INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection and methadone/buprenorphine monitoring conducted on February 27, 2023 through March 1, 2023 by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, Avenues Recovery Medical Center at Valley Forge 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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704.7(b) LICENSURE Counselor Qualifications
704.7. Qualifications for the position of counselor.
(a) Drug and alcohol treatment projects shall be staffed by counselors proportionate to the staff/client and counselor/client ratios listed in 704.12 (relating to full-time equivalent (FTE) maximum client/staff and client/counselor ratios).
(b) Each counselor shall meet at least one of the following groups of qualifications:
(1) Current licensure in this Commonwealth as a physician.
(2) A Master's Degree or above from an accredited college with a major in chemical dependency, psychology, social work, counseling, nursing (with a clinical specialty in the human services) or other related field which includes a practicum in a health or human service agency, preferably in a drug and alcohol setting. If the practicum did not take place in a drug and alcohol setting, the individual's written training plan shall specifically address a plan to achieve counseling competency in chemical dependency issues.
(3) A Bachelor's Degree from an accredited college with a major in chemical dependency, psychology, social work, counseling, nursing (with a clinical specialty in the human services) or other related field and 1 year of clinical experience (a minimum of 1,820 hours) in a health or human service agency, preferably in a drug and alcohol setting. If a person's experience did not take place in a drug and alcohol setting, the individual's written training plan shall specifically address a plan to achieve counseling competency in chemical dependency issues.
(4) An Associate Degree from an accredited college with a major in chemical dependency, psychology, social work, counseling, nursing (with a clinical specialty in the human services) or other related field and 2 years of clinical experience (a minimum of 3,640 hours) in a health or human service agency, preferably in a drug and alcohol setting. If a person's experience was not in a drug and alcohol setting, the individual's written training plan shall specifically address a plan to achieve counseling competency in chemical dependency issues.
(5) Current licensure in this Commonwealth as a registered nurse and a degree from an accredited school of nursing and 1 year of counseling experience (a minimum of 1,820 hours) in a health or human service agency, preferably in a drug and alcohol setting. If a person's experience was not in a drug and alcohol setting, the individual's written training plan shall specifically address a plan to achieve counseling competency in chemical dependency issues.
(6) Full certification as an addictions counselor by a statewide certification body which is a member of a National certification body or certification by another state government's substance abuse counseling certification board.
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Observations
Based on a review of personnel records, the facility failed to ensure that all counselors met the appropriate educational and/or experiential qualifications for the position in one of eight applicable personnel records reviewed.
Employee # 5 was hired as a counselor on January 10, 2023. The employee had a bachelor's degree with a qualifying major; however, the employee did not have the required 1 year of clinical experience in a health of human service agency prior to hiring. The record only had documentation of 10 months of prior experience.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
As of 3/15/23 all resumes of potential hires will be reviewed by the HR department and the Director of Counseling to determine if the candidate is a counselor or a counselor assistant. The Director of QA will also review the resume. |
704.11(a)(3) LICENSURE Training Feedback
704.11. Staff development program.
(a) Components. The project director shall develop a comprehensive staff development program for agency personnel including policies and procedures for the program indicating who is responsible and the time frames for completion of the following components:
(3) A mechanism to collect feedback on completed training.
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Observations
Based on the review of personnel records, the facility failed to document the mechanism to collect feedback on completed training in in one of one applicable personnel record reviewed.
Employee # 7 was hired as a counselor on February 23, 2021. There were no training feedback forms documented in the personnel record for the facility ' s January 2022 through December 31, 2022 training year.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
As of 3/7/23 a training feedback form has been developed and implemented. After every training attended, the form will completed by the participant, and they will not be given a certificate of completion, until the feedback form is handed in. The HR department will scan the feedback form along with the certificate into the personnel file. |
704.11(b)(1) LICENSURE Individual training plan.
704.11. Staff development program.
(b) Individual training plan.
(1) A written individual training plan for each employee, appropriate to that employee's skill level, shall be developed annually with input from both the employee and the supervisor.
