INITIAL COMMENTS
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This report is a result of an on-site licensing inspection conducted on November 8-10, 2011, by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site licensing inspection, Center for Behavioral Health-PA, Inc 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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705.28 (d) (4) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(4) Maintain a written fire drill record including the date, time, the amount of time it took for evacuation, the exit route used, the number of persons in the facility at the time of the drill, problems encountered and whether the fire alarm or smoke detector was operative.
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Observations
Based on a review of fire drill records, the facility failed to maintain a written fire drill record which included the number of persons in the facility at the time of the drill.
The findings include:
Fire drill records for the time period of December 2010 to October 2011 were reviewed on November 8-10, 2011. The fire drill records reviewed did not include the number of persons in the facility at the time of the drill for the months of January, February, March, May, September and October, 2011.
An interview with the program manager on November 10, 2011 confirmed the findings.
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Plan of Correction
In order to comply with regulations, the Health and Safety Captain will identify the number of persons in the facility at the time of the fire drill. The Health and Safety Captain will record these findings on the Emergency Drills Testing and Analysis form to maintain a written record that includes the number of persons in the facility at the time of the drill.
Program Director will monitor to ensure this regulation is being followed. |
709.28(c) 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:
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Observations
Based on the review of client records, the facility failed to obtain an informed and voluntary consent from the client for the disclosure of information in five of sixteen client records.
The findings include:
Twenty client records were reviewed on November 8-10, 2011. Sixteen records were reviewed for compliance with the requirement to obtain an informed and voluntary consent to release information from the client. Client records # 3, 4, 5, 7 and 8 included documentation of the release of client identifying information to the Department of Public Welfare for funding verification. There were no written consents to release client identifying information to the Department of Public Welfare documented in client records # 3, 4, 5, 7 and 8.
An interview with the clinical supervisor and the program manager on November 10, 2011 confirmed the findings.
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Plan of Correction
Patients #3, 4, 5, 7, and 8 will be asked to review and sign a consent to release patient information to the PA Department of Public Welfare for funding verification. Program Manager will review patient charts to ensure consents to release are in patient chart before funding verification is obtained. Program Director will monitor for compliance to regulations and confidentiality. |
715.16(a)(1) LICENSURE Take-home privileges
(a) A narcotic treatment program shall determine whether a patient may be provided take-home medications.
(1) A narcotic treatment program may give take-home medications only to a patient who the narcotic treatment physician has determined is responsible and able to handle narcotic drugs outside the narcotic treatment program.
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Observations
Based on the review of patient records, the facility failed to document that the narcotic treatment physician determined whether a patient may be provided take-home medications in one of one patient record.
The findings include:
Twenty patient records were reviewed during the on-site licensing inspection conducted on November 8-10, 2011. Patient record #3 included documentation of take home medication privileges. There was no documentation that the narcotic treatment physician determined whether the patient may be provided with take home medication prior to the patient receiving the take home medication.
Patient # 3 was admitted on July 21, 2011 as a transfer from another treatment facility. An order dated July 21, 2011 and signed at 9:25 AM by the Certified Registered Nurse Practitioner, stated "the patient with bi weekly privileges". The patient was dosed at 9:26 AM and three take home medication bottles were dispensed at 9:30 AM. The narcotic treatment physician signed the order on July 21, 2011 at 9:49 AM. There was no documentation that the physician had provided a verbal order for the take home medication prior to the written order.
The program manager was interviewed on November 10, 2011 and confirmed the findings.
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Plan of Correction
Associates had obtained documentation to ensure program physician can make a determination to provide patient #3 with take home status.
Effective immediately, program physician will not place an order for take home medication unless documentation is in hand to identify if a patient is responsible to handle narcotic drugs outside of narcotic treatment program.
Clinical supervisor will perform audits on each admission to ensure compliance to take home medication regulation is followed. Program Director will oversee.
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715.16(a)(3) LICENSURE Take-home privileges
(a) A narcotic treatment program shall determine whether a patient may be provided take-home medications.
(3) The narcotic treatment physician shall document in the patient record the rationale for permitting take-home medication.
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Observations
Based on the review of client records, the facility failed to ensure the physician documented in the patient record the rationale for granting take home medication in one of one patient record.
The findings include:
Twenty patient records were reviewed during the on-site licensing inspection conducted on November 8-10, 2011. Patient record #3 included documentation of take home medication privileges. There was no documentation of the physician's rationale for granting the take home medication.
The program manager was interviewed on November 10, 2011 and confirmed the findings.
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Plan of Correction
To correct this deficiency, Medical Director documented the rational for the take home status ordered in patient #3 chart utilizing the 8 point form.
Effective immediately, Medical Director will clearly document the rational before ordering take home medication in the 8 point form.
Program Director will monitor for compliance. |
715.16(b)(1-8) LICENSURE Take-home privileges
(b) The narcotic treatment physician shall consider the following in determining whether, in exercising reasonable clinical judgment, a patient is responsible in handling narcotic drugs:
(1) Absence of recent abuse of drugs (narcotic or non-narcotic), including alcohol.
