INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on May 24, 2021 through May 26, 2021, by staff from the Bureau of Program Licensure. Based on the findings of the on-site inspection, Lehigh County Center for Recovery was found not to be in compliance with the applicable chapters of 28 PA Code which pertain to the facility.
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Plan of Correction
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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 the Staffing Requirements Facility Summary Report submitted on May 17, 2021 and an interview with the Facility Director on May 26, 2021, there are 5 support staff members who did not receive the minimum 6 hours of HIV/AIDS training and at least 4 hours of TB/STD training within their first 2 years of employment.
Employee # 5 hired 1/27/19 did not have TB/STD or HIV/AIDS training
Employee # 6 hired 6/20/17 did not have TB/STD training
Employee # 9 hired 3/11/19 did not have TB/STD or HIV/AIDS training
Employee # 14 did not have TB/STD or HIV/AIDS training
Employee # 15 did not have TB/STD or HIV/AIDS training
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Program Director and Nursing Manager developed and will be holding approved HIV/AIDS and TB & Sexually transmitted disease twice a year. All current staff deficient of required trainings will be trained by July 31, 2021. |
704.11(c)(3) & (4) LICENSURE Training types and amounts
704.11. Staff development program.
(c) General training requirements.
(3) At least one-half of all training in this section shall be provided by trainers not directly employed by the project unless the project employs staff persons specifically to provide training for its organization and staff.
(4) An individual who holds more than one position in a facility shall meet the training requirement hours set forth for the individual's primary position. Subject areas shall be selected according to the individual's training plan. Primary position is defined as that position for which an individual was hired.
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Observations
Based on a review of the Staffing Requirements Facility Summary Report submitted on May 17, 2021 and an interview with the Facility Director on May 26, 2021, the facility failed to ensure that employee # 4 obtained one-half of their trainings from outside of the project for the training year of January 1, 2020 though December 31, 2020.
Employee # 4, hired as a Counselor on 10/21/19, had a total of 20 training hours with 16 of those hours provided by the project.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
Clinical Director met with his clinical staff and discussed that half of the training hours must be provided from outside the project. Clinical Director will monitor on a quarterly basis, through individual supervision, on the total hours of trainings and specified trainings are outside the project. |
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 and an interview with maintenance personnel, conducted on May 24, 2021, the facility failed to be maintained in good repair. One client bedroom (#128) had an overhead light that would not illuminate due to needing a new ballast.
Also, during the physical plant inspection, it was observed that the window sill in the kitchen, beside the food serving area, was dusty, dirty and had dead files on it.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Facility manager was waiting on parts that were ordered for the faulty light. New part arrived and was fixed on 5/26/2021. Facility manager will inspect on a monthly basis the working conditions of the facility ad document all deficiencies and place work orders appropriately. |
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 May 24, 2021, the facility failed to store all garbage in a covered container. The commercial garbage bin lid was observed to be open and could not be shut due to the bin being placed too close to the fence behind it.
This finding was discussed with facility staff during the inspection process.
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Plan of Correction
Facility manager addressed the placement of the garbage bin with the new waste management vendor about placing the garbage can further away from the fence on May 27t in order to close the lid properly. This was corrected on May 27th. Facility manager and/or his designee will monitor on a daily basis that garbage bin is placed and closed properly. Facility manager will address deficiency with Program director and waste management company as needed. |
705.4 (2) LICENSURE Counseling areas.
705.4. Counseling areas.
The residential facility shall:
(2) Maintain counseling areas with furnishings which are in good repair.
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Observations
Based on a physical plant inspection that was conducted on May 24, 2021, the facility failed to maintain furnishings in good repair.
Employee # 4, a counselor, had a chair in their office, with material that was worn bare.
The conference room had a total of 9 chairs that were each worn bare and the material on them was ripping.
These findings were discussed with facility staff during the inspection process.
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Plan of Correction
Program Director is ordering new furniture for the conference room and one counseling office with corporate approval. Furniture will arrive and be assembled by August 1, 2021. Facility Manager will monitor for worn furniture in his monthly facility audits and will notify Program Director to address it as needed. |
705.8 (2) LICENSURE Heating and cooling.
705.8. Heating and cooling.
The residential facility:
(2) May not permit in the facility heaters that are not permanently mounted or installed.
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Observations
Based on a physical plant inspection conducted on May 24, 2021, there was a portable heater observed in the closet of the admissions office.
This finding was discussed with the facility staff during the licensing process.
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Plan of Correction
Facility Manager reminded staff that no portable heaters are allowed on the premises on May 27, 2021. This heater was removed from the premises on May 27, 2021. This will be monitored by monthly facility inspections by the Facility Manager |
705.10 (d) (8) LICENSURE Fire safety.
705.10. Fire safety.
(d) Fire drills. The residential facility shall:
(8) Set off a fire alarm or smoke detector during each fire drill.
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Observations
Based on a review of the fire drill records, from September 2020 through April 2020, during the licensing inspection conducted May 24, 2021 through May 26, 2021, the facility failed to indicate that either the fire alarm or a smoke detector was set off during each fire drill. This occurred on the fire drills dated October 6, 2020 and January 20, 2021.
These findings were iscussed with facility staff during the licensing process.
