INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on September 7-8, 2017 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Interim House West 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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705.24 (7) LICENSURE Bathrooms.
705.24. Bathrooms.
The nonresidential facility shall:
(7) Maintain each bathroom in a functional, clean and sanitary manner at all times.
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Observations
A physical plant inspection was conducted on September 8, 2017.
In the shared bathroom for bedrooms # 204A and 204B, substantial mold was observed in the bathtub/shower. Additionally, in the shared bathroom for bedrooms #305A and 305B, mold was observed in the bathtub/shower.
These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
The maintenance assistant cleaned and removed the mold in the shared bathtub/shower in rooms 204a/204b and 305a/305b.
Household management class with participants was conducted on September 13, 2017 with the Facility Manager in which she focused on the cause of mold, cleaning to prevent mold , identifying mold, and the process of removing the mold in bathtub/shower.
The residential assistant will inspect and monitor all shared bathtub/showers and provide weekly reports to facility manager to ensure all mold is removed and remain mold free.
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715.1(a)(b) LICENSURE General Provisions
(a) An entity within this Commonwealth which uses agents for maintenance or detoxification of persons shall obtain the approval of the Department to operate a narcotic treatment program.
(b) The Department's approval of a narcotic treatment program shall be contingent upon the narcotic treatment program's compliance with the standards and conditions in this part. In addition, the program shall comply with applicable Federal laws and regulations.
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Observations
A licensing renewal inspection was conducted on September 7-8, 2017. The facility began conducting narcotic treatment services utilizing Buprenorphine prior to applying for and receiving the Department's approval, in the inpatient treatment activity.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
On June 13, 2017 Interim House West's Program Director submitted an exception request to DDAP to commence the use of buprenorphine in our residential program. This request was approved by DDAP per a letter dated July 12, 2017.
Interim House West will collaborate with Public Health Management Corporation's Total Quality Improvement (TQI) Department to ensure that all pertinent regulations are identified and reviewed prior to implementation. This will ensure adherence to licensing standards. The IHW Program Director will be responsible for confirming with the PHMC BHS Managing Director and TQI Managing Director that a review of licensing alerts, bulletins, and discussion with designated state licensing personnel have occurred prior to new program implementation.
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715.6(e) LICENSURE Physician Staffing
(e) A physician assistant or certified registered nurse practitioner may perform functions of a narcotic treatment physician in a narcotic treatment program if authorized by Federal, State and local laws and regulations, and if these functions are delegated to the physician assistant or certified registered nurse practitioner by the medical director, and records are properly countersigned by the medical director or a narcotic treatment physician. One-third of all required narcotic treatment physician time shall be provided by a narcotic treatment physician. Time provided by a physician assistant or certified registered nurse practitioner may not exceed two-thirds of the required narcotic treatment physician time.
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Observations
Three client records were reviewed for treatment services utilizing Buprenorphine on September 7-8, 2017. The facility failed to document a physical examination conducted by a narcotic treatment physician or a certified registered nurse practitioner for client record #1. Additionally, the facility failed to document the countersignature of the medical director or a narcotic treatment physician on records of physical examinations conducted by a certified registered nurse practitioner in client records #2 and 3.
Client # 1 was admitted into treatment on 4/21/17 and was discharged on 6/14/17. The physical exam conducted on 4/27/17 was completed by a registered nurse.
Client # 2 was admitted into treatment on 5/24/17 and was still active in treatment. The physical exam conducted on 5/25/17 was completed by a certified registered nurse practitioner. The physician failed to countersign the physical exam report.
Client # 3 was admitted into treatment on 1/20/17 and was still active in treatment. The physical exam conducted on 1/26/17 was completed by a certified registered nurse practitioner. The physician failed to countersign the physical exam report.
These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
All clients that enter Interim House West obtain a physical examination within the first two weeks of admission by a provided Certified Registered Nurse Practitioner or, if they opt out, by an outside provider of their choice.
Prior to any implementation of medication assisted narcotic treatment, the registered nurse will provide the narcotic treatment physician the completed physical exam reports for countersignature by the narcotic treatment physician. The program director will monitor this via weekly supervision with the registered nurse and clinical director.
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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.
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Observations
Three client records were reviewed for treatment services utilizing Buprenorphine on September 7-8, 2017. The narcotic treatment physician failed to document their face-to-face determination of dependency prior to the administration of Buprenorphine for client record # 1.
Client # 1 was admitted into treatment on 4/21/17 and was discharged on 6/14/17. Documentation in the client's record indicated that the client received an initial dose of 4 mg of Buprenorphine on 4/26/17. The physician's face-to-face determination of dependency was documented on 4/27/17.
