INITIAL COMMENTS
|
This report is a result of an on-site licensure renewal inspection conducted on February 20 - 21, 2014 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Arc Manor 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
|
705.10 (d) (5) LICENSURE Fire safety.
705.10. Fire safety.
(d) Fire drills. The residential facility shall:
(5) Conduct a fire drill during sleeping hours at least every 6 months.
|
Observations
Based on a review of fire drill records, the facility failed to conduct a fire drill during sleeping hours at least every six months.
The findings include:
Fire drill records were reviewed on February 20, 2014. Sleeping hours are from 11:00 PM until 7:30 AM. Fire drills were conducted during sleeping hours on January 15, 2013 at 12:02 AM and January 13, 2014 at 12:05 AM. A fire drill during sleeping hours was due to be conducted no later than July 2013. The facility failed to conduct a fire drill during sleeping hours at least every six months.
The findings were confirmed by the Assistant Director.
|
Plan of Correction
ARC Manor's Disaster Plan Policy does specify that every 6 months a fire drill must be conducted during sleeping hours. The fire drill during sleeping hours should be performed by the Clinical Assistant Staff at any time between 11:30 p.m. to 6:30 a.m. according to ARC Manor's current residential schedule. ARC Manor's Safety Committee will meet on March 18th to review this issue and the policy will also be reviewed with all Clinical Assistant staff at their monthly meeting on March 25, 2014. ARC Manor's Safety Committee will review the fire drill documentation on a monthly basis to ensure that the fire drills are in compliance with the monthly schedule. |
709.81(b)(3)(iii) LICENSURE Intake and admission
709.81. Intake and admission.
(b) Intake procedures shall include documentation of:
(3) Histories, which include the following:
(iii) Personal history.
|
Observations
Based on a review of client records, the facility failed to document a personal history including a recreational history in three of four client records. In addition, the facility failed to document a personal history including a sexual history in one of four client records.
The findings include:
Four partial hospitalization client records were reviewed on February 21, 2014. Four client records were reviewed for personal histories including a recreational and sexual history. The facility failed to document a recreational history in client records # 6, 7 and 9. The facility failed to document a sexual history in client record # 9.
Client # 6 was admitted into treatment on January 2, 2014. A personal history was completed on December 19, 2013. The personal history of client # 6 did not include a recreational history.
Client # 7 was admitted into treatment on January 17, 2014. A personal history was completed on January 22, 2014. The personal history of client # 7 did not include a recreational history.
Client # 9 was admitted into treatment on July 1, 2013. A personal history was completed on June 4, 2013. The personal history of client # 9 did not include a recreational and sexual history.
The project/facility director did not dispute the findings.
|
Plan of Correction
ARC Manor will add the following questions to section 2 of the Psychosocial Evaluation Summary no later than March 31, 2014:
a. Describe client's recreational history (including hobbies, favorite pasttimes, and extracurricular activities)
b. Degree to which alcohol/drugs impacted client's recreational activities (client perspective and clinical perspective)
c. Describe client's sexual history (including gender identity concerns, trauma, or abuse)
d. Degree to which alcohol/drugs impacted client's sexual activities (client perspective and clinical perspective)
These changes to the psychosocial evaluation summary will be reviewed with clinical staff in staffing no later than April 3, 2014. |
709.32(c)(3) LICENSURE Medication Control
709.32. Medication control.
(c) The project shall have a written policy regarding medications used by clients which shall include, but not be limited to:
(3) Inspection of storage areas.
|
Observations
Based on a review of administrative materials, the facility failed to conduct quarterly inspections of the medication storage areas.
The findings include:
Administrative materials were reviewed on February 21 and 24, 2014. Inspections of the medication storage areas were completed for the quarters ending March 31, 2013 and September 30, 2013. There were no inspections documented for the medication storage areas for the quarters ending June 30, 2013 and December 30, 2013.
The Assistant Director and Clinical Assistant confirmed the findings.
|
Plan of Correction
ARC Manor's policy clearly states that inspection of medication and medical related matters is to be conducted on a quarterly basis. To ensure that these inspections are being done in a timely manner the following plan will be put into place effective immediately. Medication inventories must be completed no later than the 15th of the month following the end of each quarter (October 15th, January 15th, April 15th, and July 15th). The quarterly inspection report will be submitted to the Residential Supervisor for review and then submitted to the Executive Director for review with the Evaluation & Monitoring Committee. ARC Manor's Executive Director will be responsible for amending the Medication Control Policy to establish this timeline and for ensuring that the information is submitted to the Evaluation & Monitoring Committee each quarter for review. |
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.
|
Observations
Based on a review of patient records, the facility failed to verify that the individual had reached 18 years of age prior to the administration of a narcotic agent in four of four patient records.
