INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection and inspection conducted for the approval to use a narcotic agent, specifically Methadone, in the treatment of narcotic addiction. This inspection was conducted on October 16-17, 2014, by staff from the Department of Drug and Alcohol Programs, Program Licensure Division. Based on the findings of the on-site inspection, Center for Behavioral Health for Behavioral Health- PA, Inc. was found not to be in compliance with the applicable chapters of 4 PA Code and 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 the review of personnel records, the facility failed to document that staff persons received a minimum of and at least 4 hours of tuberculosis, sexually transmitted diseases and other health related topics training in one of four personnel records.
The findings include:
Four personnel records were reviewed on October 16-17, 2014. Four records were reviewed for the completion of at least 4 hours of tuberculosis, sexually transmitted diseases and other health related topics training. The training was not documented in personnel record # 4.
Employee # 4 was hired as a counselor on August 19, 2013. The tuberculosis, sexually transmitted diseases and other health related topics training was due to be completed by August 19, 2014. There was no documentation that the employee completed the training.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Because the supervisor was not successful locating a training outside of our facility, Employee #4 will complete an in house training on TB/STD to adhere to DDAP regulations. To prevent future citations with this regulation, if an outside training cannot be located an in house training will take place before the Associate's 1 year anniversary.
Clinical Supervisor will arrange the training and Program Director will ensure that it had been completed on or before the corrective action date. |
715.16(a)(4) LICENSURE Take-home privileges
(a) A narcotic treatment program shall determine whether a patient may be provided take-home medications.
(4) A narcotic treatment physician may rescind take-home medication privileges.
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Observations
Based on the review of patient records, the facility failed to document that the narcotic treatment physician rescinded take-home medication privileges in one of three patient records.
The findings include:
Eighteen patient records were reviewed on October 16-17, 2014. Three were reviewed for take home medication privileges. The facility did not document that the narcotic treatment physician rescinded take-home medication privileges in patient record # 7.
Patient # 7 was admitted on July 22, 2013. An order, dated and signed by the physician on July 30, 2014, granted the patient take home medication privileges. Documentation showed that the order had been cancelled by a nurse. There was no documentation that the narcotic treatment physician had rescinded the take-home medication privileges of the patient.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
In order to comply with this regulation and to prevent future citations, after a nurse obtains approval to cancel an order from the narcotic treatment physician, the narcotic treatment physician will create and sign a medical note in the patient's chart approving the change within 24 hours.
The narcotic treatment physician will ensure this documentation is in place. Program Director will perfom audits for cancelled orders to ensure compliance with DDAP regulations. |