This finding was reviewed with facility staff during the licensing inspection.
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Plan of Correction
Prior to any implementation of medication assisted narcotic treatment, the narcotic treatment physician will perform and document a face-to-face determination of dependency and verify dependency for at least 1 year prior to the initiation of treatment. This will be documented in the client's chart. The program director will monitor this via weekly supervision with the registered nurse. |
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
Three client records were reviewed for treatment services utilizing Buprenorphine on September 7-8, 2017. The facility failed to obtain a complete written informed patient consent prior to the administration of Buprenorphine, for maintenance treatment in client records, # 1, 2, and 3.
Client #1 was admitted into treatment on 4/21/17 and was discharged on 6/14/17. Documentation in the client's record indicated that the client received an initial dose of 4 mg of Suboxone on 4/26/17. An informed written patient consent was not documented.
Client # 2 was admitted into treatment on 5/24/17 and was still active in treatment. Documentation in the client's record indicated that the client received an initial dose of 8 mg of Suboxone on 8/3/17. The informed written patient consent documented in the client's record was signed by the client on 9/5/17. In addition, the following did not appear on the patient consent form:
- That Buprenorphine is an addictive medication and may, like other drugs used in medical practices, produce adverse results.
- That alternative methods of treatment exist.
Client # 3 was admitted into treatment on 1/20/17 and was still active in treatment. Documentation in the client's record indicated that the client received an initial dose of 8 mg of Buprenorphine on 1/24/17. The informed written patient consent documented in the client's record was signed by the client on 9/5/17. In addition, the following did not appear on the patient consent form:
- That Buprenorphine is an addictive medication and may, like other drugs used in medical practices, produce adverse results.
- That alternative methods of treatment exist.
These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
Prior to any implementation of medication assisted narcotic treatment, the narcotic treatment physician will review with the client the informed written consent. The informed written consent at IHW has been revised to include that: (1) bupenorphrine is a narcotic and can be harmful if taken without medical supervision (2) bupenorphrine is an addictive medication and may, like other drugs used in medical practices, produce adverse results. (3) alternative methods of treatment exist (4) possible risks and complications of treatment have been explained to the patient (5) bupenorphrine is transmitted to the unborn child and will cause physical dependence.
This written consent must be reviewed and signed by the client, the narcotic treatment physician, and a witness prior to implementation of any doses of bupenorphrine. The Program Director will receive weekly updates to ensure this task is being completed via weekly supervision with the registered nurse.
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715.17(c)(1)(i-vi)) LICENSURE Medication control
(c) A narcotic treatment program shall develop and implement written policies and procedures regarding the medications used by patients which shall include, at a minimum:
(1) Administration of medication.
(i) A narcotic treatment physician shall determine the patient 's initial and subsequent dose and schedule. The physician shall communicate the initial and subsequent dose and schedule to the person responsible for the administration of medication. Each medication order and dosage change shall be written and signed by the narcotic treatment physician.
(ii) An agent shall be administered or dispensed only by a practitioner licensed under the appropriate Federal and State laws to dispense agents to patients.
(iii) Only authorized staff and patients who are receiving medication shall be permitted in the dispensing area.
(iv) There shall be only one patient permitted at a dispensing station at any given time.
(v) Each patient shall be observed when ingesting the agent.
(vi) Administering and dispensing shall be conducted in a manner that protects the patient from disruption or annoyance from other individuals.
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Observations
A licensing renewal inspection was conducted on September 7-8, 2017. The facility failed to implement written policies and procedures ensuring that Buprenorphine is administered or dispensed only by a practitioner licensed under the appropriate Federal and State laws to dispense agents to patients. Based on interviews with facility staff, a review of Medication Administration Records, and a review of the facility's medication policy, staff persons in the residential assistant and medical assistant positions had been permitted to dispense Buprenorphine when a license practitioner was not onsite.
This finding was reviewed with facility staff during the licensing inspection.
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Plan of Correction
The Medical Director changed the suboxone times for current clients to 8:30 am to ensure that during the weekday, only the registered nurse is dispensing bupenorphrine. Effective November 09th, 2017, the Program Director will hire an licensed practical nurse on the weekends to ensure that the dispensing of bupenorphrine is only performed by a licensed medical practitioner. The registered nurse has revised the medication policies to adhere to 715.7(c)(1)(i-vi). The Program Director will ensure the implementation of this policy via weekly review or the RN and LPN's work schedule and weekly supervision with the registered nurse. |
715.17(c)(4)(i-viii) 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:
(4) Method for control and accountability of drugs. A narcotic treatment program shall develop and implement written policies and procedures regarding who is authorized to remove drugs from the storage area and the method for accounting for all stored drugs. An agent or other drug prescribed or administered shall be documented on an individual medication record or sheet in a manner sufficient to maintain an accurate accounting of medication at all times and shall include:
(i) The name of the medication.
