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 July 20-21, 2015, by staff from the Department of Drug and Alcohol Programs, Program Licensure Division. Based on the findings of the on-site inspection, The Consortium 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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705.23 (3) LICENSURE Counseling or activity areas and office space
705.23. Counseling or activity areas and office space.
The nonresidential facility shall:
(3) Ensure privacy so that counseling sessions cannot be seen or heard outside the counseling room. Counseling room walls shall extend from the floor to the ceiling.
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Observations
Based on a physical plant inspection, the facility failed to ensure privacy so that counseling sessions cannot be seen or heard outside the counseling room.
The findings include:
A physical plant inspection was conducted on July 22, 2015. During the physical plant inspection it was observed that the facility failed to provide window treatments for room # 205 in which the doctor may perform physical examinations.
These findings were reviewed and confirmed with facility staff during the licensing process.
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Plan of Correction
Responsible: The Facilities Department is responsible for ensuring that all windows have window treatments to ensure confidentiality for all members.
Timeframe: The window treatments for the physical examination room, #205 will be completed by the Facilities staff, by 8/28/15.
Monitoring: The Facilities Department will conduct daily rounds to ensure the physical exam room is consistent with having window treatments in place. |
705.24 (1) LICENSURE Bathrooms.
705.24. Bathrooms.
The nonresidential facility shall:
(1) Provide bathrooms to accommodate staff, clients and other users of the facility.
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Observations
Based on an inspection of the physical plant, the facility failed to provide paper towels or mechanical dryer in each bathroom and provide toilet paper at each toilet, at all times.
The findings include:
A physical plant inspection was conducted on July 22, 2015 at 11 AM. During the physical plant inspection, it was noted that the men's single-stall bathroom on the first floor near the elevator, did not have paper towels or a mechanical dryer.
The ladies' single-stall bathroom on the first floor near the security booth was inspected on July 21, 2015. It was noted at 9:00 AM that there was no toilet paper in this unit. Facility staff was informed of the lack of toilet paper at 9:05 AM. The ladies' bathroom was re-inspected at 11:30 AM and again at 2:00 PM. During each subsequent inspection, there was no toilet paper in the ladies' bathroom.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Responsible: The Facilities Dept is responsible for ensuring that all bathrooms have an acceptable toilet paper supply.
Timeframe: The Facilities Dept will ensure that toilet paper is present at all times starting 8/21/15.
Monitoring: The Facilities Dept will conduct daily rounds, including ensuring that all bathrooms have toilet paper at all times. |
705.26 (2) LICENSURE Heating and cooling.
705.26. Heating and cooling.
The nonresidential facility:
(2) May not permit in the facility heaters that are not permanently mounted or installed.
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Observations
Based on a physical plant inspection, the facility failed to ensure that all heaters were permanently mounted or installed.
The findings include:
A physical plant inspection was conducted on July 22, 2015. At approximately 11:00 AM a portable space heater was found on the floor behind the desk in room 157.
These findings were reviewed and confirmed with facility staff during the licensing process.
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Plan of Correction
Responsible Party:
All staff is responsible for ensuring that all heaters are permanently mounted or installed.
Plan of Correction:
The Facilities will conduct a review of each room in the building to ensure that all heaters are permanently installed. Additionally, they will ensure that each room is free of space heaters. This review will be completed by 8/28/15.
Monitoring:
The Facilities Department will include the search for portable space heaters into their daily facilities round. Any space heaters found will be reported to the Program Director and removed immediately. |
705.28 (c) (4) LICENSURE Fire safety.
705.28. Fire safety.
(c) Fire extinguishers. The nonresidential facility shall:
(4) Instruct staff in the use of the fire extinguisher upon staff employment. This instruction shall be documented by the facility.
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Observations
Based on the review of personnel records, the facility failed to document that fire extinguisher training was provided upon employment.
The findings include:
Three personnel records were reviewed for documentation of fire extinguisher training on July 20, 2015. The facility did not document that fire extinguisher training was provided upon employment in two out of three personnel records reviewed, specifically records #6 and 8.
Employee #3 was hired on March 13, 2013, but the training certificate indicated this training occurred on April 9, 2013.
Employee # 6 was contracted as a counselor on May 26, 2015. However, personnel record # 6 did not include documentation of fire extinguisher training at the time of inspection.
Employee # 8 was contracted as a counselor on April 29, 2015. However, personnel record # 8 did not include documentation of fire extinguisher training at the time of inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Responsible Party(s):
The Training and Licensing Director in conjunction with the Human Resources Director are responsible for ensuring that new hires are instructed in the use of the fire extinguisher upon staff employment.
