within 3 business days following an unusual incident involving:
(1) Physical or sexual assault by staff or a client.
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Observations
During a review of the facility's policy and procedure manual on September 11, 2019, the facility failed to have a policy addressing that physical or sexual assault by staff or client will be reported to the Department within 3 business days.
The facility had no policy or procedure to document physical or sexual assault by staff or a client will be documented on an unusual incident form and reported to the Department within 3 business days.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Executive Director will develop a policy to state that physical or sexual assault by staff or client will be documented on an unusual incident form and reported to the Department within 3 business days. The Executive Director will conduct an in-service training with staff on its policy for reporting physical or sexual assault to the Department within 3 business days and how to complete and file reporting documents. The training will include information on state and federal confidentiality laws. Staff will acknowledge receiving this information through signed and dated signature that will be retained in personnel files. Newly hired staff will receive this training within 3 days of hire. The policy will be developed and included in the facility's standard operating procedures manual and staff will be trained by 10/8/19 |
709.34 (c) (2) LICENSURE Reporting of unusual incidents
§ 709.34. Reporting of unusual incidents.
(c) To the extent permitted by State and Federal confidentiality laws, the project shall file a written unusual incident report with the Department within 3 business days following an unusual incident involving:
(2) Death or serious injury due to trauma, suicide, medication error or unusual circumstances.
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Observations
During a review of the facility's policy and procedure manual on September 11, 2019, the facility failed to have a policy addressing that death or serious injury due to trauma, suicide, medication error or unusual circumstances will be reported to the Department within 3 business days.
The facility had no policy or procedure to document that death or serious injury due to trauma, suicide, medication error or unusual circumstances will be documented on an unusual incident form and reported to the Department within 3 business days.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Executive Director will develop a policy to document on an unusual incident form and report to the Department within 3 business days incidents of death or serious injury due to trauma, suicide, medication error or unusual circumstance. The Executive Director will conduct an in-service training with staff on reporting incidents of death or serious injury due to trauma, suicide or medication error or unusual circumstance; the training will include information on how to complete the log and when and where to file with DDAP and state and government confidentiality laws, staff will acknowledge receipt of this information through dated signature; a copy will be retained in personnel files; newly hired staff will receive this training within 3 days of hire
The policy will be included in the facility's standard operating procedures manual and staff will be trained by 10/8/19. |
715.9(a)(1) 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:
(1) Verify that the individual has reached 18 years of age.
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Observations
During a review of patient records on September 11, 2019, the facility failed to verify that the individual had reached 18 years of age prior to administration of an agent in a narcotic treatment program.
The facility failed to screen each individual to determine eligibility for admission and administration of an agent in a narcotic treatment program, by verifying that the individual had reached 18 years of age in one out of three records reviewed.
These findings were reviewed with program staff during the licensing process.
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Plan of Correction
The Executive Director will develop a policy requiring that state or government issued identification is obtained to verify that all clients had reached 18 years of age prior to enrollment/admission and receiving/administering narcotic treatment. Copies of Identification will be stored in client records. The Office Manager will be responsible for assuring that government issued identification is verified and copies are stored in client records; this will be done by approving all client charts during the intake process and also through weekly inspection of client records. The physician will also verify identification before providing narcotic treatment and The Executive Director will inspect client records on a monthly basis to make sure that this policy is being adhered to. The policy will be included in the facility's standard operating procedures manual by 10/8/19. |
715.9(a)(2) 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:
(2) Verify the individual 's identity, including name, address, date of birth, emergency contact and other identifying data.
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Observations
During a review of patient records on September 11, 2019, the program failed to verify the individual's identity, including name, address, date of birth, emergency contact and other identifying data prior to administration of an agent in a narcotic treatment program.
The program failed to screen each individual to determine eligibility for admission by verifying the individual's identity, including name, address, date of birth, emergency contact and other identifying data in one out of three records reviewed.
These findings were reviewed with program staff during the licensing process.
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Plan of Correction
The Executive Director will develop a policy to verify the identity and name of all clients by obtaining a copy of state or federal identification and also obtaining the client's address, date of birth, emergency contact and other identifying data prior to admission to and administration of narcotic treatment. The Office Manager will be responsible for assuring that federal identification, address, date of birth, emergency contact and other identifying information is received for every client; the Executive Director will verify that this is done by reviewing records of new admissions on a weekly basis. Counselors will also be required to verify client identification before providing initial assessments or other tasks associated with opening a new client chart. Counselors will be prohibited from opening a chart where identification is not present; All staff will be trained in this policy and will acknowledge receipt of this information through signed and dated signature that will be included in personnel files. Newly hired staff will be trained in this policy within 3 days of hire. The policy will be included in the facility's standard operating procedures and staff will be trained by 10/8/19. |
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
During a review of patient records on September 11, 2019, the program failed to document informed, voluntary, written consent before an agent may be administered to the patient for maintenance treatment.