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Observations
Based on a review of personnel records and the Staffing Requirements Facility Summary Report, the facility failed to document an annual, written individual training plan for each employee, appropriate to that employee's skill level and with input from both the employee and the supervisor, in one of twenty-four personnel records reviewed.
Employee#14 was hired as a recovery assistant on September 5, 2022.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
As of 4/1/23 training plans will be completed by newly hired staff at the time of orientation. HR will scan the new hire training plans into the personnel file. Existing staff will complete a training plan annually no later than 12/31 for the upcoming year. This process will be managed by each department's supervisor and overall by the QA department. All completed yearly training plans will be scanned into the system by the HR department. |
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
Based on a review of personnel records and the Staffing Requirement Facility Summary Report, the facility failed to ensure all staff persons received a minimum of 6 hours of HIV/AIDS training and/or at least 4 hours of TB/STD and other health-related topics training within the regulatory timeframe in ten of twenty-four personnel records reviewed.
Employee #15 was hired as a recovery assistant on October 9, 2019. The HIV/AIDS training and the TB/STD training was due no later than October 9, 2021. Both trainings were not completed as of the date of the inspection.
Employee #16 was hired as campus security on September 17, 2020. The HIV/AIDS training and the TB/STD training was due no later than September 17, 2022. Both trainings were not completed as of the date of the inspection.
Employee #17 was hired as campus security on December 11, 2019. The HIV/AIDS training and the TB/STD training was due no later than December 11, 2021. Both trainings were not completed as of the date of the inspection.
Employee #18 was hired as campus security on September 30, 2020. The HIV/AIDS training and the TB/STD training was due no later than September 30, 2022. Both trainings were not completed as of the date of the inspection.
Employee #19 was hired as patient care tech on September 11, 2019. The HIV/AIDS training was due no later than September 11, 2021. The HIV/AIDS training was not completed as of the date of the inspection.
Employee #20 was hired as patient care tech on September 09, 2019. The TB/STD training was due no later than September 09, 2021. The TB/STD training was not completed as of the date of the inspection.
Employee #21 was hired as patient care tech on May 5, 2020. The HIV/AIDS training and the TB/STD training was due no later than May 5, 2022. Both trainings were not completed as of the date of the inspection.
Employee #22 was hired as patient care tech on November 11, 2020. The HIV/AIDS training and the TB/STD training was due no later than November 11, 2022. Both trainings were not completed as of the date of the inspection.
Employee #23 was hired as patient care tech on April 8, 2020. The HIV/AIDS training and the TB/STD training was due no later than April 8, 2022. Both trainings were not completed as of the date of the inspection.
Employee #24 was hired as a recovery assistant on October 14, 2020. The HIV/AIDS training and the TB/STD training was due no later than October 14, 2022. Both trainings were not completed as of the date of the inspection.
This is a repeat citation from the March 9, 2022 through March 10, 2022 annual licensing renewal inspection.
The findings were discussed with facility staff during the licensing process.
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Plan of Correction
As of 3/13/23, VFMC Nurse Educator, has been approved by DDAP to facilitate TB/STD and HIV trainings. Beginning on 5/10/23, during orientation week, all new hires will attend training HIV and TB/STD training. HR will scan all certificates and feedback forms into the personnel charts. Current staff will be assigned a time to attend TB/STD and HIV training. All existing staff will have trainings completed by 9/1/23. QA Department to monitor for compliance. |
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
Based on a review of the personnel records, the facility failed to ensure that each counselor completed at least 25 clock hours of training annually during the facility's January 2022 through December 2022 2022 training year in one of one applicable personnel record reviewed.
Employee # 7 was hired as a counselor on February 23, 2021. The personnel record documented 21 hours of training for the reviewed training year.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
As of 4/15/23, HR will send an email to all supervisors with the number of required training hours, and the number of completed training hours that each staff member has completed for the current year. The training hours are completed through Relias as well as any outside trainings staff may have attended. The Supervisors will forward the email to each staff member and remind them of the required number of training hours. The emails will be sent at least quarterly. |
705.2 (2) LICENSURE Building exterior and grounds.
