INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on December 26-28, 2018 by staff from the Department of Drug and Alcohol Programs, Bureau of Quality Assurance for Prevention & Treatment with the inspection also conducted for the approval to use Methadone and Buprenorphine in the treatment of narcotic addiction. Based on the findings of the on-site inspection, The Healing Way 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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709.30 (1) 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.
(1) A client receiving care or treatment under section 7 of the act (71 P. S. § 1690.107) shall retain civil rights and liberties except as provided by statute. No client may be deprived of a civil right solely by reason of treatment.
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Observations
The facility failed to document written acknowledgement by client that they have been notified of client rights in one client record reviewed on December 26-28, 2018.
Client # 5 was admitted on 12/5/2018 and was still current at the time of the inspection. Client #5 had no written documentation that their rights had been reviewed with them.
These findings were reviewed with the facility staff during the licensing process.
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Plan of Correction
A 2 page document of the client wrights was developed and added to the patients chart. The patients wrights are also in the patient handbook. The supervisor will be responsible to see that a signed copy of the clients wrights, as well as a signed copy of the patient handbook is in the patient chart when the monthly individual supervision is done. Employee will bring a few chart to be checks at that time. At the weekly staff supervision meeting the staff will be reminded that every patient must sign that they received a copy of the patients wrights. The director will oversee that the supervisor is checking the patient charts on a regular basis. |
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
The facility failed to remove outdated drugs per the facility's Medication Use and Management Policy that states outdated, and contaminated drugs shall be removed and destroyed according to federal and state regulations.
During inspection of the safe in the dosing area on December 26, 2018, an outdated filled prescription of suboxone was found. This was not house stock but belonged to a former client that no longer received services at the facility.
These findings were reviewed with the facility staff during the licensing process.
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Plan of Correction
The Rule is No other drugs are to be in the safe at any time but Methadone. A sign will be put on the front of the safe stating that. If medication is collected form a patient for any reason and it is to be disposed of it will be in a locked box in the locked nursing station and will be taken to a hospital or pharmacy that has a medication disposal box for old medication. The Nurse or Director will be responsible to take the medication to be disposed an note it in a log book.The Head nurse is responsible to let the other nurses know. At the weekly staff supervision meeting it will also be brought up. The Director will oversee that it is done and check the safe periodically to sure no other medication other than Methadone is in the safe. |
715.6(d) LICENSURE Physician Staffing
(d) A narcotic treatment program shall provide narcotic treatment physician services at least 1 hour per week onsite for every ten patients
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Observations
A narcotic treatment program shall provide narcotic treatment physician services at least one hour per week onsite for every ten patients.
Weekly physician time sheets and client census reports were reviewed on December 26-28, 2018 for the period of July 30, 2018 through December 2, 2018. Based on a review of this documentation, the facility failed to provide at least one hour of physician services per week on site for each week within the reviewed time period.
For the week of September 2, 2018, the patient census was 119. The facility was required to to provide at least 11.9 onsite physician hours. There were eight onsite physician hours documented for this week.
For the week of November 19, 2018, the patient census was 119. The facility was required to provide 11.9 onsite physician hours. There were eight onsite physician hours documented for this week.
These findings were reviewed with facility staff during the licensing process.
This was a repeat citation from the December 6, 2017 licensing inspection.
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Plan of Correction
The Medical Director and Chief Compliance Officer was notified of this situation on 1/14 and it's being rectified. The census will be checked at the end of every week so the doctor's time can be adjusted for the following week with the 1 to 10 ratio. The Chief Compliance Officer CCO will be responsible to check the census weekly on Friday (or her designee). The Director will check with the CCO that this is being done and is correct.
During holiday weeks The Healing Way Medical Director will change her day off that week in the event more hours are needed. The CCO will keep track of the Holiday time for the physician(s). The Director will check the CCO is overseeing the holiday time. |
715.17(c)(3)(i-v) 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:
(3) Inspection of storage areas. A narcotic treatment program shall inspect all drug storage areas and the dispensing station at least quarterly to ensure that the areas are maintained in compliance with Federal, State and local laws and regulations. A narcotic treatment program shall develop and implement written policies and procedures regarding who performs the inspections, how often, and in what manner the inspections are to be documented. The policies and procedures shall include the following:
(i) Disinfectants and drugs for external use shall be stored separately from oral and injectable drugs.
(ii) Drugs requiring special conditions for storage to insure stability shall be properly stored.