The facility failed to get informed consent in three out of three records reviewed.
These findings were reviewed with program staff during the licensing process.
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Plan of Correction
The Executive Director will develop a policy that will assure that the facility obtains informed and voluntary consent before an agent may be administered to the patient for medication maintenance treatment. The Executive Director will conduct an in-service training on obtaining informed consent which will occur at intake. The Office Manager will be responsible for assuring that all clients give informed consent; Counselors will not be allowed o provide services to clients when informed consent is not present in the client record. The Executive Director will conduct a weekly review of all new admissions to verify that this is completed on every client. Newly hired staff will receive training on this policy within 3 days of hire, all staff will acknowledge receipt of this information through dated signature that will be included in personnel records. Staff training will occur and the policy will be included in the facility's standard operating procedures manual by 10/8/19 |
715.13(a) LICENSURE Patient identification
(a) A narcotic treatment program shall use a system for patient identification for the purpose of verifying the correct identity of a patient prior to administration of an agent.
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Observations
During a review of patient records on September 11, 2019, the program failed to use a system for patient identification for the purpose of verifying the correct identity of a patient prior to administration of an agent.
The program failed to document the use of a system for patient identification for the purpose of verifying the correct identity of the patient prior to administration of an agent in one out of three records reviewed.
These findings were reviewed with program staff during the licensing process.
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Plan of Correction
The Executive Director will develop a policy for obtaining state or government issued identification for the purpose of verifying the correct identity of a patient prior to the administration of an agent. Copies of identification will be collected at intake and stored in the client record. All staff will be trained in this policy, newly hired staff will be trained within 3 days of hire. The Office Manager will be responsible for verifying and making sure that the correct identity of all clients has been verified prior to the client receiving services. The
Executive Director will review intake charts weekly to assure that the facility is in full compliance of this regulation. The Executive Director will provide training and staff will acknowledge receipt of this information through dated signature that will be stored in personnel record. The training will be conducted and the policy will be included in the facility's standard operating procedures manual by 10/8/19 |
715.13(b) LICENSURE Patient identification
(b) A narcotic treatment program shall maintain onsite a photograph of each patient which includes the patient 's name and birth date. The narcotic treatment program shall update the photograph every 3 years.
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Observations
During a review of patient records on September 11, 2019, the program failed to maintain onsite a photograph of each patient which included the patient ' s name and birth date.
The facility had no documentation of a photograph of each patient with their name and birth date in one out of three records reviewed.
These findings were reviewed with program staff during the licensing process.
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Plan of Correction
The Executive Director will develop a policy to maintain onsite photograph of each patient to include the patient's name and date of birth. A copy of each client' photo identification will be obtained at intake; clients will not be admitted to the program without photo identification that includes the client's name and date of birth. The Office Manager will be responsible for obtaining a copy of photo identification and filing in client charts; the Executive Director will verify compliance by reviewing all intake charts on a weekly basis. All staff will be trained on this policy; counselors will not be allowed to open a chart for any client where photo identification is not present. The Executive Director will conduct a training with all staff on this policy, newly hired staff will be trained within 3 day of hire; all staff will acknowledge receipt of this information through dated signature that will be included in personnel files. The training and the policy will be included in the facility's standard operating procedures manual to be completed by 10/8/19. |
715.19(1) LICENSURE Psychotherapy services
A narcotic treatment program shall provide individualized psychotherapy services and shall meet the following requirements:
(1) A narcotic treatment program shall provide each patient an average of 2.5 hours of psychotherapy per month during the patient 's first 2 years, 1 hour of which shall be individual psychotherapy. Additional psychotherapy shall be provided as dictated by ongoing assessment of the patient.
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Observations
During a review of patient records on September 11, 2019, the narcotic treatment program failed to provide each patient with an average of 2.5 hours of psychotherapy per month during the patients first 2 years of treatment.
Patient # 1 was admitted on November 13, 2018 and was current at the time of the inspection. Patient #1 had 2 hours of individual therapy in May 2019, 2 hours of individual therapy in June of 2019 and 2 hours of individual therapy in July of 2019.
Patient #2 was admitted on November 26, 2018 and was current at the time of the inspection. Patient #2 had 2 hours of individual therapy in March of 2019, 2 hours of individual therapy in April of 2019, 2 hours and 45 minutes of individual therapy in May of 2019, 4 hours and 15 minutes of individual therapy in June of 2019, 1 hour of individual therapy in July of 2019 and 1 hour of individual therapy in August of 2019.
