INITIAL COMMENTS
|
This report is a result of an on-site licensure renewal inspection conducted on June 3 through June 4, 2013 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Diakon Lutheran Social Ministries 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.
|
Plan of Correction
|
705.28 (c) (4) LICENSURE Fire safety.
705.28. Fire safety.
(c) Fire extinguishers. The nonresidential facility shall:
(4) Instruct staff in the use of the fire extinguisher upon staff employment. This instruction shall be documented by the facility.
|
Observations
Based on a review of personnel records, the facility failed to document fire extinguisher training upon staff employment two out of eight records reviewed.
The findings include:
Eight personnel records were reviewed on June 3, 2013 . Two of the eight records required documentation that staff had been instructed in the use of a fire extinguisher upon employment The facility failed to document the completion of fire extinguisher training upon staff employment in personnel records # 4 and 5.
Employee # 4 was hired on 3/19/2013. Fire extinguisher training was due upon hire. The facility failed to documented fire extinguisher training until 4/17/2013.
Employee # 5 was hired 11/20/2012. Fire extinguisher training was due upon hire. The facility failed to documented fire extinguisher training until. 12/06/2012.
|
Plan of Correction
Preparation and submission of this plan of correction is required by State and Federal Law. This Plan of Correction does not constitute admission for purposes of general liability, professional malpractice or any other court proceeding.
The Clinical Director/designee will insure all new employees are instructed in the use of fire extinguishers upon hire.
Any identified issues with the process will be addressed by the Executive Director as appropriate. |
705.28 (d) (3) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(3) Ensure that all personnel on all shifts are trained to perform assigned tasks during emergencies.
|
Observations
Based on the review of personnel records, the facility failed to ensure that all personnel on all shifts are trained to perform assigned tasks during emergencies.
The findings include:
Eight personnel records were reviewed on June 3, 2013. Two personnel records requiring documentation that all personnel on all shifts are trained to perform assigned tasks during emergencies.
The facility failed to document that all personnel on all shifts are trained to perform assigned tasks during emergencies in records # 4 and 5.
Employee # 4 was hired on 3/19/2013. Training to perform assigned tasks during emergencies was due upon hire. The facility failed to documented this training in until 4/17/2013.
Employee # 5 was hired 11/20/2012. Training to perform assigned tasks during emergencies was due upon hire. The facility failed to document this training until 12/06/2012.
|
Plan of Correction
The Clinical Director/designee will ensure all new employees will be trainied on their assigned responsibilities in the event of an emergency within the first week of hire.
Any identified issues will be addressed by the Executive Director as appropriate. |
715.10(b) LICENSURE Pregnant patients
(b) A narcotic treatment program shall give pregnant patients the opportunity for prenatal care either by the narcotic treatment program or by referral to appropriate health-care providers.
|
Observations
Based on the review of patient records, the facility failed to document the provision of prenatal care in one of one patient record reviewed.
The findings include:
Fourteen patient records were reviewed on June 3-4, 2013. One patient record was reviewed for the provision of referral for prenatal care. Patient # 14 contained documentation in the record that the patient became pregnant during their treatment with Subutex. Employee # 8 recorded the confirmation of the patient's pregnancy in the record. The record failed to include documentation on whether the patient was afforded the opportunity to receive prenatal care by the program or by referral to an appropriate healthcare provider.
This finding was discussed with the Facility Director and Counselor on June 4, 2013 and was not disputed.
|
Plan of Correction
The prescribing physician/designee will ensure that all pregnant patients are offered a referral to a healthcare provider for prenatal care.
Documentation of ther referral will be included in the patient record.
Random chart audits will be conducted by the Clinical Director/designee to ensure 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.
|
Observations
Based on a review patient records, the facility failed to fully inform each female patient of the possible risk to her and her unborn child of continued use of illicit drugs and from the use of, or withdrawal from a narcotic drug administered or dispensed by the program for comprehensive maintenance or detoxification treatment.
The findings include:
Fourteen patient records were reviewed June 3-4, 2013. Eight Subutex patient records were reviewed. Based on the review of the "Patient Treatment Agreement" the facility failed to fully inform female patients of the possible risks to her unborn child of continued use of illicit drugs and from the use of, or withdrawal from a narcotic drug administered or dispensed by the program for comprehensive maintenance or detoxification treatment. The treatment agreement also did not inform patients that alternative methods of treatment exist.
