INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection and methadone monitoring inspection conducted on June 11-12, 2024 by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, New Directions Healthcare, LLC 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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709.34 (c) (2) LICENSURE Reporting of unusual incidents
§ 709.34. Reporting of unusual incidents.
(c) To the extent permitted by State and Federal confidentiality laws, the project shall file a written unusual incident report with the Department within 3 business days following an unusual incident involving:
(2) Death or serious injury due to trauma, suicide, medication error or unusual circumstances.
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Observations
Based on a review of administrative information and client lists, the facility failed to inform the Department of an unusual incident within the required three days.
The facility had an unusual incident occur on February 26, 2024, March 1, 2024 and March 7, 2024 which involved death of a client. The facility had not submitted a written unusual incident report to the Department.
This finding was reviewed with the facility staff during the licensing process.
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Plan of Correction
This was corrected while DDAP on site on June 12 2024 submitting the patient death online. The Clinical Supervisors educated staff on 6-18-2024 the requirement. The Project Director will be responsible to ensure that all patient deaths are reported to DDAP by submitting online within 3 days any patient deaths. An unusual incidents folder with all reported deaths will be kept in the Project Directors office in a locked drawer. Any patients death an email will be sent out by the Clinical Director to the Medical Director and Project Director for notification of incident. |
709.34 (c) (4) LICENSURE Reporting of unusual incidents
§ 709.34. Reporting of unusual incidents.
(c) To the extent permitted by State and Federal confidentiality laws, the project shall file a written unusual incident report with the Department within 3 business days following an unusual incident involving:
(4) Event at the facility requiring the presence of police, fire or ambulance personnel.
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Observations
Based on a review of administrative information, the facility failed to inform the Department of an unusual incident within the required three days.
The facility had an unusual incident occur on July 31, 2023 and February 16, 2024 which involved police or EMS personnel onsite. The facility had not submitted a written unusual incident report to the Department.
This finding was reviewed with the facility staff during the licensing process.
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Plan of Correction
The Clinical Supervisor educated all front staff that any unusual incidences involving police, EMS onsite must be submitted online on DDAP portal with in 3 days on 6-12-24. All staff will be educated at the staff meeting on 7-2-24. An email to all staff was sent out on 6-27-24 by the Project Director educating all staff on the requirement. Once any EMS or police are called to the clinic staff must notify a clinical supervisor who will report to DDAP within 3 days. An email with the unusual report will be sent to the Project Director and Medical Director. The unusual incidences' are kept in a locked drawer in the Project Directors' office and the Project Director will be responsible for ensuring it is done. |
715.20(4) LICENSURE Patient transfers
A narcotic treatment program shall develop written transfer policies and procedures which shall require that the narcotic treatment program transfer a patient to another narcotic treatment program for continued maintenance, detoxification or another treatment activity within 7 days of the request of the patient.
(4) The receiving narcotic treatment program shall document in writing that it notified the transferring narcotic treatment program of the admission of the patient and the date of the initial dose given to the patient by the receiving narcotic treatment program.
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Observations
Based on a review of patient records, the facility failed to document, in writing, that they notified the transferring narcotic treatment program of the date of the admission of a patient and the date of the initial dose given to the patient in one of one patient records reviewed.
Patient #3 was transferred in/admitted from another narcotic treatment program on November 10, 2023 and was still active at the time of inspection. There was a letter documented in the chart but no verification that it was sent.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
The Clinical Supervisor met with the front desk staff on 6-12-24 staff and educated on the requirement that all transfers must have the date of admission and date of initial dose documented in writing in the patients 'chart. The verification of transfer must be signed by the a clinical Supervisor prior to scanning in the patients chart. The verification form must be obtained prior to the patient getting admitted. Also, any patient transferring and or admitted in must have the requirement that verification must be received and documented in the patients chart. The Clinical Supervisors will be responsible for ensuring this is done for all new intakes or transfers in. This verification is part of our quality assurance audit and the audits need to be signed off by a clinical supervisor. |