This report is a result of a complaint investigation conducted on June 15, 2009 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the complaint investigation, the allegations made against The Consortium were unsubstantiated. However, while conducting the complaint investigation, the facility was found not to be in compliance with a portion of the applicable chapters of 28 PA Code which pertain to the facility. The following deficiencies were identified during this inspection and a plan of correction is due on July 8, 2009.
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Plan of Correction
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715.28(c)(1-5) LICENSURE Unusual incidents
(c) A narcotic treatment program shall file a written Unusual Incident Report with the Department within 48 hours following an unusual incident including the following:
(1) Complaints of patient abuse (physical, verbal, sexual and emotional).
(2) Death or serious injury due to trauma, suicide, medication error or unusual circumstances.
(3) Significant disruption of services due to a disaster such as a fire, storm, flood or other occurrence.
(4) Incidents with potential for negative community reaction or which the facility director believes may lead to community concern.
(5) Drug related hospitalization of a patient.
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Observations
Based on a review of a client record and interviews of staff during a complaint investigation, the facility failed to file unusual incident reports to the Department of Health within 48 hours of the unusual incident in one of one client records reviewed.
The findings include:
On June 15, 2009, interviews were conducted with the Facility Director, the Narcotic Treatment Program Manager, and the Nursing Supervisor. A client record which was the subject of a complaint investigation was reviewed. The client record contained documentation which indicated the facility failed to file incident reports to the Department on February 7, 2009, when the client fell in the facility's parking lot and sustained injuries. A progress note dated 3/24/09 stated that this client had been in a serious auto accident that resulted in a hospitalization that did not end until 3/23/09, but the facility failed to file an incident report with the Department for this trauma and hospitalization. A copy of an internal incident report showed that this client fell in the parking lot on April 10, 2009, but the facility failed to file an incident with the Department. Progress notes dated 4/20/09 documented that this patient expired in the hospital on 4/19/09, but the facility failed to file an incident report with the Department. The June 15, 2009 interview with the Narcotic Treatment Program Manager confirmed that the facility did not file an incident report with the Department in each of the four occasions which required incident reports to be filed with Department.
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Plan of Correction
Responsible: The Facility Director shall ensure that all Unusual Incident Reports are filed with the Department within 48 hrs. following an unusual incident including: complaints of client abuse, Death or serious injury, Significant disruption of services due to disaster such as a fire, storm, flood or other occurrences, incidents with potential negative community reaction or which the Facility Director believes may lead to community concerns, and drug related hospitalization.
Time Frame: Effective July 17, 2009
Monitoring: The Clinical Supervisors will ensure that the Unusual Incident Reports are written and given to the Facility Director within 24 hrs. for the Facility Director to review and then file the report.
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