705.2. Building exterior and grounds.
The residential facility shall:
(2) Keep the grounds of the facility clean, safe, sanitary and in good repair at all times for the safety and well-being of residents, employees and visitors. The exterior of the building and the building grounds or yard shall be free of hazards.
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Observations
Based on a physical plant inspection, conducted on March 1, 2023, the facility failed to keep the grounds of the facility clean, safe, sanitary and in good repair at all times for the safety and well-being of residents, employees and visitors and the facility failed to keep the exterior of the building and the building grounds or yard free of hazards.
- The areas in front of and behind the campus maintenance building had piles of debris sitting and refuse was dumped on the hill behind the maintenance building.
- The entrances into every bedroom, along the bottom, from the hallway were covered in duct tape and was peeling away, thus causing a tripping hazard.
- There were chipped flooring and missing floor tiles in bedrooms 207, 225, 220 210.
- The chair railings in bedrooms 220, 212, 215, 216, 216, 218, 219, 220 were chipped.
- There was missing floor tiles and broken tiles covered in duct tape in the lower-level hallway.
- Bedroom 211 had a heating cover missing and was exposing a hot water pipe to clients and staff.
- Bedroom 211 had window blinds that were inoperable and the blinds in bedroom 219 were broken.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
a.) As of 4/1/23 all trash will be removed and placed in the garbage container. The maintenance department has been informed of the expectation of trash storage procedures. The maintenance department will monitor daily for compliance.
b.) As of 4/30/23 all duct tape will be removed and transitions will installed. This will be verified by the Facilities Director, and the Director of QA. Each month a walk through, of the entire building will be conducted by the Executive Director, Facilities Director and the Director of QA. During the walk through, a logbook will be maintained to note any repairs, pursuant to 705.2 building exterior and grounds, which need to be attended to. Within forty-eight hours of the deficiency being noted, a crew will be assigned to fix it. The crew will have twenty-four hours to begin to fix the deficiency and report to the Facilities Director and the Director of QA that the item has been corrected. Within 48 hours of completion of the repair, it will be verified by the Facilities Director, the Director of QA or the Executive Director.
c.) The chipped flooring and missing floor tiles in rooms 207,225,220, and 210 will be repaired or replaced by 4/30/23. This will be verified by the Facilities Director, and the Director of QA. Each month a walk through, of the entire building will be conducted by the Executive Director, Facilities Director and the Director of QA. During the walk through, a logbook will be maintained to note any repairs, pursuant to 705.2 building exterior and grounds, which need to be attended to. Within forty-eight hours of the deficiency being noted, a crew will be assigned to fix it. The crew will have twenty-four hours to begin to fix the deficiency and report to the Facilities Director and the Director of QA that the item has been corrected. Within 48 hours of completion of the repair, it will be verified by the Facilities Director, the Director of QA or the Executive Director.
d.) The chair railings in bedrooms 220,212,215,216,218,219 and 220 will be repainted by 4/30/23. This will be verified by the Facilities Director, and the Director of QA. Each month a walk through, of the entire building will be conducted by the Executive Director, Facilities Director and the Director of QA. During the walk through, a logbook will be maintained to note any repairs, pursuant to 705.2 building exterior and grounds, which need to be attended to. Within forty-eight hours of the deficiency being noted, a crew will be assigned to fix it. The crew will have twenty-four hours to begin to fix the deficiency and report to the Facilities Director and the Director of QA that the item has been corrected. Within 48 hours of completion of the repair, it will be verified by the Facilities Director, the Director of QA or the Executive Director.
e.) The missing floor tiles and broken tiles covered with duct tape in the lower-level hallway will be repaired/replaced by 4/30/23. This will be verified by the Facilities Director, and the Director of QA. Each month a walk through, of the entire building will be conducted by the Executive Director, Facilities Director and the Director of QA. During the walk through, a logbook will be maintained to note any repairs, pursuant to 705.2 building exterior and grounds, which need to be attended to. Within forty-eight hours of the deficiency being noted, a crew will be assigned to fix it. The crew will have twenty-four hours to begin to fix the deficiency and report to the Facilities Director and the Director of QA that the item has been corrected. Within 48 hours of completion of the repair, it will be verified by the Facilities Director, the Director of QA or the Executive Director.
