INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection and capacity increase inspection conducted on March 10 - 12, 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, Spiritlife, 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.
The facility will be notified by a separate letter of the determination regarding the capacity increase request.
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Plan of Correction
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704.11(c)(1) LICENSURE Mandatory Communicable Disease Training
704.11. Staff development program.
(c) General training requirements.
(1) Staff persons and volunteers shall receive a minimum of 6 hours of HIV/AIDS and at least 4 hours of tuberculosis, sexually transmitted diseases and other health related topics training using a Department approved curriculum. Counselors and counselor assistants shall complete the training within the first year of employment. All other staff shall complete the training within the first 2 years of employment.
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Observations
The facility failed to document HIV/AIDS and TB/STD training in four of five personnel/training records reviewed on March 10, 2020.
Employee # 6 was hired as a counselor January 18, 2019.
Employee # 7 was hired as a counselor October 28, 2018.
Employee # 10 was hired as support staff November 28, 2016.
Employee # 11 was hired as support staff October 5, 2015.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Employees #6, #7, #10, #11 will be scheduled and receive the required HIV/AIDS and TB/STD Training prior to 04/30/2020. Compliance Coordinator will review all new hires at the six months of employment to assure that they have attended the required training. Completion of the training will be monitored by the Medical Director or their designee. |
715.9(a)(1) 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:
(1) Verify that the individual has reached 18 years of age.
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Observations
The facility failed to document the individual had reached 18 years of age prior to administration of a narcotic agent in two of four patient records reviewed on March 10 - 12, 2020.
Patient # 1 was admitted December 24, 2019. Buprenorphine was administered to patient # 1 on December 28, 2019.
Patient # 2 was admitted October 10, 2019 and discharged December 27, 2019. Buprenorphine was administered to patient # 2 on October 13, 2019.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Effective Immediately, all clients being admitted into SpiritLife, regardless of level of care, must present upon admission, a state issued ID, passport or a photo ID with address and/or birth date. The admissions coordinator will make a copy of the ID and it will be available for review in the client's chart. Monthly chart audits will be conducted, by the Medical Records Department, Medical Director or their designee will monitor process to assure compliance. |
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 document verification of the individual's identity including name, address and date of birth prior to administration of a narcotic agent in two of four patient records reviewed on March 10 - 12, 2020.
Patient # 1 was admitted December 24, 2019. Buprenorphine was administered to patient # 1 on December 28, 2019.
Patient # 2 was admitted October 10, 2019 and discharged December 27, 2019. Buprenorphine was administered to patient # 2 on October 13, 2019.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Effective immediately, all clients being admitted into SpiritLife, regardless of level of care, must present upon admission, a state issued ID, passport or a photo ID with address and birth date. The admissions coordinator will make a copy of the ID and it will be available for review in the client's chart. Monthly chart audits will be conducted, by the Medical Records Department , the Medical Director or their designee will monitor process to assure compliance. |
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's physician failed to document in the patient's record the basis for the determination of current dependency upon a narcotic drug and evidence of a one year history of addiction prior to administration of an agent in four of four patient records reviewed on March 10 - 12, 2020.
Patient # 1 was admitted December 24, 2019. The face-to face was conducted December 26, 2019 and buprenorphine was administered on December 28, 2019.
Patient # 2 was admitted October 10, 2019 and discharged December 27, 2019. The face-to-face was conducted October 11, 2019 and buprenorphine was administered on October 13, 2019.
Patient # 3 was admitted September 27, 2019 and discharged November 18, 2019. The face-to-face was conducted September 30, 2019. Buprenorphine was administered on September 27, 2019, prior to the face-to-face examination of patient # 3.
Patient # 4 was admitted September 9, 2019 and discharged October 28, 2019. The face-to-face was conducted September 10, 2019 and buprenorphine was administered on September 12, 2019.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Upon admission for narcotics treatment clients will be thoroughly screened thru a face to face review by the narcotics treatment physician. The narcotic treatment physician shall document in the client's record the basis for the determination of the current dependency and evidence of a one-year addiction history. MAT Nurse Navigator updated and informed all attending physicians on the process. This will be monitored by the Medical Director or their designee for the facility to assure compliance. |
715.10(f) LICENSURE Pregnant patients
(f) The narcotic treatment program shall ensure that each female patient is fully informed of the possible risk to her or her unborn child from continued use of illicit drugs and from use of, or withdrawal from a narcotic drug administered or dispensed by the program in comprehensive maintenance or detoxification treatment.
