INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on January 29, 2020 to January 31, 2020 by staff from the Department of Drug and Alcohol Programs, Bureau of Quality Assurance for Prevention and Treatment. Based on the findings of the on-site inspection, UHS Recovery Foundation, 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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715.9(a)(2) LICENSURE Intake
(a) Prior to administration of an agent, a narcotic treatment program shall screen each individual to determine eligibility for admission. The narcotic treatment program shall:
(2) Verify the individual 's identity, including name, address, date of birth, emergency contact and other identifying data.
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Observations
The facility failed to verify the individual's identity, which is to include the name, address and date of birth, prior to the administration of a narcotic agent in eight of eight applicable patient records.
Patient # 1 was admitted to the detoxification level of care on August 2, 2018 and was discharged on August 7, 2018.
Patient # 2 was admitted to the detoxification level of care on September 6, 2019 and was discharged on September 10, 2019.
Patient # 4 was admitted to the detoxification level of care on January 27, 2020 and was active at the time of the inspection.
Patient # 5 was admitted to the detoxification level of care on January 26, 2020 and was active at the time of the inspection.
Patient # 6 was admitted to the detoxification level of care on December 30, 2019 and was discharged on January 3, 2020.
Patient # 7 was admitted to the detoxification level of care on January 8, 2019 and was discharged on January 11, 2019.
These findings were reviewed with project and facility staff during the licensing process.
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Plan of Correction
The facility will have all clients who are unable to verify their identity by means of official identification, indicating name, address and date of birth, sign an attestation indicating the particulars outlined. In addition, the facility will attempt to validate the client's identity thorough corroboration with the respective insurance carrier. In the event that verification is required from the insurance carrier, the Director of Admissions will be responsible for coordinating the receipt of that information. For clients who are indicated as being treated with MAT at the time of intake, the admissions staff will be responsible for verification of identity. For clients being initiated on MAT after time of admission, the nursing staff will be responsible to verify identify. All Admissions and Nursing staff will be trained in this protocol by the Director of Admissions and Director of Nursing, respectively by 3/6/2020. Each indicated Director will conduct compliance checks as a part of their ongoing monthly chart audits, and will report compliance to the Performance Improvement Committee on a monthly basis. |
715.21(1)(i-iv) LICENSURE Patient termination
A narcotic treatment program shall develop and implement policies and procedures regarding involuntary terminations. Involuntary terminations shall be initiated only when all other efforts to retain the patient in the program have failed.
(1) A narcotic treatment program may involuntarily terminate a patient from the narcotic treatment program if it deems that the termination would be in the best interests of the health or safety of the patient and others, or the program finds any of the following conditions to exist:
(i) The patient has committed or threatened to commit acts of physical violence in or around the narcotic treatment program premises.
(ii) The patient possessed a controlled substance without a prescription or sold or distributed a controlled substance, in or around the narcotic treatment program premises.
(iii) The patient has been absent from the narcotic treatment program for 3 consecutive days or longer without cause.
(iv) The patient has failed to follow treatment plan objectives.
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Observations
The facility failed to ensure that the patient's involuntary termination met the regulatory conditions in one of three applicable records reviewed.
Patient # 7 was admitted to the detoxification level of care on January 8, 2019 and was involuntarily discharged on January 11, 2019.
These findings were reviewed with project and facility staff during the licensing process.
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Plan of Correction
The facility leadership has re-reviewed the regulation related to involuntary treatment termination, in order to assure ongoing compliance. Clinical, Utilization Review, Risk Management and Continuing Care (discharge planning) staff have received re-educated, by the Chief Clinical Officer, in alignment with the regulations. Effective immediately following the inspection feedback, the agency's practices were adjusted to be compliant with these regulation. Ongoing compliance will be monitored by the process of monthly chart audits, conducted by the Clinical Manager, and will be reported to the Performance Improvement Committee on a monthly basis. |
709.14(b)(5) LICENSURE Subchapter B.Licensing Procedures.Restriction
709.14. Restriction on license.
(b) The licensee, using Department forms, shall notify the Department within 90 days of the occurrence of any of the following conditions:
(5) Change in authorized maximum capacity.
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Observations
The facility failed to notify the Department, within 90 days, of a change in the authorized maximum capacity. The facility is licensed for the Inpatient Hospital Detox activity (capacity of 42) and the Inpatient Non-Hospital Drug Free activity (capacity of 95). Additionally, the facility had not been approved for a flex bed exception. Based on the Staffing Requirements Facility Summary Report, submitted on January 29, 2020, the facility had 10 clients in the Inpatient Non-Hospital Detox activity and 102 clients in the Inpatient Non-Hospital Drug Free activity. At the time of the inspection, the facility was seven clients over the approved capacity for the Inpatient Non-Hospital Drug Free activity.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The facility has applied for, and has been granted, an exception to flexibly use 42 bed for either detox or rehab. The facility will maintain a census that does not exceed the total licensed capacity. |