INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on April 1-4, 2019, by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Cove Forge Behavioral Health System at Williamsburg 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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704.1-704.2(a) LICENSURE Staffing Compliance Plan
CHAPTER 704. STAFFING REQUIREMENTS FOR DRUG AND ALCOHOL TREATMENT ACTIVITIES
704.1. Scope.
This chapter applies to staff persons employed by drug and alcohol treatment facilities which are licensed or approved under Chapters 157, 709 and 711 (relating to drug and alcohol services; standards for licensure of freestanding treatment activities; and standards for certification of treatment activities which are a part of a health care facility) with the exception of staff persons employed in intake, evaluation and referral facilities as delineated in Chapter 709, Subchapter D (relating to standards for intake, evaluation and referral activities) and Chapter 711, Subchapter C (relating to standards for intake, evaluation and referral activities). Staff persons shall possess the qualifications set forth in this chapter and shall also participate in training as required in this chapter.
704.2. Compliance plan.
(a) The project's governing body shall approve a written compliance plan to insure that the staff persons affected by this chapter meet the appropriate educational and experiential qualifications and receive training as stipulated in this chapter.
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Observations
Based on a review of the project's policy and procedure manual, position descriptions, and an interview with facility staff, the project failed to ensure that the staff persons meet the educational and experiential qualification requirements of chapter 704. The position description for the Director of Program Management, also known as the Facility Director, does not include the requirement that the person have experience in program planning. The facility staff stated that their Counselor 2 position, was the equivalent of a counselor as per the Department of Drug and Alcohol Programs staffing regulations. However, the position description for a Counselor 2, only requires a high school diploma, and not an Associate degree or higher. The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The HR department ensure the need for experience in program planning as a qualification for the Facility Director role will be added to the system's job description.
The line stating that a high school diploma is acceptable for a Counselor level position will be removed from the Counselor 2 job description by the HR manager. A line stating the education requirement for a counselor is a minimum of an associate's degree in chemical dependency, psychology, social work, counseling, nursing (with a clinical specialty in human services) or other related field will be added by the HR manager.
The executive director's designee will review the project's policies and procedures against DDAP regulations annually to ensure compliance. |
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 ensure that all of its staff completed the required training in communicable diseases. A total of 25 staff records were reviewed during the administrative review conducted on March 18-21, 2019. Staff Person #7 was hired as a counselor on November 6, 2017, and was required to have 6 hours of HIV/AIDS and 4 Hours of TB/STD training by November 6, 2018, but at the time of the administrative review there was no documentation that the staff person received the training. Staff Person #18 was hired as a counselor assistant on November 6, 2017, and was required to have 6 hours of HIV/AIDS and 4 Hours of TB/STD training by November 6, 2018, but at the time of the administrative review there was no documentation that the staff person received the training. Staff Person #23 was hired as a support staff person on September 28, 2015, and was required to have 6 hours of HIV/AIDS and 4 Hours of TB/STD training by September 28, 2017, but at the time of the administrative review there was no documentation that the staff person received the 4 hours of training in TB/STD's. Staff Person #24 was hired as a support staff person on February 10, 2014, and was required to have 6 hours of HIV/AIDS and 4 Hours of TB/STD training by February 10, 2016, but at the time of the administrative review there was no documentation that the staff person received the training. Staff Person #25 was hired as a support staff person on March 13, 2017, and was required to have 6 hours of HIV/AIDS and 4 Hours of TB/STD training by March 13, 2019, but at the time of the administrative review there was no documentation that the staff person received the training. These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
A training for HIV/AIDS and TB/STD will be held by July 1, 2019. The 5 individuals identified as not having their HIV/AIDS and/or TB/STD training will complete these trainings by July 1, 2019.
Moving forward, the HR dept will monitor timely completion of these trainings via spreadsheet.
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705.4 (3) LICENSURE Counseling areas.