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Observations
The facility failed to document that each female patient was fully informed of the possible risk to her or her unborn child from continued use of illicit drugs and from use of, or withdrawal from a narcotic drug administered by the the program in maintenance treatment in two of four patient records reviewed on March 10 - 12, 2020.
Patient # 2 was admitted October 10, 2019 and discharged December 27, 2019.
Patient # 4 was admitted September 9, 2019 and discharged October 28, 2019.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The MAT Nurse Navigator created an Informed Buprenorphine Consent form, that documents informing the patient of the possible risks to an unborn child from continued use of illicit drugs and from the use of or withdrawal from a narcotic drug administered by the facility has been created and implemented by 4/15/2020. This requires a staff and client signature acknowledging the understanding of the content. Monthly chart audits completed by the Medical Records Department. Nurse Manager will ensure that every female client has a signed consent prior to administration of a controlled substance for treatment purposes. |
715.12(1-5) LICENSURE Informed patient consent
A narcotic treatment program shall obtain an informed, voluntary, written consent before an agent may be administered to the patient for either maintenance or detoxification treatment. The following shall appear on the patient consent form:
(1) That methadone and LAAM are narcotic drugs which can be harmful if taken without medical supervision.
(2) That methadone and LAAM are addictive medications and may, like other drugs used in medical practices, produce adverse results.
(3) That alternative methods of treatment exist.
(4) That the possible risks and complications of treatment have been explained to the patient.
(5) That methadone is transmitted to the unborn child and will cause physical dependence.
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Observations
The facility failed to document an informed, voluntary, written consent was obtained from the patient that included all of the required components prior to administration of an agent for maintenance treatment in four of four patient records reviewed on March 10 - 12, 2020.
Patient # 1 was admitted December 24, 2019. Buprenorphine was administered to patient # 1 on December 28, 2019.
Patient # 2 was admitted October 10, 2019 and discharged December 27, 2019. Buprenorphine was administered to patient # 2 on October 13, 2019.
Patient # 3 was admitted September 27, 2019 and discharged November 18, 2019. Buprenorphine was administered to patient # 3 on September 27, 2019.
Patient # 4 was admitted September 9, 2019 and discharged October 28, 2019. Buprenorphine was administered to patient # 4 on September 12, 2019.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The MAT Nurse Navigator created a consent which contains the following 5 critical information points: (1) That methadone and LAAM are narcotic drugs which can be harmful if taken without medical supervision. (2) That methadone and LAAM are addictive medications and may, like other drugs used in medical practices, produce adverse results. (3) That alternative methods of treatment exist. (4) That the possible risks and complications of treatment have been explained to the patient. (5) That methadone is transmitted to the unborn child and will cause physical dependence. Effective immediately, prior to the administration of a narcotic agent, all clients will sign an informed consent. This consent includes the risks and possible adverse effects from continued use of illicit drugs and from use of, or withdrawal from, a narcotic drug administered in treatment. All nursing staff will be trained on the importance of this standard. Monthly chart audits will be conducted by Medical Records Department to assure compliance. |
715.14(a) LICENSURE Urine testing
(a) A narcotic treatment program shall complete an initial drug-screening urinalysis for each prospective patient and a random urinalysis at least monthly thereafter.
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Observations
The facility failed to document a random monthly drug-screening urinalysis in three of four patient records reviewed on March 10 - 12, 2020.
Patient # 1 was admitted December 24, 2019. No drug screen was documented for February 2020 in patient record # 1.
Patient # 2 was admitted October 10, 2019 and discharged December 27, 2019. No drug test was documented for November 2019 in patient record # 2.
Patient # 3 was admitted September 27, 2019 and discharged November 18, 2019. No drug screen was documented for October 2019 in patient record # 3.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
All medical staff will be trained in the protocol and policies that requires that clients have a initial urinalysis completed prior to the administration of a narcotic agent. The training will address SpiritLife protocol and policy that all clients that are opiate dependent will receive a urinalysis at the time of admission. Also the training will include the protocol and policies the the results of the urinalysis be placed in the client record as soon as the results are obtained, which is during the admission process. The training will be completed by 4/30/2020. The documentation of the training will be maintained in the employee records. Effective immediately, MAT Nurse Navigator will conduct random monthly drug screens on all clients receiving buprenorphine.To ensure that all staff are familiar with the protocol and policies it will be a requirement of new employees orientation and maintained in their employee record. Monthly chart audits will be conducted by the Medical Records Department to assure compliance. |