Plan of Correction:
New hires will sign?off on having participated in the fire extinguisher training and the sign-off sheet will be filed in their personnel record upon employment.
Employees #6 and 8 will have documentation of fire extinguisher training in their personnel records by 8/26/15.
Monitoring: The Human Resources Director will monitor personnel records for the documentation of instruction in the use of the fire extinguisher and filing of the sign-off sheet for receiving fire extinguisher training. |
705.28 (d) (1) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(1) Conduct unannounced fire drills at least once a month.
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Observations
Based on a review of the fire drill record log, the facility failed to document fire drills at least once a month.
The findings include:
The fire drill record log was reviewed on July 20, 2015. The log was reviewed for the time period covering July 2014 to June 2015. There was no documentation that a fire drill had been conducted during December 2014.
These findings were reviewed and confirmed with facility staff during the licensing process.
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Plan of Correction
Responsible Party:
The Security Supervisor is responsible for ensuring that fire drills occur at least once per month.
Plan of Correction:
The Security Supervisor will complete a tentative schedule for all monthly fire drills at least one month in advance prior to the actual scheduled drill date. Additionally, the Security Supervisor will ensure that the scheduled monthly drill occurs as scheduled.
Monitoring:
All monthly fire drill logs and schedules will be reviewed at least once monthly to ensure compliance with this standard. |
705.28 (d) (3) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(3) Ensure that all personnel on all shifts are trained to perform assigned tasks during emergencies.
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Observations
Based on a review of personnel records, the facility failed to ensure that all personnel on all shifts were trained to perform assigned tasks during emergencies.
The findings include:
Three personnel records were reviewed for verification of emergency training on July 20, 2015. The facility failed to document the completion of emergency training in two of three personnel records reviewed, specifically employees # 6 and 8.
Employee # 6 was contracted as a counselor on May 26, 2015. However, personnel record # 6 did not include documentation of emergency training at the time of inspection.
Employee # 8 was contracted as a counselor on April 29, 2015. However, personnel record # 8 did not include documentation of emergency training at the time of inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Responsible Party:
The Training and Licensing Director in conjunction with the Human Resources Director are responsible for ensuring that staff on all shifts is trained to perform assigned tasks during emergencies upon hire.
Plan of Correction:
Employees #6 and 8 will receive training to perform assigned tasks during emergencies by the Licensing and Training Director by 8/26/15.
Monitoring: The Human Resource Director will monitor personnel records of new hires for the documentation that staff on all shifts are trained to perform assigned tasks during emergencies. |
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 shall be in writing and include, but not be limited to:
(2) Specific information disclosed.
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Observations
Based on a review of the patient records, the facility released information that exceeded what was permissible by 4Pa. Code 255.5(b).
The findings include:
Fourteen patient records requiring consents to release information were reviewed on July 20-21, 2015. Six out of fourteen patient records reviewed contained release information that allowed for the release of information that exceeded that which is permissible to be released by 4Pa. Code 255.5 (b), specifically records # 6, 7, 8, 9, and 10.
4 Pa. Code states:
Information released to judges, probation or parole officers, insurance company, health or hospital plan or governmental officials, pursuant to paragraphs (1), (2), (4),(7), (8) or subsection (a) of this section, is for the purpose of determining the advisability of continuing the client with the assigned project and shall be restricted to the following.
(1) Whether the client is or is not in treatment.
(2) Client's prognosis.
(3) The nature of the project.
(4) A brief description of the client's progress.
(5) A short statement as to whether the client has relapsed into drug or alcohol abuse and the frequency of such relapse.
Patient # 6 was re-admitted into treatment on June 10, 2015. A release of information form was signed on June 3, 2015 for the patient's insurance provider which indicated the facility was to release the patient's " billing information " .
Patient # 7 was admitted into treatment on June 24, 2015. A release of information form was signed on June 16, 2015 for the patient's insurance provider which indicated the facility was to release the patient's " cost reimbursement " .
Patient # 8 was admitted into treatment on March 31, 2015. A release of information form was signed on March 26, 2015 for the patient's insurance provider which indicated the facility was to release the patient's " billing information " . An additional consent to release form was signed for an insurance provider on March 26, 2015 which had the box marked " other " checked off, however the facility failed to specify what other information was to be released.