f.) The missing heating cover in room 211 will be replaced by 4/30/23. This will be verified by the Facilities Director, and the Director of QA. Each month a walk through, of the entire building will be conducted by the Executive Director, Facilities Director and the Director of QA. During the walk through, a logbook will be maintained to note any repairs, pursuant to 705.2 building exterior and grounds, which need to be attended to. Within forty-eight hours of the deficiency being noted, a crew will be assigned to fix it. The crew will have twenty-four hours to begin to fix the deficiency and report to the Facilities Director and the Director of QA that the item has been corrected. Within 48 hours of completion of the repair, it will be verified by the Facilities Director, the Director of QA or the Executive Director.
g.) The window blinds in room 211 and 219 will be replaced by 4/30/23. This will be verified by the Facilities Director, and the Director of QA. Each month a walk through, of the entire building will be conducted by the Executive Director, Facilities Director and the Director of QA. During the walk through, a logbook will be maintained to note any repairs, pursuant to 705.2 building exterior and grounds, which need to be attended to. Within forty-eight hours of the deficiency being noted, a crew will be assigned to fix it. The crew will have twenty-four hours to begin to fix the deficiency and report to the Facilities Director and the Director of QA that the item has been corrected. Within 48 hours of completion of the repair, it will be verified by the Facilities Director, the Director of QA or the Executive Director.
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705.2 (4) LICENSURE Building exterior and grounds.
705.2. Building exterior and grounds.
The residential facility shall:
(4) Store all trash, garbage and rubbish in noncombustible, covered containers that prevent the penetration of insects and rodents, and remove it, at least once every week.
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Observations
Based on a physical plant inspection conducted on March 1, 2023, the facility failed to store all trash, garbage, and rubbish in noncombustible, covered containers that prevent insects and rodents. The outside trash dumpsters had lids that were open and the side door of one of the dumpsters was left open at the time of the inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
As of 3/6/23 all dumpster lids were closed and are being monitored daily by the housekeeping department to ensure compliance. Facilities and QA Director to follow up with monitoring, daily. |
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
Based on a physical plant inspection conducted on March 1, 2023, the facility failed to ensure privacy so that counseling sessions cannot be seen or heard outside the counseling room.
During the inspection, the DDAP representative observed, from a hallway, a group counseling session being held inside one of the group counseling rooms due to the room's doors being propped open.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
As of 4/1/23 a training will be conducted by leadership in regards to the basics of confidentiality. All staff will be assigned a confidentiality training in Relias. In addition, supervisors will make rounds during group sessions, every day, and make sure all doors are closed. |
705.5 (a) (1) LICENSURE Sleeping accommodations.
705.5. Sleeping accommodations.
(a) In each residential facility bedroom, each resident shall have the following:
(1) A bed with solid foundation and fire retardant mattress in good repair.
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Observations
Based on a physical plant inspection conducted on March 1, 2023, the facility failed to ensure that in each residential facility bedroom, each resident shall have a fire-retardant mattress that is in good repair.
In bedroom 221, there were two mattresses that were stained and not in good repair.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
As of 4/1/23 the leadership team will order a new mattresses from room 221. The mattresses will be delivered and placed in the patient's room. During the monthly inspection of the facility, the Facilities Director, Executive Director and the Director of QA will review the condition of mattresses and discard any that do not meet specifications. |
705.6 (5) LICENSURE Bathrooms.
705.6. Bathrooms.
The residential facility shall:
(5) Ventilate toilet and wash rooms by exhaust fan or window.
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Observations
Based on a physical plant inspection conducted on March 1, 2023, the facility failed to ensure that each bathroom was properly ventilated by either an exhaust fan or window.