705.4. Counseling areas.
The residential facility shall:
(3) Ensure privacy so that counseling sessions cannot be seen or heard outside the counseling room. Counseling room walls shall extend from the floor to the ceiling.
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Observations
At the time of the physical plant inspection conducted on April 4, 2019, the group counseling room in the Dilbert building, had uncovered windows that allowed persons outside of the building to see into the group counseling room. These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The facility director will ensure the windows in Dibert will be covered via shades or window treatment film by June 1, 2019.
Moving forward, the facility director will ensure that all counseling areas with windows have curtains, blinds or some form of window treatment that does not allow persons outside of the counseling room to see inside the counseling room. |
705.6 (3) LICENSURE Bathrooms.
705.6. Bathrooms.
The residential facility shall:
(3) Have hot and cold water under pressure. Hot water temperature may not exceed 120F.
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Observations
On April 4, 2019, during the physical plant inspection, the downstairs bathroom of Hope House had a tested temperature of 130 degrees Fahrenheit. On April 4, 2019, during the physical plant inspection, a bathroom in Knepp House had a tested temperature of 130 degrees Fahrenheit. These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The hot water heaters in Knepp and Hope House will be adjusted so water temperatures do not exceed 120 degrees.
Temperatures will be checked and logged weekly for the next 6 weeks to ensure compliance. Results will be kept in a file in the maintenance office.
The facility director will ensure compliance with hot water temperatures. |
705.6 (7) LICENSURE Bathrooms.
705.6. Bathrooms.
The residential facility shall:
(7) Maintain each bathroom in a functional, clean and sanitary manner at all times.
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Observations
On April 4, 2019, during the physical plant inspection, there was a hole in the wall approximately six inches in diameter above the bathtub in a bathroom in Fellowship Hall. These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The hole in the wall above the bathtub was fixed prior to completion of inspection. There have been no other issues.
The on-call process for patient issues is currently discussed in patient orientation.
Tech staff will do daily room checks to ensure that patient areas are in good repair. If deficiencies are found, the issue will be reported to the facility director for immediate repair. |
705.7 (b) (5) LICENSURE Food service.
705.7. Food service.
(b) A residential facility may operate a central food preparation area to provide food services to multiple facilities or locations. A residential facility that operates an onsite food preparation area or a central food preparation area shall:
(5) Keep cold food at or below 40F, hot food at or above 140F, and frozen food at or below 0F.
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Observations
On April 4, 2019, during the physical plant inspection, the walk-in freezer had a temperature of 10 degrees fahrenheit. These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Dietary director will monitor the freezer temperature and log the freezer temperature daily to ensure that does not exceed 0 degrees Fahrenheit.
Logs will be kept in a binder.
Staff members were reminded to keep the freezer door shut and to not let it remain open for extended periods of time. |
709.26 (a) (1) LICENSURE Personnel management.
§ 709.26. Personnel management.
(a) The governing body shall adopt and have implemented written project personnel policies and procedures in compliance with State and Federal employment laws. In addition, the written policies and procedures must specifically include, but are not limited to:
(1) Utilization of volunteers.
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Observations
Based on a review of the project's policy and procedure manual, the project does not have a policy or procedure for utilization of volunteers.These findings were reviewed with facility during the licensing inspection.
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Plan of Correction
The executive director will create a policy in relation to volunteers for the system.
The executive director's designee will review the project's policies and procedures annually against DDAP regulations to ensure ongoing compliance. |
709.28 (a) (1) LICENSURE Confidentiality
§ 709.28. Confidentiality.
(a) A written procedure shall be developed by the project director which shall comply with 4 Pa. Code § 255.5 (relating to projects and coordinating bodies: disclosure of client-oriented information). The procedure must include, but not be limited to:
(1) Confidentiality of client identity and records. Procedures must include a description of how the project plans to address security and release of electronic and paper records and identification of the person responsible for maintenance of client records.