(2) Regular narcotic treatment program attendance.
(3) Absence of serious behavioral problems at the narcotic treatment program.
(4) Absence of known recent criminal activity.
(5) Stability of the patient 's home environment and social relationships.
(6) Length of time in comprehensive maintenance treatment.
(7) Assurance that take-home medication can be safely stored within the patient 's home.
(8) Whether the rehabilitative benefit to the patient derived from decreasing the frequency of attendance outweighs the potential risks of drug diversion.
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Observations
Based on the review of patient records, the facility failed to document that the narcotic treatment physician considered the criteria for take-home privileges in one of one patient record.
The findings include:
Twenty patient records were reviewed during the on-site licensing inspection conducted on November 8-10, 2011. Patient record #3 included documentation of take home medication privileges. There was no documentation that the narcotic treatment physician considered the required criteria.
The program manager was interviewed on November 10, 2011 and confirmed the findings.
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Plan of Correction
To correct this deficiency, the Medical Director utilized and considered the 8 criteria from regulations to determine patient #3's take home status.
To prevent this deficiency in the future, the Medical Director will review and consider the 8 point criteria before ordering take home medication.
Program Director will perform audits regularly to ensure compliance to this regulation. |
709.92(a)(3) LICENSURE Treatment and rehabilitation services
709.92. Treatment and rehabilitation services.
(a) An individual treatment and rehabilitation plan shall be developed with a client. This plan shall include, but not be limited to, written documentation of:
(3) Proposed type of support service.
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Observations
Based on a review of client records, the facility failed to provide written documentation of the proposed type of support service, in the individual treatment and rehabilitation plans, in seven of sixteen client records.
The findings include:
Twenty client records were reviewed on November 8 - 10, 2011. Sixteen client records required documentation of an individual treatment and rehabilitation plan which included the proposed type of support services. The facility did not document the proposed type of support services on the treatment plans in client records # 4, 6, 8, 12, 13, 14 and 19.
Client # 4 was admitted into treatment on March 7, 2011. The individual treatment and rehabilitation plan was completed on April 11, 2011. There was no documentation of support services in the treatment plan.
Client # 6 was admitted into treatment on January 24, 2011. The individual treatment and rehabilitation plan was completed on February 22, 2011. There was no documentation of support services in the treatment plan.
Client # 8 was admitted into treatment on April 28, 2011. The individual treatment and rehabilitation plan was completed on May 25, 2011. There was no documentation of support services in the treatment plan.
Client # 12 was admitted into treatment on March 4, 2011. The individual treatment and rehabilitation plan was completed on April 12, 2011. There was no documentation of support services in the treatment plan.
Client # 13 was admitted into treatment on May 6, 2011. The individual treatment and rehabilitation plan was completed on June 7, 2011. There was no documentation of support services in the treatment plan.
Client # 14 was admitted into treatment on May 19, 2011. The individual treatment and rehabilitation plan was completed on June 17, 2011. There was no documentation of support services in the treatment plan.
Client # 19 was admitted into treatment on September 2, 2011. The individual treatment and rehabilitation plan was completed on October 7, 2011. There was no documentation of support services in the treatment plan.
An interview with the clinical supervisor and program manager on November 10, 2011 confirmed the findings.
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Plan of Correction
Support services will be added to the treatment plans of patients #4, 6, 8, 12, 13, 14 and 19.
Treatment plan training was conducted with Clinical Associates on 12/1/2011. PA Department of Health regulation 709.92 was an item reviewed.
Clinical Supervisor will review each treatment plan before approval. Clinical Supervisor will not approve a treatment plan that does not include a support service.
Program Director will perform spot checks to ensure each comprehensive treatment plan includes a support service. |
709.93(a)(10) 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:
(10) Discharge summary.
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Observations
Based on a review of patient records, the facility failed to document a discharge summary within one week of discharge in three of seven client records.
The findings include:
Twenty client records were reviewed on November 8-10, 2011. Discharge summaries were required in seven client records. The facility did not document a discharge summary within one week of discharge in client records # 1, 18 and 19.
Client # 1 was readmitted on September 23, 2011. The client had been previously discharged on August 11, 2011. The discharge summary was to be completed by August 18, 2011. The discharge summary was completed on August 22, 2011.
Client # 18 was admitted on February 2, 2010 and discharged on September 22, 2011. The discharge summary was to be completed by September 29, 2011. The discharge summary was completed on September 30, 2011.
Client # 19 was admitted on September 2, 2011 and discharged on October 16, 2011. The discharge summary was to be completed by October 23, 2011. The discharge summary was completed on October 25, 2011.
The clinical supervisor and program manager were interviewed on November 10, 2011 and confirmed the findings.
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Plan of Correction
A training was conducted on 12/01/2011 to review Discovery House policy as well as PA Department of Health regulation 709.93.
During this training, it was emphasized with clinical Associates the importance of completing work on or before the due date identified by the computerized alert system.
Clinical Supervisor will review "services due" report daily. Any work that is not completed by the due date will be discussed with the clinician during supervision.
Program Director will oversee to ensure policy and regulations are being followed. |