The bathroom, located in bedroom 215, had an exhaust fan that was not operable at the time of the inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
As of 4/1/23 a new exhaust fan will be installed by maintenance in room 215. This will be verified by the Facilities Director, and the Director of QA. Each month a walk through, of the entire building will be conducted by the Executive Director, Facilities Director and the Director of QA. During the walk through, a logbook will be maintained to note any repairs, pursuant to 705.2 building exterior and grounds, which need to be attended to. Within forty-eight hours of the deficiency being noted, a crew will be assigned to fix it. The crew will have twenty-four hours to begin to fix the deficiency and report to the Facilities Director and the Director of QA that the item has been corrected. Within 48 hours of completion of the repair, it will be verified by the Facilities Director, the Director of QA or the Executive Director. |
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
Based on a physical plant inspection conducted on March 1, 2023, the facility failed to maintain each bathroom in a functional, clean, and sanitary manner at all times.
The following bathrooms were found to be either non-functional or not clean or sanitary at the time of the inspection:
- The bathroom in bedroom 209 had an exposed electric outlet.
- The bathroom in bedroom 212 had a missing shower handle.
- The bathrooms in bedrooms 202, 207, 210, 209, 211, 212, 215, 218, and 219, had rust on the pipes/shower rods and what appeared to be mold or mildew in the showers and/or bathtubs.
- The bathroom in bedroom 214 had damaged drywall and holes in the shower walls.
- The bathroom in bedroom 216 had damaged drywall that was pulling away from the wall.
- The bathrooms in bedrooms 284, 286, and 287 had dirt/grime and/or cigarette butts/ashes in the toilets.
This is a repeat citation from the March 9, 2022 through March 10, 2022 annual licensing renewal inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
a) As of 4/30/23, the bathroom in bedroom 209 will have a new electrical outlet cover installed. This will be verified by the Facilities Director, and the Director of QA. Each month a walk through, of the entire building will be conducted by the Executive Director, Facilities Director and the Director of QA. During the walk through, a logbook will be maintained to note any repairs, pursuant to 705.2 building exterior and grounds, which need to be attended to. Within forty-eight hours of the deficiency being noted, a crew will be assigned to fix it. The crew will have twenty-four hours to begin to fix the deficiency and report to the Facilities Director and the Director of QA that the item has been corrected. Within 48 hours of completion of the repair, it will be verified by the Facilities Director, the Director of QA or the Executive Director.
b. As of 4/30/23 the bathroom in bedroom 212 will have a new shower handle installed. This will be verified by the Facilities Director, and the Director of QA. Each month a walk through, of the entire building will be conducted by the Executive Director, Facilities Director and the Director of QA. During the walk through, a logbook will be maintained to note any repairs, pursuant to 705.2 building exterior and grounds, which need to be attended to. Within forty-eight hours of the deficiency being noted, a crew will be assigned to fix it. The crew will have twenty-four hours to begin to fix the deficiency and report to the Facilities Director and the Director of QA that the item has been corrected. Within 48 hours of completion of the repair, it will be verified by the Facilities Director, the Director of QA or the Executive Director.
c. As of 4/30/23 the bathrooms in bedrooms 202,207,210,209,211,212,215,218 and 219 will have the rust removed and the shower rods replaced. This will be verified by the Facilities Director, and the Director of QA. Each month a walk through, of the entire building will be conducted by the Executive Director, Facilities Director and the Director of QA. During the walk through, a logbook will be maintained to note any repairs, pursuant to 705.2 building exterior and grounds, which need to be attended to. Within forty-eight hours of the deficiency being noted, a crew will be assigned to fix it. The crew will have twenty-four hours to begin to fix the deficiency and report to the Facilities Director and the Director of QA that the item has been corrected. Within 48 hours of completion of the repair, it will be verified by the Facilities Director, the Director of QA or the Executive Director.
