INITIAL COMMENTS
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This report is a result of an on-site licensure renewal and a methadone monitoring inspection conducted on May 18-19, 2021 by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, PA Care, LLC d/b/a State College Medical 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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705.22 (2) LICENSURE Building exterior and grounds.
705.22. Building exterior and grounds.
The nonresidential facility shall:
(2) Keep the grounds of the facility clean, safe, sanitary and in good repair at all times for the safety and well being of clients, employees and visitors. The exterior of the building and the building grounds or yard shall be free of hazards.
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Observations
Based on the facility physical plant inspection, the facility failed to keep the grounds of the facility clean, safe, sanitary and in good repair at all times for the safety and well-being of clients, employees, and visitors. The exterior stairs outside the rear fire exit door were in disrepair with the concrete on several stairs broken and missing.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Landlord was notified of this issue. Concrete steps will be repaired by June 15. Exterior inspection will be completed monthly by Executive Director/Health and Safety Officer |
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 two of eight client records reviewed, the facility failed to obtain an informed and voluntary consent from the client for the disclosure of information to include the specific information disclosed to not exceed Pa code 255. 5 (b) to a government agency.Client # 4 was admitted on July 30, 2020 and was still active at the time of the inspection. An informed and voluntary consent to a county agency, signed and dated by the client on May 12, 2021, allowed for the release of "General medical record" to include "history and physical, physician, nurse, and other provider notes, social work/case management notes, psychiatric/mental health/development disabilities information, consultation reports, x-ray, test, and study results. Also, alcohol/drug abuse diagnosis/treatment information. "Client # 5 was admitted on November 2, 2020 and was discharged on February 9, 2021. An informed and voluntary consent to a correctional facility, signed and dated by the client on November 6, 2020, allowed for the release of "General medical record" to include "history and physical, physician, nurse, and other provider notes, social work/case management notes, psychiatric/mental health/development disabilities information, consultation reports, x-ray, test, and study results. Also, alcohol/drug abuse diagnosis/treatment information. "These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Review of 255.5 will occur in staff meeting on 6/2/21. Focus will be given to the limits of information to be released to county agencies, as to not exceed the 5 points of information. Lead Counselor and Executive Director will review consents completed weekly to be sure that each staff member is adhering to 255.5 |
709.32 (b) LICENSURE Medication control
§ 709.32. Medication control.
(b) Verbal orders for medication can be given only by a physician or other medical professional authorized by State and Federal law to prescribe medication and verbal orders may be received only by another physician or medical professional authorized by State and Federal law to receive verbal orders. When a verbal or telephone order is given, it has to be authenticated in writing by a physician or other medical professional authorized by State and Federal law to prescribe medication. In detoxification levels of care, written authentication shall occur no later than 24 hours from the time the order was given. Otherwise, written authentication shall occur within 3 business days from the time the order was given.
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Observations
Based on four of eight client records reviewed, the facility failed to document verbal orders by a physician prior to the administration of medication. Also, the facility failed to have the physician document written authentication within 3 business days from the time the order was given.Client # 1 was admitted on September 24, 2020 and was still active at the time of the inspection. A patient report of a dose increase occurred on October 19, 2020 from 53 mg to 60 mg. There was no documentation of a verbal order being given and the physician did not provide written authorization until October 21, 2020. A patient report of a dose increase occurred on November 23, 2020 from 60 mg to 66 mg. There was no documentation of a verbal order being given and the physician did not provide written authorization until November 25, 2020. A patient report of a dose increase occurred on March 4, 2021 from 80 mg to 87 mg. There was no documentation of a verbal order being given and the physician did not provide written authorization until March 15, 2021. A patient report of a dose increase with a verbal order occurred on April 30, 2021 from 103 mg to 109 mg. The physician did not provide written authorization until May 5, 2021. A patient report of a dose increase occurred on May 3, 2021 from 109 mg to 114 mg. There was no documentation of a verbal order being given and the physician did not provide written authorization until May 5, 2021.Client # 4 was admitted on July 30, 2020 and was still active at the time of the inspection. A patient report of a dose increase with a verbal order occurred on March 23, 2021 from 53 mg to 59 mg. The physician did not provide written authorization until March 29, 2021. Client # 5 was admitted on November 2, 2020 and was discharged on February 9, 2021. A patient report of a dose increase with a verbal order occurred on November 5, 2020 from 30 mg to 37 mg. The physician did not provide written authorization until November 9, 2020. A patient report of a dose increase occurred on November 11, 2020 from 45 mg to 53 mg. There was no documentation of a verbal order being given and the physician did not provide written authorization until November 16, 2020. A patient report of a dose increase occurred on November 24, 2020 from 61 mg to 69 mg. There was no documentation of a verbal order being given and the physician did not provide written authorization until November 25, 2020. Client # 8 was admitted on August 11, 2014 and was discharged on April 26, 2021. A patient report of a dose decrease occurred on May 20, 2020 from 8 mg to 7 mg. There was no documentation of a verbal order being given and the physician did not provide written authorization until May 27, 2020. A patient report of a dose decrease occurred on January 6, 2021 from 3 mg to 2 mg. There was no documentation of a verbal order being given and the physician did not provide written authorization until January 11, 2021. These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Verbal orders by doctor will be signed within 3 business days. Nurses will monitor this and call the doctor on day 3 if they have not been signed yet. When the physician documents the order, he will authenticate the order on that same day. Nurses will monitor this daily.