The findings include:
Eighteen client records were reviewed on February 20 - 21, 2014. Four records pertained to patients who were prescribed Suboxone and required verification that the individual had reached 18 years of age prior to the administration of Suboxone. The facility failed to verify that the individual had reached 18 years of age prior to the administration of Suboxone in patient records # 6, 12, 13 and 14.
Patient # 6 was admitted into treatment on January 2, 2014. Patient # 6 was prescribed 8 mg/2 mg Suboxone daily on January 3, 2014, prior to verifying that the individual had reached 18 years of age.
Patient # 12 was admitted into treatment on October 11, 2013. Patient # 12 was prescribed 4 mg/1 mg Suboxone daily on November 13, 2013, prior to verifying that the individual had reached 18 years of age.
Patient # 13 was admitted into treatment on May 29, 2013. Patient # 13 was prescribed 4 mg/1 mg Suboxone daily on November 13, 2013, prior to verifying that the individual had reached 18 years of age.
Patient # 14 was admitted into treatment on September 16, 2013. Patient # 14 was prescribed 8 mg/2 mg Suboxone daily on September 4, 2013, prior to verifying that the individual had reached 18 years of age.
The project/facility director was interviewed throughout the inspection and confirmed the findings.
|
Plan of Correction
ARC Manor's policy for 715.9 specifies that verification of age and identity is required for all individuals seeking services through photo identification. Upon review of these files, staff failed to make a photocopy of the client's photo identification prior to scheduling the client for a Buprenorpine service (evaluation or med check). To correct this error, a "checklist" has been created for staff identifying the key components that are to be in a file for any client who is referred for Buprenorphine services. In addition, all Buprenorphine scheduling will be coordinated through ARC Manor's Clinical Director who will ensure that all components of the checklist are in place before the service is scheduled. ARC Manor's Clinical Director has already gone through the entire caseload of current Buprenorphine clients and identified where photo identification was not collected. Clinical staff have been advised to collect this information and enter it into the clinical file immediately. The Buprenorphine checklist will be reviewed with all clinicians during Clinical Staffing on March 13, 2014. |
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.
|
Observations
Based on a review of patient records, the facility failed to verify the individual's identity, including name, address and date of birth prior to the administration of a narcotic agent in four of four patient records. In addition, the facility failed to verify the emergency contact in one of four patient records.
The findings include:
Eighteen client records were reviewed on February 20 - 21, 2014. Four records pertained to patients who were prescribed Suboxone and required verification of the individual's identity, including name, address, date of birth and emergency contact prior to the administration of Suboxone. The facility failed to verify the individual's identity, including the name, address, date of birth prior to the administration of Suboxone in patient records # 6, 12, 13 and 14. The facility failed to verify the emergency contact in patient record # 12.
Patient # 6 was admitted into treatment on January 2, 2014. Patient # 6 was prescribed 8 mg/2 mg Suboxone daily on January 3, 2014, prior to verifying the individual's identity including the name, address and date of birth.
Patient # 12 was admitted into treatment on October 11, 2013. Patient # 12 was prescribed 4 mg/1 mg Suboxone daily on November 13, 2013, prior to verifying the individual's identity including the name, address, date of birth and emergency contact.
Patient # 13 was admitted into treatment on May 29, 2013. Patient # 13 was prescribed 4 mg/1 mg Suboxone daily on May 29, 2013, prior to verifying the individual's identity including the name, address and date of birth.
Patient # 14 was admitted into treatment on September 16, 2013. Patient # 14 was prescribed 8 mg/2 mg Suboxone daily on September 4, 2013, prior to verifying the individual's identity including the name, address and date of birth.