d. As of 4/30/23 the bedroom in 214 will have the dry wall repaired in the bedroom and bathroom. This will be verified by the Facilities Director, and the Director of QA. Each month a walk through, of the entire building will be conducted by the Executive Director, Facilities Director and the Director of QA. During the walk through, a logbook will be maintained to note any repairs, pursuant to 705.2 building exterior and grounds, which need to be attended to. Within forty-eight hours of the deficiency being noted, a crew will be assigned to fix it. The crew will have twenty-four hours to begin to fix the deficiency and report to the Facilities Director and the Director of QA that the item has been corrected. Within 48 hours of completion of the repair, it will be verified by the Facilities Director, the Director of QA or the Executive Director.
e. As of 4/30/23 the drywall in the bathroom of room 216 will be repaired. This will be verified by the Facilities Director, and the Director of QA. Each month a walk through, of the entire building will be conducted by the Executive Director, Facilities Director and the Director of QA. During the walk through, a logbook will be maintained to note any repairs, pursuant to 705.2 building exterior and grounds, which need to be attended to. Within forty-eight hours of the deficiency being noted, a crew will be assigned to fix it. The crew will have twenty-four hours to begin to fix the deficiency and report to the Facilities Director and the Director of QA that the item has been corrected. Within 48 hours of completion of the repair, it will be verified by the Facilities Director, the Director of QA or the Executive Director.
f. As of 3/6/23 the bathrooms in bedrooms 284, 286 and 287 have been cleaned and the dirt/grime and ashes have been removed from the toilets. This was
verified by the Facilities Director, and the Director of QA. Each month a walk through, of the entire building will be conducted by the Executive Director, Facilities Director and the Director of QA. During the walk through, a logbook will be maintained to note any repairs, pursuant to 705.2 building exterior and grounds, which need to be attended to. Within forty-eight hours of the deficiency being noted, a crew will be assigned to fix it. The crew will have twenty-four hours to begin to fix the deficiency and report to the Facilities Director and the Director of QA that the item has been corrected. Within 48 hours of completion of the repair, it will be verified by the Facilities Director, the Director of QA or the Executive Director.
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705.10 (c) (4) LICENSURE Fire safety.
705.10. Fire safety.
(c) Fire extinguisher. The residential facility shall:
(4) Instruct all staff in the use of the fire extinguishers upon staff employment. This instruction shall be documented by the facility.
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Observations
Based on a review of personnel records, the facility failed to instruct all staff in the use of a fire extinguisher upon staff employment in every personnel record reviewed.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
Beginning 3/8/23 all staff were trained on how to use fire extinguishers. Moving forward training will take place during new hire orientation and is conducted by campus safety. The campus safety officer who conducts the training will sign the training certificate and HR will scan it into the personnel files. |
705.10 (d) (3) LICENSURE Fire safety.
705.10. Fire safety.
(d) Fire drills. The residential facility shall:
(3) Ensure that all personnel on all shifts are trained to perform assigned tasks during emergencies.
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Observations
Based on a review of personnel records, the facility failed to ensure that all personnel on all shifts were trained to perform assigned tasks during emergencies in every personnel record reviewed.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Beginning 3/8/23 all staff have been trained on what their role is in an emergency. During the training staff was instructed on their role during an emergency. Moving forward the training will take place at new hire orientation by a campus safety officer. The campus safety officer who conducts the training will sign the training certificates and the HR department will scan it into the personnel files. |
715.11 LICENSURE Confidentiality of patient records
A narcotic treatment program shall physically secure and maintain the confidentiality of all patient records in accordance with 42 CFR 2.22 (relating to notice to patients of Federal confidentiality requirements) and § 709.28 (relating to confidentiality).
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Observations
Based on a review of patient records, the narcotic treatment program failed to maintain the confidentiality of all patient records, in accordance with Federal and State laws and regulations, by not documenting a client-signed consent to release information form prior to the disclosure of information in two of eight applicable patient records reviewed.
Patient #1 was admitted into the hospital detox activity on February 19, 2023 and was active at the time of inspection. There was documentation of billing to the funding source during the patient's treatment episode; however, there was no consent to release information form on file prior to the disclosures of information.