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Observations
Based on a review of the project's policy and procedure manual, the project's confidentiality policy does not include 4 Pa. 255.5(a)(6) identifying the limitation of information that may be disclosed to employers or prospective employers of the client. In addition, the project's policy and procedure manual does not identify the person responsible for maintaining electronic records. These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
The executive director will revise the confidentiality policy so it includes the limitation of information that may be disclosed to employers of the client.
The executive director will revise the confidentiality policy to include identification of the person responsible for maintaining electronic records.
The executive director's designee will review the project's policies and procedures annually against DDAP regulations to ensure ongoing compliance. |
709.28 (a) (2) LICENSURE Confidentiality
§ 709.28. Confidentiality.
(a) A written procedure shall be developed by the project director which shall comply with 4 Pa. Code § 255.5 (relating to projects and coordinating bodies: disclosure of client-oriented information). The procedure must include, but not be limited to:
(2) Identification of project staff having access to records, and the methods by which staff gain access.
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Observations
Based on a review of the project's policy and procedure manual, the project's procedures do not address the methods by which staff gain access to electronic records.These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
The executive director will revise the confidentiality policy so it addresses the methods by which staff gain access to medical records.
The executive director's designee will review the project's policies and procedures annually against DDAP regulations to ensure ongoing compliance. |
709.28 (c) (3) 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 must be in writing and include, but not be limited to:
(3) Purpose of disclosure.
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Observations
The facility failed to ensure that it included all of the required information on its consent to release information forms. A total of 20 patient records were reviewed during the on-site inspection. Patient #3's signed consent to release information form for the patient's funding source dated September 11, 2018, did not include the purpose of the disclosure. Patient #5's signed consent to release information form for the patient's funding source dated September 14, 2018, did not include the purpose of the disclosure. Patient #7's signed consent to release information form for probation dated September 25, 2018, did not include the purpose of the disclosure. Patient #9's signed consent to release information forms for the patient's funding source and for probation, both dated March 7, 2019, did not include the purpose of the disclosures. Patient #10's signed consent to release information forms for the patient's funding source and for probation, both dated August 18, 2018, did not include the purpose of the disclosures. Patient #9's signed consent to release information forms for the patient's funding source and for probation, both dated August 25, 2018, did not include the purpose of the disclosures. The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The manager of patient information/medical records will re-educate the staff who complete consents on the importance of proper completion of a consent as well as how to properly complete a consent via a series of trainings.
The manager of patient information/medical records will add proper completion of consents to the chart audit tool to ensure compliance.
The manager of patient information will ensure compliance. |
709.30 (2) LICENSURE Client rights
§ 709.30. Client rights.
The project shall develop written policies and procedures on client rights and document written acknowledgement by clients that they have been notified of those rights.
(2) The project may not discriminate in the provision of services on the basis of age, race, creed, sex, ethnicity, color, national origin, marital status, sexual orientation, handicap or religion.
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Observations
Based on a review of the project's policy and procedure manual, the project failed to include in its policies that the project may not discriminate in the provision of services based on age, ethnicity, marital status and/or creed.In the project's Rights Responsibilities and Ethics (RI), subject "Patients Rights" Policy and Procedure, Under Procedure: A. 1. "creed" is not included.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The executive director will revise the patient rights so they include that the project may not discriminate in the provision of services based on age, ethnicity, marital status and/or creed.
The executive director will add "creed" to the Rights Responsibilities and Ethics subject "Patient Rights" policy and procedure A.1. section.
The executive director's designee will review the project's policies and procedures annually against DDAP regulations to ensure ongoing compliance. |
709.32 (c) (1) (i) - (ii) 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:
(1) Administration of medication, including the documentation of the administration of medication:
(i) By individuals permitted to administer by Pennsylvania law.
(ii) When self administered by the client.