The project/facility director was interviewed throughout the licensing inspection and confirmed the findings.
|
Plan of Correction
ARC Manor's policy for 715.9 specifies that verification of age and identity is required for all individuals seeking services through photo identification. ARC Manor's policy also specifies that an Emergency Contact should be identified for the client.Upon review of these files, staff failed to make a photocopy of the client's photo identification and failed to consistently identify emergency contacts prior to scheduling the client for a Buprenorpine service (evaluation or med check). To correct this error, a "checklist" has been created for staff identifying the key components that are to be in a file for any client who is referred for Buprenorphine services. In addition, all Buprenorphine scheduling will be coordinated through ARC Manor's Clinical Director who will ensure that all components of the checklist are in place before the service is scheduled. ARC Manor's Clinical Director has already gone through the entire caseload of current Buprenorphine clients and identified where photo identification and emergency contact information were not collected. Clinical staff have been advised to collect this information and enter it into the clinical file immediately. The Buprenorphine checklist will be reviewed with all clinicians during Clinical Staffing on March 13, 2014. The Clinical Director has also created a specific "Emergency Contact" release that will be part of the client's file. The release will specifically allow for communication regarding the location of the client and the nature of the emergency. This release will also be reviewed all clinician's in Clinical Staffing on March 13th is listed on the Buprenorphine checklist. |
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.
|
Observations
Based on a review of patient records, the facility's physician failed to document in the patient's record the evidence of a 1 year history of addiction prior to the administration of a narcotic agent in four of four patient records.
The findings include:
Eighteen client records were reviewed on February 20 - 21, 2014. Four patients were prescribed Suboxone. These patient records were reviewed for documentation that the physician made a face-to-face determination of whether the individual was currently physiologically dependent upon a narcotic drug and had been physiologically dependent for at least 1 year prior to admission for maintenance treatment. The physician failed to document in the patient's record the evidence of a 1 year history of addiction prior to administration of a narcotic agent in patient records # 6, 12, 13 and 14.
Patient # 6 was admitted into treatment on January 6, 2014. The physician conducted a face-to-face visit with patient # 6 on January 3, 2014 and prescribed 8 mg/2 mg Suboxone daily. The physician failed to document the evidence of a 1 year history of addiction prior to the admission of patient # 6 for maintenance treatment.
Patient # 12 was admitted into treatment on October 11, 2013. The physician conducted a face-to-face visit with patient # 12 on November 13, 2013 and prescribed 4 mg/1 mg Suboxone daily. The physician failed to document the evidence of a 1 year history of addiction prior to the admission of patient # 12 for maintenance treatment.
Patient # 13 was admitted into treatment on May 29, 2013. The physician conducted a face-to-face visit with patient # 13 on May 29, 2013 and prescribed 4 mg/1 mg Suboxone daily. The physician failed to document the evidence of a 1 year history of addiction prior to the admission of patient # 13 for maintenance treatment.
Patient # 14 was admitted into treatment on September 16, 2013. The physician conducted a face-to-face visit with patient # 14 on September 4, 2013 and prescribed 8 mg/2 mg Suboxone daily. The physician failed to document the evidence of a 1 year history of addiction prior to the admission of patient # 14 for maintenance treatment.
The project/facility director was interviewed throughout the licensing inspection and did not dispute the findings.
|
Plan of Correction
For the client records in question, the one year history of addiction was documented in the clients' psychosocial evaluation, however, there was not documentation of this information on the Medical Assessment form that is completed by the physician. To correct this issue, ARC Manor is adding a question to the Medical Assessment form under the section of General Appearance & Impressions to ensure that the physician is documenting evidence of a 1 year history of addiction prior to the administration of a narcotic agent. Documentation of the client's current dependency is already indicated on the Medical Assessment form by the completion of the Axis 1 Diagnosis. |
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 a review of patient records, the facility failed to maintain onsite a photograph of each patient which includes the patient's name and birth date in four of four patient records.
The findings include:
Eighteen client records were reviewed on February 20 - 21, 2014. Four records pertained to patients who were prescribed Suboxone and required documentation of a photograph including the patient's name and date of birth. The facility failed to maintain onsite a photograph of each patient which includes that patient's name and birth date in patient records # 6, 12, 13 and 14.
Patient # 6 was admitted into treatment on January 2, 2014. Patient # 6 was prescribed 8 mg/2 mg Suboxone daily on January 3, 2014. The facility failed to maintain onsite a photograph of patient # 6 which includes their name and birth date.
Patient # 12 was admitted into treatment on October 11, 2013. Patient # 12 was prescribed 4 mg/1 mg Suboxone daily on November 13, 2013. The facility failed to maintain onsite a photograph of patient # 12 which includes their name and birth date.