(ii) The date prescribed.
(iii) The dosage.
(iv) The frequency.
(v) The route of administration.
(vi) The date and time administered.
(vii) The name of the person administering the medication.
(viii) The take-home schedule, if applicable.
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Observations
Three client records were reviewed for treatment services utilizing Buprenorphine on September 7-8, 2017. The facility failed to maintain a complete medication administration record for client records # 1, 2, and 3.
Client #1 was admitted into treatment on 4/21/17 and was discharged on 6/14/17. A medication administration record sheet documented in the client's record identified Suboxone as a prescribed medication. This sheet did not document the date and time of day Suboxone was administered to the client, and the charting month was not documented.
Client # 2 was admitted into treatment on 5/24/17 and was still active in treatment. A medication administration record sheet documented in the client's record, for the month of August 2017, identified Suboxone as a prescribed medication. This sheet did not document the time of day Suboxone was administered to the client.
Client # 3 was admitted into treatment on 1/20/17 and was still active in treatment. A medication administration record sheet documented in the client's record, for the month of January 2017, identified Buprenorphine as a prescribed medication. This sheet did not document the time of day Buprenorphine was administered to the client.
These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
The registered nurse at IHW will coordinate with Tepper Pharmacy to ensure that the time of day that bupenorphrine is to be administered is recorded on the medication administration record. The licensed medical practitioner dispensing the medication will ensure that all aspects of the medication are properly labeled on the medication administration record as well as the narcotic count record to ensure that there is a proper account of all medication in the facility. The Program Director will ensure the implementation of this policy via weekly supervision with the registered nurse. |
715.17(c)(6)(i-iv) 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:
(6) Inventories. A narcotic treatment program shall conduct monthly inventories of agents and other controlled substances stored. Each inventory record shall include:
(i) The date the inventory was conducted.
(ii) The time of day it was conducted.
(iii) The name and amount of each product on hand at the time of the inventory.
(iv) The name of the individual conducting the inventory.
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Observations
A licensing renewal inspection was conducted on September 7-8, 2017. Monthly inventory records for Buprenorphine were reviewed for the period of November 2016 - August 2017. The facility failed to document the time of day the inventories were conducted.
This finding was reviewed with facility staff during the licensing inspection.
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Plan of Correction
The Medical Director changed the suboxone times for current clients to 8:30 am to ensure that during the weekday, only the registered nurse is dispensing bupenorphrine. Effective November 09th, 2017, the Program Director will hire an licensed practical nurse on the weekends to ensure that the dispensing of bupenorphrine is only performed by a licensed medical practitioner. The registered nurse has revised the medication policies to adhere to 715.7(c)(1)(i-vi). The Program Director will ensure the implementation of this policy via weekly review or the RN and LPN's work schedule and weekly supervision with the registered nurse. |
709.52(b) LICENSURE TX Plan update
709.52. Treatment and rehabilitation services.
(b) Treatment and rehabilitation plans shall be reviewed and updated at least every 30 days. For those projects whose client treatment regime is less than 30 days, the treatment and rehabilitation plan, review and update shall occur at least every 15 days.
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Observations
Nine client records were reviewed on September 7-8, 2017. The facility failed to document a treatment plan update at least every 30 days for client records # 2, 4, 6, and 9.
Client # 2 was admitted into treatment on 5/24/17 and was still active in treatment. A master treatment plan was completed for the client on 6/23/17. A treatment plan update was then completed for the client on 8/18/17.
Client # 4 was admitted into treatment on 5/16/17 and was still active in treatment. A master treatment plan was completed for the client on 5/31/17. A treatment plan update was then completed for the client on 8/18/17.
Client # 6 was admitted into treatment on 11/14/16 and was discharged on 7/11/17. The most recent treatment plan update documented in the client's record was completed on 5/31/17. A subsequent treatment plan update was due to be completed by 6/31/17, and one was not documented in the client's record.
Client # 9 was admitted into treatment on 5/2/17 and was discharged on 8/31/17. The last two treatment plan updates documented in the client's record were completed on 6/20/17 and 8/16/17.
These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
In charts audited Interim House West staff failed to review and updated treatment plan every thirty days.
Interim House West Clinical Director will hold staff training to review 709.52 regulations as it pertains to treatment plan documentation. The therapist will ensure that treatment plans are updated every 30 days with each participant. The clinical director/program director will sign off on all treatment plans to ensure updates are being completed every 30 days.
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