This finding was discussed with the Facility Director and Counselor and was not disputed.
|
Plan of Correction
The prescribing physician/designee will discuss with all female patients treatment options, as well as risks of continued substance use, and the risk of withdrawal from and use of Subutex during pregnancy.
Documentation will be included in the patient record.
The "Patient Treatment Agreement" will be modified to include statements addressing treatment options and risks.
Random chart audits will be conducted by the Clinical Director/designee to ensure compliance. |
715.13(b) LICENSURE Patient identification
(b) A narcotic treatment program shall maintain onsite a photograph of each patient which includes the patient 's name and birth date. The narcotic treatment program shall update the photograph every 3 years.
|
Observations
Based on the review of the policy and procedures, patient records, and staff interviews, the facility failed to have a system for maintaining an onsite photographs of each patient that included their name and birth date which shall be updated every three years.
The findings include:
Patient # 15 was admitted on November 26, 2008. The counselor was interviewed on June 4, 2013 and indicated the facility does not have a current system in place to update patient photographs every three years. Currently, the facility is using a copy of the patient's state issued photo identification card. The state issued identification card is updated every four years.
|
Plan of Correction
The Clinical Director/designee will ensure photographs are in each patient's chart. Photographs will be renewed every three years and include patient's date of birth and name.
Random chart audits will be conducted to ensure compliance.
Any identified issues with be addressed by the Executive Director as appropriate. |
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.
|
Observations
Based on review of the patient records, the facility failed to obtain a complete drug screen urinalysis prior to the administration of Subutex, a narcotic agent. A complete drug screen includes receiving the results from the CLIA and Department of Health approved laboratory. Additionally, the facility failed to ensure random monthly urinalysis for each patient.
The findings include:
Fourteen patient records were reviewed on June 3-4, 2013. Four patient records were required to complete a drug screen urinalysis prior to the administration of Subutex, a narcotic agent. Eight patient records were required to have random monthly urinalysis. A complete urine drug screen includes receiving the results from the CLIA and Department of Health approved laboratory. The facility failed to obtain a complete drug screen urinalysis prior to the administration of Subutex, a narcotic agent in three of the four records, # 4, 5 and 7. The facility failed to document a random monthly urinalysis in four of eight patient records # 7, 11, 12 and 13.
Patient #4 was admitted on 12/13/12 and received their first dose of Subutex. The patient provided their initial urine drug screen on 12/7/2012, however, the facility did not receive the results until 12/17/12, after the initial dose was given.
Patient # 5 was admitted on 11/8/2012 and received their first dose of Subutex. The patient provided their initial urine drug screen on 11/8/2012, however, the facility did not receive the results until 11/15/2012, after the initial dose was given.
Patient # 7 was admitted on 7/10/2012 and received their first dose of Subutex. The patient provided their initial urine drug screen on 7/17/2012 and the facility did not receive the results until 7/24/2012, after the initial dose was given. The facility also failed to document a monthly urinalysis for March 2013 in this patient record.
Patient # 11 was admitted on 5/17/2011. The patient was required to have random monthly urinalysis. The facility failed to document a monthly urine drug screen for December 2012, March 2013 and April 2013.
Patient # 12 was admitted on 6/16/2011. The patient was required to have random monthly urinalysis. The facility failed to document a monthly urine drug screen for December 2012, February 2013 and May 2013.
Patient # 13 was admitted on 3/1/2012. The patient was required to have random monthly urinalysis. The facility failed to document a monthly urine drug screen for November 2012, December 2012, January 2013, February 2013 and March 2013.
An interview with the Counselor revealed the doctor is completing instant drug screen tests and reviewing those results prior to their initial dose. However, the results of the instant drug tests are not documented in the patient record and the facility does not have an approved exception from the department to use this method of urinalysis.
|
Plan of Correction
The prescribing physician/designee will ensure urine screen results will be obtained on all patients prior to the initial administration of Subutex.
Random monthly urine screens will obtained on all patients.
Documentation of all urine screen results will be included in the patient chart.
Random chart audits will be conducted by the Clinical Director/designee to ensure compliance. |