Patient # 13 was admitted into treatment on May 29, 2013. Patient # 13 was prescribed 4 mg/1 mg Suboxone daily on May 29, 2013. The facility failed to maintain onsite a photograph of patient # 13 which includes their name and birth date.
Patient # 14 was admitted into treatment on September 16, 2013. Patient # 14 was prescribed 8 mg/2 mg Suboxone daily on September 4, 2013. The facility failed to maintain onsite a photograph of patient # 14 which includes their name and birth date.
The project/facility director was interviewed throughout the licensing inspection and confirmed the findings.
|
Plan of Correction
ARC Manor's policy for 715.13 specifies that verification of identity is required for all individuals seeking services in the form of a PA Driver's License, DPW Photo Identification, or PA Identification Card. Upon review of these files, staff failed to make a photocopy of the client's photo identification prior to scheduling the client for a Buprenorpine service (evaluation or med check). To correct this error, a "checklist" has been created for staff identifying the key components that are to be in a file for any client who is referred for Buprenorphine services. In addition, all Buprenorphine scheduling will be coordinated through ARC Manor's Clinical Director who will ensure that all components of the checklist are in place before the service is scheduled. ARC Manor's Clinical Director has already gone through the entire caseload of current Buprenorphine clients and identified where photo identification was not collected. Clinical staff have been advised to collect this information and enter it into the clinical file immediately. The Buprenorphine checklist will be reviewed with all clinicians during Clinical Staffing on March 13, 2014. |
715.19(1) LICENSURE Psychotherapy services
A narcotic treatment program shall provide individualized psychotherapy services and shall meet the following requirements:
(1) A narcotic treatment program shall provide each patient an average of 2.5 hours of psychotherapy per month during the patient 's first 2 years, 1 hour of which shall be individual psychotherapy. Additional psychotherapy shall be provided as dictated by ongoing assessment of the patient.
|
Observations
Based on a review of patient records, the facility failed to provide each patient an average of 2.5 hours of psychotherapy per month during the patient's first 2 years of treatment in two of four patient records.
The findings include:
Eighteen client records were reviewed on February 20 - 21, 2014. Four clients were prescribed Suboxone. These records were reviewed for documentation of an average of 2.5 hours of psychotherapy per month. The facility failed to provide each patient with an average of 2.5 hours of psychotherapy per month during the patient's first 2 years of treatment in patient records # 13 and 14.
Patient # 13 was admitted into treatment on May 29, 2013. Patient # 13 was prescribed Suboxone on May 29, 2013. Patient # 13 was provided the following number of hours of psychotherapy: 1.5 hours in November 2013, 1/2 hour in December 2013 and 1 hour in January 2014. The facility failed to provide an average of 2.5 hours of psychotherapy per month.
Patient # 14 was admitted into treatment on September 16, 2013. Patient # 14 was prescribed Suboxone on September 4, 2013. Patient # 14 was provided the following number of hours of psychotherapy: 1.5 hours in November 2013, 1 hour in December 2013 and 1 hour in January 2014. The facility failed to provide an average of 2.5 hours of psychotherapy per month.
The findings were not disputed by the project/facility director.
|
Plan of Correction
This regulation will be reviewed with Clinical Staff during Clinical Staffing on March 13, 2014. In addition to review of the regulation, Treatment supervisors will spot check Buprenorphine client files to ensure that clinicians are scheduling the client for services accordingly. It appears that this issue is primarily occurring at the Outpatient level when clients are only being scheduled for individual services and have no other requirement in the treatment plan for group attendance. |
709.91(b)(6) LICENSURE Intake and admission
709.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(6) Psychosocial evaluation.
|
Observations
Based on a review of client records, the facility failed to document a psychosocial evaluation that included a clinical assessment of the client's assets/strengths, coping mechanisms and negative factors in four of six outpatient client records.
The findings include:
Eight outpatient client records were reviewed on February 20 - 21, 2014. Six client records were reviewed for psychosocial evaluations that included a clinical assessment of the client. The facility failed to document a psychosocial evaluation that included a clinical assessment of the client's assets/strengths, coping mechanisms and negative factors in client records # 12, 13, 14 and 16.
Client # 12 was admitted into treatment on October 11, 2013. A psychosocial evaluation was completed on June 26, 2013. The psychosocial evaluation for client # 12 did not include a clinical assessment of the client's assets/strengths, coping mechanisms and negative factors and only included client reported historical information.