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715.14(a) LICENSURE Urine testing
(a) A narcotic treatment program shall complete an initial drug-screening urinalysis for each prospective patient and a random urinalysis at least monthly thereafter.
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Observations
Based on two of eight patient records reviewed, the facility failed to provide documentation of an initial drug-screening urinalysis for each prospective patient and a random urinalysis at least monthly thereafter.Patient # 4 was admitted on July 30, 2020 and was still active at the time of the inspection. There was no documentation of a drug-screening urinalysis for the month of February 2021.Patient # 8 was admitted on August 11, 2014 and was discharged on April 26, 2021. There was no documentation of a drug-screening urinalysis for the month of December 2020 or February 2021.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Receptionist will review list of drug screens that are still outstanding prior one week before the end of the month. She will check scheduled events listing in EHR and be sure that the patients who are outstanding are scheduled. If they are not she will schedule them manually and report the error in scheduling to Methasoft. |
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 two of eight patient records reviewed, the facility to have a narcotic treatment physician determine the patient 's initial and subsequent dose and schedule for patient # 4. Also, upon readmit for patient # 1, the facility failed to document each medication order and dosage change to be written and signed by the narcotic treatment physician prior to the administration of an agent.Patient # 1 was re-admitted on September 24, 2020 and was still active at the time of the inspection. The patient was dosed 25 mg on September 24, 2020 and 27 mg on September 25, 2020. There was no order documented until September 26, 2020 and there was no written authorization by the physician until September 28, 2020. Patient # 4 was admitted on July 30, 2020 and was still active at the time of the inspection. The initial dose of 30 mg was ordered by the physician assistant on July 30, 2020.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Readmission process was reviewed with medical staff. Patient will see the doctor/PA before being readmitted. Lead Counselor and Executive Director will monitor this. |
715.23(c)(1-7) LICENSURE Patient records
(c) An annual evaluation of each patient 's status shall be completed by the patient 's counselor and shall be reviewed, dated and signed by the medical director. The annual evaluation period shall start on the date of the patient 's admission to a narcotic treatment program and shall address the following areas:
(1) Employment, education and training.
(2) Legal standing.
(3) Substance abuse.
(4) Financial management abilities.
(5) Physical and emotional health.
(6) Fulfillment of treatment objectives.
(7) Family and community supports.
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Observations
Based on two of three applicable patient records reviewed, the facility failed to document an annual evaluation of the patient 's status in patient records # 3 and # 6.Patient # 3 was admitted on April 11, 2019 and was still active at the time of the inspection. An annual evaluation of the patient status was due to occur no later than April 10, 2021. The last documented annual evaluation occurred on April 10, 2020.Patient # 6 was admitted on April 26, 2018 and was discharged on May 5, 2021. An annual evaluation of the patient status was due to occur no later than April 24, 2021. The last documented annual evaluation occurred on April 24, 2020.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Review of time frames of required documents will be reviewed with counselors at 6/2/21 meeting. Lead Counselor will review list of annual evaluations monthly and monitor timely completion. |