Patient # 9 was admitted into treatment on September 23, 2014. A release of information form was signed on September 11, 2014 for the patient's insurance provider which indicated the facility was to release the patient's " cost reimbursement " . Additionally, faxes were sent out to Mercy Hospital on May 27, 2015 referencing the patient ' s lab results from 2/12/15, 3/17/15, 4/82/15, and 5/13/15; the patient's PCPC summary sheet dated 5/27/15; and a letter identifying information about the patient dated 5/25/15. There was no documentation that a release had been signed by patient #9 allowing for the release of information to Mercy Hospital.
Patient # 10 was admitted into treatment on November 26, 2014. A release of information form was signed on November 19, 2014 for the patient's insurance provider; however there was no indication of what information was to be released. Additionally, a release of information form was signed on November 26, 2014 for the patient's insurance provider which indicated the facility was to release the patient's " demographic information " .
Patient # 17 was admitted into treatment on October 8, 2014. A release of information form was signed on October 2, 2014 for the patient's insurance provider which indicated the facility was to release the patient's " billing and authorization " .
These findings were reviewed with facility staff during the inspection process.
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Plan of Correction
Responsible Party:
Clinical and Business Office Staff are responsible for ensuring that all releases are filled out accurately and do not include information exceeding what is permissible.
Plan of Correction: Release of information form was updated as of 7/30/15 to exclude "billing information " . All insurance related releases now only allow for 5 areas permissible according to the 4 PA code. Releases for records #6, 7, 8, 9, `0 and 17 will be updated to ensure that the release is sufficient.
Training will also occur on ensuring the accuracy of completing releases of information forms. This training will occur by 9/30/15.
Monitoring:
Admission and all other current patient records will be reviewed once per month to ensure proper completion of all releases.
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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 the review of patient records, the facility failed to complete annual evaluations in two out of twenty-one patient records reviewed.
The findings included:
Seven of the twenty-one records reviewed required documentation of an annual clinical review. Two of those patient records did not include documentation of an annual review, specifically records # 11 and 20.
Patient #11 was admitted into treatment on 8/14/13, an annual review was due by 8/14/14. There was no documentation of an annual clinical review for client #11 by the date of monitoring.
Patient #20 was admitted into treatment 12/30/11, an annual review was due by 12/30/14. There was no documentation of an annual clinical review for client #14 by the date of monitoring.
The findings were reviewed with facility staff during the monitoring process.
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Plan of Correction
Responsible Party:
The Clinical Staff is responsible for ensuring that annual evaluations are completed at each member's anniversary date.
Plan of Correction:
Annual Evaluations will be completed for all deficient records #11 and 20 by 8/28/15.
Monitoring:
Supervisors will monitor due dates of all annual evaluations and ensure counselor completion on the anniversary of each member as scheduled. |
709.93(a) LICENSURE Client records
709.93. Client records.
(a) There shall be a complete client record on an individual which includes information relative to the client's involvement with the project. This shall include, but not be limited to, the following:
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Observations
Based on the review of patient records the facility failed to ensure that a complete record was documented in six out of twenty-one patient records reviewed. Seven of the twenty-one records reviewed required documentation of a follow-up attempt; however, six of those seven records did not include documentation of a follow-up attempt.
The findings include:
Seven patient records were reviewed for documentation of a follow-up on July 20-21, 2015. The facility failed to document a follow-up attempt in six out of seven discharged records, specifically patient records #13, 14, 17, 19, 20, and 21.
Patient #13 was admitted on 4/19/11 and discharged on 2/25/15. As of the date of inspection, there was no documentation of a follow-up attempt for patient #13.
Patient #14 was admitted on 7/10/13 and discharged on 6/9/15. As of the date of inspection, there was no documentation of a follow-up attempt for patient #14.
Patient #17 was admitted on 10/8/14 and discharged on 6/8/15. As of the date of inspection, there was no documentation of a follow-up attempt for patient #17.
Patient #19 was admitted on 6/1/11 and discharged on 9/9/14. As of the date of inspection, there was no documentation of a follow-up attempt for patient #19.
Patient #20 was admitted on 12/30/11 and discharged on 6/12/14. As of the date of inspection, there was no documentation of a follow-up attempt for patient #20.
Patient #21 was admitted on 11/19/14 and discharged on 4/21/15. As of the date of inspection, there was no documentation of a follow-up attempt for patient #21.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Responsible Party: The Counselor of records is responsible for ensuring that all discharged members have a documented follow up attempt.
Plan of Correction: The Counselor of record for charts #13, 14, 17, 19, 20, and 21, will complete a follow up attempt on each record by 9/11/15.
Additionally training to update staff on the completion of follow up attempts will be completed by 9/18/15.
Monitoring:
Clinical Supervisors will review all discharges at 30 days post discharge to ensure all follow up attempts are documented as required.
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