Patient #10 was admitted into the hospital residential activity care on February 15, 2023 and was active at the time of inspection. There was documentation of billing to the funding source during the patient's treatment episode; however, there was no consent to release information form on file prior to the disclosures of information.
This finding was reviewed with facility staff during the licensing inspection.
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Plan of Correction
As of 5/1/23 a new EMR will be instituted. The new EMR will have a dashboard which will alert staff when any documentation is missing, including ROI. Weekly chart audits by Nursing and QA departments will monitor and review all documentation including missing or unsigned consents. |
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
Based on a review of patient records, the narcotic treatment program failed to obtain an informed, voluntary, written consent before an agent may be administered to the patient for either maintenance or detoxification treatment in two applicable patient records reviewed.
Patient #1 was admitted into the hospital detox level of care on February 19, 2023 and was active at the time of inspection. The patient received their first medication dose on February 19, 2023; however, the patient consent to treat form, documented in the record, was signed by the patient on February 20, 2023.
Patient #14 was admitted into the hospital residential level of care on May 21, 2023 and was discharged June 7, 2022. There was no signed consent to treat form documented in the record at the time of the inspection.
This is a repeat citation from the March 9, 2023 through March 10, 2023 annual licensing renewal inspection.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
As of 3/4/23, all patients are to sign consents for MAT at the time of admission. The nursing intake staff review the consents with the patient and explains MAT. The MAT consent has been added to the intake checklist. Weekly audits of charts will be conducted by the Nursing or QA department to secure continued compliance. |
715.23(b)(24) LICENSURE Patient records
(b) Each patient file shall include the following information:
(24) Follow-up information regarding the patient.
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Observations
Based on a review of patient records, the narcotic treatment program failed to document, in the patient record, follow-up information regarding the patient in one of one applicable patient record reviewed.
Patient #14 was admitted into the hospital residential activity on May 21, 2023 and was discharged June 7, 2022. There was no follow-up information documented in the record as of the date of the inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
As of 4/17/23, the Peer Support department will begin to document follow up phone calls with every discharged patient. The staff will be trained on the process and given a list of required questions. The Director of Peer Support will monitor weekly for compliance |
711.53(a)(7) LICENSURE Follow-up Information
711.53. Client records.
(a) Record requirements. There shall be a complete client record on an individual which includes information relative to the client's involvement with the project. In addition to the requirements contained in 115.32 (relating to contents), the client record shall include the following:
(7) Follow-up information.
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Observations
Based on a review of client records, the facility failed to document a complete client record, which is to include follow-up information, in two of two applicable records reviewed.
Client # 18 was admitted into the non-hospital residential activity on December 13, 2022 and was discharged October 4, 2022. There was no follow-up information documented in the record as of the date of the inspection.
Client # 21 was admitted into the non-hospital residential activity on April 11. 2022 and was discharged May 16, 2022. There was no follow-up information documented in the record as of the date of the inspection.
The findings were discussed with facility staff during the licensing process.
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Plan of Correction
As of 4/17/23, the Peer Support department will begin to document follow up phone calls with every discharged patient. The staff will be trained on the process and given a list of required questions. The Director of Peer Support will monitor weekly for compliance |
710.23(a) LICENSURE Patient Records
§ 710.23. Patient records.
(a) In addition to the requirements contained in § 115.32 (relating to contents), the patient ' s medical record shall contain a drug and alcohol support plan, follow-up information, and an aftercare plan, if applicable.
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Observations
Based on a review of patient records, the facility failed to include documentation of follow-up information in the patient's medical record in one of two applicable records reviewed.
Client # 5 was admitted into the hospital detoxification activity on July 14, 2022 and was discharged July 19, 2022. There was no follow-up information documented in the record as of the date of the inspection.
The findings were discussed with facility staff during the licensing process.
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Plan of Correction
As of 4/17/23, the Peer Support department will begin to document follow up phone calls with every discharged patient. The staff will be trained on the process and given a list of required questions. The Director of Peer Support will monitor weekly for compliance |