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Observations
Based on a review of the project's policy and procedure manual, the project does not have a policy or procedure for documentation of medication administration when self-administered by the client.These findings were reviewed with facility staff during the licensing inspection
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Plan of Correction
The executive director will revise the current policy that exists on medication administration and self-administration so it includes reference to the current self medication documentation form.
The executive director's designee will review the project's policies and procedures annually against DDAP regulations to ensure ongoing compliance. |
709.32 (c) (3) (i) - (v) LICENSURE Medication control
§ 709.32. Medication control.
(3) Inspection of storage areas that ensures compliance with State and Federal laws and program policy. The policy must include, but not be limited to:
(i) What is to be verified through the inspection, who inspects, how often, but not less than quarterly, and in what manner it is to be recorded.
(ii) Disinfectants and drugs for external use are stored separately from oral and injectable drugs.
(iii) Drugs requiring special conditions for storage to insure stability are properly stored.
(iv) Outdated drugs are removed.
(v) Copies of drug-related regulations are available in appropriate areas.
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Observations
Based on a review of the project's policy and procedure manual, the project does not have a policy relating to maintaining copies of drug-related regulations being available in appropriate areas.These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
The executive director will add a policy that addresses the need to maintain copies of drug-related regulations in appropriate areas to the regional policy and procedure manual.
The executive director's designee will review the project's policies and procedures annually against DDAP regulations to ensure ongoing compliance. |
709.82(b) LICENSURE Treatment and rehabilitation services
709.82. Treatment and rehabilitation services.
(b) Treatment and rehabilitation plans shall be reviewed and updated at least every 30 days.
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Observations
The facility failed to update patient treatment plans in 3 of 7 applicable partial hospital records reviewed during the on-site inspection. Patient #14 was an active patient at the time of the on-site inspection. The patient's individualized treatment plan was dated February 8. 2019, and was due to be updated on March 8, 2019, but there was no documented treatment plan update at the time of the onsite inspection. Patient #16 was discharged on September 25, 2018. The patient's individualized treatment plan was dated July 18, 2018, and was due to be updated on August 18, but the patient's treatment plan was never updated. Patient #19 was discharged on November 10, 2018. The patient's individualized treatment plan was dated October 1, 2018, and was due to be updated on November 1, 2018, but the patient's treatment plan was never updated. The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
On April 24, 2019 the partial hospital counselors were re-educated on the importance of completing treatment plan updates within the correct timeframes.
The manager of patient information/medical records will add completion of treatment plan updates to the medical records chart audit tool.
Pt #14 has been discharged. |
709.83(a)(10) LICENSURE Client records
709.83. 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
The facility failed to complete discharge summaries in 3 of 7 applicable partial hospital records reviewed during the on-site inspection. Patient #16 was discharged on September 25, 2018. Patient #18 was discharged on September 25, 2018.Patient #19 was discharged on November 10, 2018.The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
On April 24, 2019 the partial hospital counselors were re-educated on the importance of completing discharge summaries within the correct timeframe.
The manager of patient information/medical records will add completion of discharge summaries to the medical records chart audit tool.
The deficient discharge summaries will be completed by the designated counselor or PHP program director by June 15, 2019. |
715.6(e) LICENSURE Physician Staffing
(e) A physician assistant or certified registered nurse practitioner may perform functions of a narcotic treatment physician in a narcotic treatment program if authorized by Federal, State and local laws and regulations, and if these functions are delegated to the physician assistant or certified registered nurse practitioner by the medical director, and records are properly countersigned by the medical director or a narcotic treatment physician. One-third of all required narcotic treatment physician time shall be provided by a narcotic treatment physician. Time provided by a physician assistant or certified registered nurse practitioner may not exceed two-thirds of the required narcotic treatment physician time.
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Observations
The facility failed to ensure that physical exams performed by physician assistants were properly countersigned by by the medical director or a narcotic treatment physician in 1 of 5 narcotic treatment program records reviewed. Patient #1 was admitted for narcotic detoxification on August 30, 2018. The patient's physical exam was completed on August 30, 2018, by a physician's assistant, but at the time of the on-site inspection the physical exam was never countersigned by the medical director or a narcotic treatment physician. The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The CEO will remind medical staff of the importance of MDs co-signing physician assistant documents.
