INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection and an on-site inspection conducted for the approval to use a narcotic agent, specifically buprenorphine, in the treatment of narcotic addiction. This inspection was conducted on March 27-29, 2018 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Teen Challenge Training Center, 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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704.11(f)(2) LICENSURE Trng Hours Req-Coun
704.11. Staff development program.
(f) Training requirements for counselors.
(2) Each counselor shall complete at least 25 clock hours of training annually in areas such as:
(i) Client recordkeeping.
(ii) Confidentiality.
(iii) Pharmacology.
(iv) Treatment planning.
(v) Counseling techniques.
(vi) Drug and alcohol assessment.
(vii) Codependency.
(viii) Adult Children of Alcoholics (ACOA) issues.
(ix) Disease of addiction.
(x) Aftercare planning.
(xi) Principles of Alcoholics Anonymous and Narcotics Anonymous.
(xii) Ethics.
(xiii) Substance abuse trends.
(xiv) Interaction of addiction and mental illness.
(xv) Cultural awareness.
(xvi) Sexual harassment.
(xvii) Developmental psychology.
(xviii) Relapse prevention.
(3) If a counselor has been designated as lead counselor supervising other counselors, the training shall include courses appropriate to the functions of this position and a Department approved core curriculum or comparable training in supervision.
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Observations
The facility failed to document that each counselor completed at least 25 hours of training for the 2017 training year.
The staff training hours for the 2017 training year were reviewed on March 27, 2018. Staff #4 was required to complete at least 25 hours of training for the 2017 training year. Staff #4 completed 19 hours of training for the 2017 training year.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
L0083- In order to ensure clinical staff are completing all necessary training hours, a staff member has been assigned to review training files on a monthly basis to ensure staff are completing required trainings. The assigned staff member will complete a full audit of training files on a quarterly basis and follow up with staff needing to complete trainings. The organization will follow up with performance counseling for staff who are repeatedly found to not be in compliance with training requirements. |
709.32 (c) LICENSURE Medication control
§ 709.32. Medication control.
(c) The project shall have and implement a written policy and procedures regarding all medications used by clients which shall include, but not be limited to:
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Observations
The facility failed to document inspections of the medication storage areas at least quarterly.
A physical plant inspection was conducted on March 23, 2018. The inspection documentation for the medication storage area was requested during the physical plant inspection. There was one inspection of the storage area completed in the timeframe reviewed, March 2017 - March 2018.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
POC ? Teen Challenge has contacted (4/20/18) our contracted Pharmacy and set up quarterly medication inspections. We will have quarterly inspections done by our contracted pharmacy and this will be over seen by our medical director. |
715.9(a)(4) 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:
(4) Have a narcotic treatment physician make a face-to-face determination of whether an individual is currently physiologically dependent upon a narcotic drug and has been physiologically dependent for at least 1 year prior to admission for maintenance treatment. The narcotic treatment physician shall document in the patient 's record the basis for the determination of current dependency and evidence of a 1 year history of addiction.
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Observations
The facility failed to document that the physician made a face to face determination of current physiological dependence upon a narcotic drug.
Four buprenorphine patient records were reviewed on March 27-29, 2018. The physical exam and medical history documentation documented in patient records #2, 4 and 5 were signed by the nurse and physician; however, it was unclear, based on the documentation provided, that the physican met face to face with patients #2, 4 and 5 and determined their current physiological dependence upon a narcotic drug. Patient #3's physical exam and medical history form was completed by the CRNP. The physician's determination of current physiological dependence was not documented in patient record #3.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
POC ? Teen Challenge Training Center has redesigned (4.20.18) our complete medical assessment to include a section for the medical director's direct observations, rational explanation and recommendations. We have trained the medical staff to utilize this new medical assessment. The nurse manager will conduct periodic chart audits to ensure compliance.
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715.15(b) LICENSURE Medication dosage
(b) The narcotic treatment physician shall determine the proper dosage level for a patient, except as otherwise provided in this section. If the narcotic treatment physician determining the initial dose is not the narcotic treatment physician who conducted the patient examination, the narcotic treatment physician shall consult with the narcotic treatment physician who performed the examination before determining the patient 's initial dose and schedule.
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Observations
The facilty failed to determine that the narcotic treatment physician documented the proper dosage level for a patient.
Four buprenorphine patient records were reviewed on March 27-29, 2018. The narcotic treatment physician wrote the order for buprenorphine in 3 of 4 patient records reviewed. The CRNP completed the physical and buprenorphine order in patient record #3.
Patient #3 was admitted on March 25, 2018. The intake physical and initial buprenorphine order was written on March 26, 2018 by the CRNP.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
POC- The Teen Challenge medical doctor will directly conduct or supervise all OTP medical assessments. Our medical doctor will write all OTP medical orders. The medical director has assigned the nurse manager to audit charts quarterly to ensure compliance. The clinical team was notified of this policy change on 4.20.2018.
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709.53(a) LICENSURE Complete Client Record
709.53. 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
The facility failed to document a complete client record which included case consultations, aftercare plans, discharge summaries and follow up.
Four inpatient client records were reviewed on March 27-29, 2018. Client records #4, 6 and 7 did not include documentation of a case consultation, aftercare plan, discharge summary and/or follow up.
Client #4 was admitted on 1/23/18 and discharged on 2/20/18. Client record #4 did not include documentation of a case consultation, aftercare plan, discharge summary and follow up.
Client #6 was admitted on 10/23/17 and discharged on 11/21/17. Client record #6 did not include documentation of a case consultation.
Client #7 was admitted on 1/25/18 and discharged on 2/22/18. Client record #7 did not include documentation of a case consultation.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
All missing documentation that was able to be completed (follow up contacts and discharge summaries) was completed for the indicated charts.
Counselors were addressed as a group regarding the importance of completing discharge summaries, case consultations, aftercare plans and follow up contacts. Individual counselors were addressed as they were identified from the deficient charts. One counselor was given internal agency disciplinary action due to deficiencies identified in the audit. That counselor has developed a plan of improvement to develop in these areas, including increased supervision and training.
Training was provided to all counselors on 4/19/18 regarding chart documentation and the importance of maintaining charts according to standards.
Additionally, the clinical treatment team has been asked to report daily in their morning treatment team meeting on the length of stay for each patient, in order to identify the need for time sensitive documentation. Team members have also been asked to report on aftercare planning process, and give updates on required documentation .
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