INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection and buprenorphine monitoring inspection conducted on September 18 - 19, 2018 by staff from the Department of Drug and Alcohol Programs, Bureau of Quality Assurance for Prevention and Treatment, Division of Accountability and Program Improvement. Based on the findings of the on-site inspection, Gaudenzia Erie, Inc. Crossroads 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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709.32 (b) LICENSURE Medication control
§ 709.32. Medication control.
(b) Verbal orders for medication can be given only by a physician or other medical professional authorized by State and Federal law to prescribe medication and verbal orders may be received only by another physician or medical professional authorized by State and Federal law to receive verbal orders. When a verbal or telephone order is given, it has to be authenticated in writing by a physician or other medical professional authorized by State and Federal law to prescribe medication. In detoxification levels of care, written authentication shall occur no later than 24 hours from the time the order was given. Otherwise, written authentication shall occur within 3 business days from the time the order was given.
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Observations
The facility's physician failed to authenticate, in writing, detoxification verbal orders no later than 24 hours from the time the order was given in three of five detoxification client records reviewed on September 18 - 19, 2018.
Client # 2 was admitted June 5, 2018 and discharged June 9, 2018. A verbal order was given by the physician on June 5, 2018.
Client # 3 was admitted May 18, 2018 and discharged May 23, 2018. A verbal order was given by the physician on May 18, 2018.
Client # 5 was admitted June 21, 2018 and discharged June 25, 2018. A verbal order was given by the physician on June 21, 2018.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Detoxification Unit Nurse Manager will meet with all nursing staff and Physicians and review regulations and requirements for signing/authenticating verbal orders within 24 hours.
The Nurse Manager will conduct monthly chart audits to ensure authentication of verbal orders is being completed. The monthly chart audits will begin in November 2018.
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709.63(a) LICENSURE Client record
709.63. 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:
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Observations
The facility failed to document a complete client record including drug and alcohol support plans in three of five detoxification client records reviewed on September 18 - 19, 2018.
Client # 2 was admitted June 5, 2018 and discharged June 9, 2018.
Client # 3 was admitted May 18, 2018 and discharged May 23, 2018.
Client # 4 was admitted May 14, 2018 and discharged May 19, 2018.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Facility Nurse Manager will meet with all detox nurses and review a complete chart and required documentation by 10/19/18.
Facility Nurse Manager will develop a checklist to help ensure all required items are completed for support plans by 10/19/18.
Facility Nurse Manager will complete monthly chart audits to ensure that all detox clients receive a support plan. these monthly chart audits will begin in November 2018. |
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
The facility failed to document an informed, voluntary written consent prior to the administration of a narcotic agent to the patient for detoxification in two of five patient records reviewed on September 18 - 19, 2018.
Patient # 1 was admitted September 14, 2018 and discharged September 18, 2018. Patient # 1 was administered Suboxone on September 15, 2018.
Patient # 4 was admitted May 14, 2018 and discharged May 19, 2018. Patient # 4 was administered Suboxone on May 15, 2018.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Nurse Manager will meet with all nursing staff and review the informed consent requirement with all nurses by 10/19/2018.
Nurse Manager will conduct monthly chart audits starting in November 2018 to ensure that signed informed consents are completed prior to clients receiving narcotic agents. |
709.52(a) LICENSURE Individual TX and REHAB Plan
709.52. Treatment and rehabilitation services.
(a) An individual treatment and rehabilitation plan shall be developed with a client. This plan shall include, but not be limited to, written documentation of:
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Observations
The facility failed to document an individual treatment plan that included the type and frequency of treatment and rehabilitation services in four of five residential client records reviewed on September 18 - 19, 2018.
Client # 6 was admitted June 9, 2018 and discharged July 13, 2018. The individual treatment plan was completed on June 23, 2018.
Client # 8 was admitted May 19, 2018 and discharged June 27, 2018. The individual treatment plan was completed on May 31, 2018.
Client # 9 was admitted May 15, 2018 and discharged June 30, 2018. The individual treatment plan was completed on June 7, 2018.
Client # 10 was admitted July 11, 2018. The individual treatment plan was completed on July 20, 2018.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Program Director will meet with all clinical staff and review the requirement of type and frequency in the clients EHR by 10/19/2018.
Program Director, Program Supervisor, and Clinical Supervisor will complete chart audits monthly to ensure the type and frequency of treatment services is documented. these monthly chart audits will begin in November 2018. |
709.53(a) LICENSURE Complete Client Record
709.53. 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:
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Observations
The facility failed to document a complete client record including verification that work done by the client at the project was an integral part of their treatment and rehabilitation plan in five of five residential client records reviewed on September 18 - 19, 2018.
Client # 6 was admitted June 9, 2018 and discharged on July 13, 2018.
Client # 8 was admitted May 19, 2018 and discharged on June 27, 2018.
Client # 9 was admitted May 15, 2018 and discharged on June 30, 2018. Client # 10 was admitted July 11, 2018.
Client # 11 was admitted August 23, 2018.
The findings were reviewed with staff during the licensing process.
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Plan of Correction
Program Director/Program Supervisors/and Clinical Supervisor will meet with all clinical staff to review the requirement of having work therapy documented and listed on client records by 10/19/18.
Clinical Supervisor will complete monthly chart audits to ensure work therapy is documented appropriately in client files. These chart audits will begin in November 2018. |