Client # 13 was admitted into treatment on May 29, 2013. A psychosocial evaluation was completed on May 21, 2013. The psychosocial evaluation for client # 13 did not include a clinical assessment of the client's assets/strengths, coping mechanisms and negative factors and only included client reported historical information.
Client # 14 was admitted into treatment on September 16, 2013. A psychosocial evaluation was completed on April 11, 2013. The psychosocial evaluation for client # 14 did not include a clinical assessment of the client's assets/strengths, coping mechanisms and negative factors and only included client reported historical information.
Client # 16 was admitted into treatment on July 30, 2013. A psychosocial evaluation was completed on July 23, 2013. The psychosocial evaluation for client # 16 did not include a clinical assessment of the client's assets/strengths, coping mechanisms and negative factors and only included client reported historical information.
The project/facility director was interviewed throughout the licensing inspection and did not dispute the findings.
|
Plan of Correction
In all of the cases identified, information regarding assets, strengths, coping mechanisms and negative factors was gathered in the psychosocial assessment, but reported only from the client's perspective. There was no clinical input offered in these areas despite the fact that the information is documented in the psychosocial under the "Clinical Assessment & Impressions Section". The need for both the client's perspective and the clinical input in these categories will be reviewed with Clinical Staff in Staffing no later than March 31st. In addition, supervisors will not sign off on any psychosocial documents that do not contain this clinical perspective. The document will be re-sent to the therapist for further information and the clinician will be held accountable for completion of the document within the established agency timeframe. |
709.93(a) LICENSURE Client records
709.93. 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:
|
Observations
Based on a review of client records, the facility failed to document a complete client record on an individual which included information relative to the client's involvement with the project in three of eight outpatient client records.
The findings include:
Eight outpatient client records were reviewed on February 21 - 22, 2014. Eight client records were reviewed for medication records and consent forms for buprenorphine treatment. The facility failed to document medication records including the dosage and frequency of use in client records # 13 and 14. The facility failed to document a consent form for buprenorphine treatment in client records # 12, 13 and 14.
Client # 12 was admitted into treatment on October 11, 2013. Client # 12 was prescribed Suboxone on November 13, 2013. The facility utilizes a "consent to treatment with buprenorphine" form for clients receiving Suboxone treatment. There was no documentation of a consent form for buprenorphine treatment in client record # 12 as of February 21, 2014.
Client # 13 was admitted into treatment on May 29, 2013. Client # 13 was prescribed Suboxone on May 29, 2013. The facility utilizes a "consent to treatment with buprenorphine" form for clients receiving Suboxone treatment. There was no documentation of a consent form for buprenorphine treatment in client record # 13 as of February 21, 2014.
In addition, client # 13 was prescribed Celexa. The medication record for client # 13 did not include the dosage and frequency of use of this medication.
Client # 14 was admitted into treatment on September 16, 2013. Client # 14 was prescribed Suboxone on September 4, 2013. The facility utilizes a "consent to treatment with buprenorphine" form for clients receiving Suboxone treatment. There was no documentation of a consent form for buprenorphine treatment in client record # 14 as of February 21, 2014.
In addition, client # 14 was prescribed Prozac and Remeron. The medication record for client # 14 did not include the dosage and frequency of use of these medications.
The project/facility director did not dispute the findings.
|
Plan of Correction
There are two issues with this finding. Regarding the medication records, ARC Manor's policy requires the clinician's to complete a "Physician Update Form" for the physician at each visit that includes a medication list with dosage and frequency. It appears that this was not occurring on a consistent basis. ARC Manor will correct this item in two ways. First, the psychosocial assessment will add "dosage & frequency" to the physical health section of the form in which the client's current medications are listed. In addition, ARC Manor will add a form to the Buprenorphine Visit Packet that documents current medications, dosage and frequency at the time that the client is seeing the physician.
Similarly, ARC Manor's policy is that the client should have a signed "Buprenorphine Treatment Contract" on file at the time that they are seeing the physician. This form documents the clients consent to treatment. As mentioned in an earlier corrective action statement, ARC Manor's Clinical Director has reviewed all client files for Buprenorphine Services and has identified all cases in which this form was missing from the file. Clinicians are to have this information completed and in the client file immediately. In addition, the Buprenorphine Treatment Checklist has been updated and will be reviewed with all Clinical Staff in Staffing on March 13th. Finally, the Clinical Director or her designee will spot check all client files for the items included on the checklist before the client is scheduled with the physician. |