(iii) Outdated and contaminated drugs shall be removed and destroyed according to Federal and State regulations.
(iv) Administration of controlled substances shall be documented.
(v) Controlled substances and other abusable drugs shall be stored in accordance with Federal and State regulations.
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Observations
The facility failed to remove and destroy outdated drugs according to Federal and State regulations.
During inspection of the safe in the dosing area on December 26, 2018, an outdated filled prescription of suboxone was found. This was not house stock but belonged to a former client that no longer received services at the facility.
These findings were reviewed with the facility staff during the licensing process.
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Plan of Correction
Disposal of old medication as of 1/14/2019 The Healing Way made a form that will be kept in a log binder in the nursing station on all old medication that was disposed. The form will have who's medication, name of medication, Rx date, where it was taken and who took the medication to a disposal center. A lock box will be kept in the nursing station to put any old medication to be disposed until the nurses or director take the medication to be discarded to the nearest hospital or pharmacy that has a disposal station for old medication. The Head nurse is responsible to see that it is done and the director will oversee the Head nurse to be sure it is done. |
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.
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Observations
Six client records were reviewed for the use of Methadone in the outpatient treatment activity on December 26-28, 2018. For client records # 1, 2, and 8, the facility failed to to provide each patient with an average of 2.5 hours of psychotherapy per month during the patient's first 2 years, 1 hour of which was required to be individual psychotherapy.
Client #1 was admitted into treatment on December 4, 2017 and was still active at the time of the inspection. Documentation in the client's record indicated that the client received less than 2.5 hours of psychotherapy for the months of October and November 2018. In addition, the client received less than 1 hour of individual psychotherapy for the months of October, November and December 2018.
Client #2 was admitted on August 21, 2017 and was discharged on November 13, 2018. Documentation in the client's record indicated that the client received less than 1 hour of individual psychotherapy for the months of August, September and October 2018.
Client #8 was admitted on January 1, 2018 and discharged on August 21, 2018. Documentation in the client's record indicated that the client received less than 1 hour of individual psychotherapy for the months of June and July 2018.
These findings were reviewed with facility staff during the licensing process.
This was a repeat citation from the December 6, 2017 licensing inspection.
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Plan of Correction
A training for staffs during the weekly staffs supervision and training will be done by 1/25. During the monthly individual supervision the clinical supervisor will check random charts to see that the 2 1/2 hrs. of psychotherapy is being done. THW will also have the treatment plan say the same that 2 1/2 hrs. are in compliance. The Chief Compliance Officer will check that the supervisor is checking random charts. |
715.23(b)(5) LICENSURE Patient records
(b) Each patient file shall include the following information:
(5) The results of all annual physical examinations given by the narcotic treatment program which includes an annual reevaluation by the narcotic treatment physician.
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Observations
The facility failed to complete annual reevaluation physicals by the narcotic treatment physician.
Client #3 was admitted on May 12, 2015 and was still current at the time of inspection. Client #3 last reevaluation physical was documented on May 11, 2017.
These findings were reviewed with the facility staff during the licensing process.
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Plan of Correction
The Head Nurse will print out a six month list for when the patient is due for their annual reevaluation physical and give it to the Medical Director so she can check well in advance wen the patient is due for the physical. The Head Nurse is responsible to see that this is done and the Chief Compliance Officer is responsible to check that the Head Nurse does print out the list and she or designee will recheck that it is being done. |
709.92(b) LICENSURE Treatment and rehabilitation services
709.92. Treatment and rehabilitation services.
(b) Treatment and rehabilitation plans shall be reviewed and updated at least every 60 days.
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Observations
Based on a review of client records, the facility failed to complete sixty-day treatment plan updates in two of six client records.
Client #3 was admitted on May 12, 2015 and was still current at the time of the inspection. Client #3 had a treatment plan update on April 18, 2018 then not another until July 11, 2018.
Client #4 was admitted on September 23, 2014 and was discharged on November 13, 2018. A treatment plan update was completed on December 13, 2017 and then not another until March 1, 2018.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
A training on treatment plans and updates on treatment plans will be done at a weekly supervision/training meeting for staff. A couple of staff that did not comply with treatment plans regularly were replaced with more competent staff. The clinical supervisor will be responsible to randomly check that the treatment plans are done on time and explain that if they come due over a weekend to do them a few days up to a week early to stay in compliance. The Chief Compliance Officer will oversee that the clinical supervisor is checking during the monthly supervision (or her designee the director), |