Patient # 7 was admitted on January 7, 2019 and was discharged on April 26, 2019. Patient #7 had 2.5 hours of individual therapy in January 2019, 3 hours of individual therapy in February of 2019 and 1 hour of individual therapy in March of 2019.
These findings were reviewed with program staff during the licensing process.
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Plan of Correction
The Executive Director will develop a policy to provide each patient with an average of 2.5 hours of psychotherapy per month during the patient's first 2 years of treatment. Client's will be given a treatment schedule at intake that will include a minimum of 2.5 hours of psychotherapy per month for the first two years of treatment. The Office Manager is responsible for client scheduling. The client will acknowledge receipt of his/her treatment scheduled and also receipt of this requirement to receive narcotic treatment through dated signature that will be stored in the client's record. The Executive Director will review files on a weekly basis to verify that client's were given a schedule to reflect the minimum psychotherapy hours; clients that fail to adhere to their schedule where they do not meet the required hours will receive written notification; notices will be sent to clients by mail by the Office Manager, clients that do not complete psychotherapy hours after notification will not receive narcotic treatment until if and when they resume their treatment schedule. Patient psychotherapy hours will be documented in the client record by the primary counselor. The Executive Director will provide training to all staff on this policy, newly hired staff will be trained within 3 days of hire; all staff will acknowledge receipt of this information through dated signature. the training and the policy will be included in the facility's standard operating procedures manual by 10/8/19. |
709.91(b)(2)(ii) LICENSURE Intake and admission
709.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(2) Client orientation to the project which shall include, but is not limited to, a familiarization with the following:
(ii) Hours of operation.
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Observations
During a review of client records on September 11-12, 2019, it was found that the facility failed to have documentation of client orientation to the project which shall include the hours of operation.
The facility had no documentation of client orientation to the hours of operation of the project in seven of seven records reviewed.
This was reviewed with the facility staff during the licensing process.
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Plan of Correction
The Executive Director will assure that its policy of documenting client orientation is implemented by conducting training with intake staff on providing a copy of the agency's written program policies to clients and revising intake forms to include client signature acknowledging receipt of written orientation to the facility's hours of operation. The Office Manager will review client charts on a weekly basis to verify documentation of clients receiving orientation to the project. The Executive Director will also randomly check files on a monthly basis to verify client orientation to the project. Staff Training and revision of intake forms to be completed by 10/8/19 |
709.91(b)(2)(iii) LICENSURE Intake and admission
709.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(2) Client orientation to the project which shall include, but is not limited to, a familiarization with the following:
(iii) Fee schedule.
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Observations
During a review of client records on September 11-12, 2019, it was found that the facility failed to have documentation of client orientation to the project which shall include the fee schedule.
The facility had no documentation of client orientation of the fee schedule of the project in seven of seven records reviewed.
This was reviewed with the facility staff during the licensing process.
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Plan of Correction
The Executive Director will add the facility's fee schedule to its orientation brochure; intake staff will receive training on providing orientation/fee schedule information to clients at intake, the intake form will be revised to include client signature acknowledging receipt of orientation brochure that will include the agency's fee schedule. The Office Manager will review charts on a weekly basis to verify documentation of clients receiving orientation to the project. The Executive Director will inspect charts on a monthly basis. Training and revision of the intake form and orientation brochure will be completed by 10/8/19 and will go into effect as of this date. |
709.91(b)(2)(iv) LICENSURE Intake and admission
709.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(2) Client orientation to the project which shall include, but is not limited to, a familiarization with the following:
(iv) Services provided.
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Observations
During a review of client records on September 11-12, 2019, it was found that the facility failed to have documentation of client orientation to the project which shall include the services provided.
The facility had no documentation of client orientation to the services provided by the project in seven of seven records reviewed.
This was reviewed with the facility staff during the licensing process.
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Plan of Correction
The Executive Director will develop a brochure that will provide orientation to the project and services offered that will be given to all clients at intake; clients will acknowledge receipt of the brochure through dated signature that will be included in the client record. The Office Manager will be responsible for issuing and documenting client receipt of orientation brochures. The Office Manager will review client charts on a weekly basis to assure documentation of project orientation is stored in client records; the Executive Director will inspect files on a monthly basis to verify documentation of client receipt of orientation/project services brochure. The Counselor's will not be allowed to open a client record without verifying that the client has been provided with orientation to the project/services. The Executive Director will conduct a training to all staff on this policy, newly hired staff will be trained within 3 days of hire. Staff will acknowledge receipt of this training through dated signature that will be stored in personnel records. Staff training and the client orientation brochure will be included in the facility's standard operating procedures manual by 10/8/19. |