The manager of patient information will add checking co-signatures to the medical records chart audit tool to ensure completion of signatures.
The physician with the deficient chart will co-sign the physician assistant's documents by June 15, 2015. |
715.17(c)(1)(i-vi)) LICENSURE Medication control
(c) A narcotic treatment program shall develop and implement written policies and procedures regarding the medications used by patients which shall include, at a minimum:
(1) Administration of medication.
(i) A narcotic treatment physician shall determine the patient 's initial and subsequent dose and schedule. The physician shall communicate the initial and subsequent dose and schedule to the person responsible for the administration of medication. Each medication order and dosage change shall be written and signed by the narcotic treatment physician.
(ii) An agent shall be administered or dispensed only by a practitioner licensed under the appropriate Federal and State laws to dispense agents to patients.
(iii) Only authorized staff and patients who are receiving medication shall be permitted in the dispensing area.
(iv) There shall be only one patient permitted at a dispensing station at any given time.
(v) Each patient shall be observed when ingesting the agent.
(vi) Administering and dispensing shall be conducted in a manner that protects the patient from disruption or annoyance from other individuals.
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Observations
The facility failed to ensure that only practioners licensed under the appropriate Federal and State laws dispensed agents to patients. During the on-site inspection a nurse was observed crushing buprenorphine and administering buprenorphine to patients, but the part of the administration that required the observation that the buprenorphine had dissolved within the patients' mouths was not performed by the nurse. A support staff person, who was not a practioner licensed under the appropriate Federal and State laws to dispense agents to patients was the person who was observing the patients to ensure that the buprenorphine had dissolved in the patients' mouths. These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Dispensing staff will be re-educated on the importance of licensed practitioners being the ones to ensure that buprenorphine has dissolved in the patients' mouths.
Proof of education will be documented in the minutes from the meeting(s) when this is addressed.
The DON/ADON will ensure compliance via spot checks during dispensing times. |
715.22(b) LICENSURE Patient grievance procedures
(b) The procedure shall permit aggrieved patients a full and fair opportunity to be heard, to question and confront persons and evidence used against them and to have a fair review of their grievances by the narcotic treatment program director. If the grievance is filed against the narcotic treatment program director, the review of the case shall be conducted by either a multi-representative group of the narcotic treatment program or a subcommittee of the governing body instituted for the express purposes of grievance adjudication.
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Observations
Based on a review of the project's policy and procedure manual, the project ' s grievance procedure does not address permitting patients a full and fair opportunity to be heard, to question and confront persons and evidence used against them and to have a fair review of their grievances by the narcotic treatment program director. Based on a review of the project's policy and procedure manual, the project's grievance procedure does not address grievances filed by patients against the narcotic treatment program director.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The executive director will revise the current grievance procedure so it addresses permitting patients to have a full and fair opportunity to be heard, to question and confront persons and evidence used against them and to have a fair review of their grievances by the narcotic treatment program director and to address grievances filed by patients against the narcotic treatment program director.
The executive director's designee will review the project's policies and procedures annually against DDAP regulations to ensure ongoing compliance. |
715.22(c) LICENSURE Patient grievance procedures
(c) Penalties may not be initiated prior to final resolution with the exception that penalties may be initiated against patients who have committed acts of physical violence or who have threatened to commit acts of physical violence in or around the narcotic treatment program premises.
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Observations
Based on a review of the project's policy and procedure manual, the project's grievance procedure does not address penalties being initiated against patients prior to the final resolution of grievances. These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The executive director will update the grievance procedure to address penalties being initiated against patients prior to the final resolution of grievances.
The executive director's designee will review the project's policies and procedures annually against DDAP regulations to ensure ongoing compliance. |