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Plan of Correction
Program Director met with the safety officer on May 27th, 2021 an reviewed the proper way to record fire drill records. Program Director will monitor all fire drills on a quarterly basis to ensure proper documentation. |
709.28 (c) (3) LICENSURE Confidentiality
§ 709.28. Confidentiality.
(c) The project shall obtain an informed and voluntary consent from the client for the disclosure of information contained in the client record. The consent must be in writing and include, but not be limited to:
(3) Purpose of disclosure.
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Observations
Based on a review of client recrods during a licensing inspection conducted May 24, 2021 through May 26, 2021, the facility failed to obtain consents to release information that documented a purpose of the disclosure in 3 of 12 records.
Client # 3 - consent dated 4/29/21 for a treatment facility, has the purpose indicated as "to inform family"
Client # 10 - consent dated 8/31/20 for an emergency contact, no purpose was indicated.
Client # 11 - consent dated 2/11/21 for a treatment facility, has "other" marked as the purpose but does not specifiy what that is as directed to do on the form.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Clinical Director met with the clinical and admission staff on June 23, 2021 and reviewed proper completion of release of information. Clinical Director reviewed an example of a proper documentation of an approved release of information. Clinical Director will monitor proper documentation of release of information on a monthly basis through chart audits. All deficiencies will be addressed through individual supervisions. |
709.28 (c) (4) LICENSURE Confidentiality
§ 709.28. Confidentiality.
(c) The project shall obtain an informed and voluntary consent from the client for the disclosure of information contained in the client record. The consent must be in writing and include, but not be limited to:
(4) Dated signature of client or guardian as provided for under 42 CFR 2.14(a) and (b) and 2.15 (relating to minor patients; and incompetent and deceased patients).
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Observations
Based on a review of client records May 24, 2021 through May 26, 2021, the facility failed to obtain a consent with the client's signature in 1 of 12 records.
Client # 12 - consent dated 3/17/21 for a medical facility is missing the client signature.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
Clinical Director met with the clinical and admission staff on June 23, 2021 and reviewed proper completion of release of information. Clinical Director reviewed an example of a proper documentation of an approved release of information. Clinical Director will monitor proper documentation of release of information on a monthly basis through chart audits. All deficiencies will be addressed through individual supervisions. |
709.34 (c) (1) LICENSURE Reporting of unusual incidents
§ 709.34. Reporting of unusual incidents.
(c) To the extent permitted by State and Federal confidentiality laws, the project shall file a written unusual incident report with the Department within 3 business days following an unusual incident involving:
(1) Physical or sexual assault by staff or a client.
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Observations
Based on a review of the facility's unusual incident reports on May 26, 2021, the facility failed to file a written report with the Department within 3 business days following a physical altercation between clients on January 4, 2021.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
Program Director reviewed the DDAP regulation and is ensuring that all reportable unusual incident reports be reported to DDAP within the proper time period. All deficient incident reports were entered by June 1, 2021. This will be monitored on a weekly basis with the Risk Manager Administrative Assistant. |
709.34 (c) (4) LICENSURE Reporting of unusual incidents
§ 709.34. Reporting of unusual incidents.
(c) To the extent permitted by State and Federal confidentiality laws, the project shall file a written unusual incident report with the Department within 3 business days following an unusual incident involving:
(4) Event at the facility requiring the presence of police, fire or ambulance personnel.
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Observations
Based on a review of unusual incident reports on May 26/2021, the facility failed to notify the Department of an event requiring the presence of police and/or ambulance personnel within 3 days of the event. The incident reports reviewed were dated between September 2020 and May 2021.
9/21/20 - client transported to emergency room. Mode of transportation was not noted, however, the facility director did report that clients are usually transported via ambulance.
10/21/20 - client transported to emergency room via ambulance
3/16/21 - employee transported to emergency room via ambulance
4/2/21 - client escorted to hospital by the police via an ambulance
4/3/21 - client transported to emergency room via ambulance
4/10/21 - client transported to emergency room via ambulance
5/22/21 - client transported to hospital vial ambulance
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Program Director reviewed the DDAP regulation and is ensuring that all reportable unusual incident reports be reported to DDAP within the proper time period. All deficient incident reports were entered by June 1, 2021. This will be monitored on a weekly basis with the Risk Manager Administrative Assistant. |
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 May 24. 2021 through May 26, 2021, the facility failed to document that informed written consent was obtained prior to Buprenorphine being administered to the patent. this occured in 3 of 6 records.
Client # 1 - intial dose documented on 5/15/21 and consent was signed on 5/16/21.
Client # 3 - initial dose documented on 4/22/21 and consent was signed on 4/30/21.
Client # 9 - documentation of informed consent was not found in record.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Nursing Manager met with medical staff on June 2, 2021 to review that all proper written consent is obtained prior to administration of a MAT medication. Nursing Manager will review charts on a weekly basis to ensure compliance of consents. Program Director will review charts on a monthly basis for 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 May 24, 2021 through May 26, 2021, the facility failed to document follow up information in 1 of 5 records. Per the facility's policy, documentation of contact or an attempt to contact is to be completed within 30 business days after a patient leaves without a referral for continued care. This documentation is to be placed in the medical record.
Patient # 8 - admitted 9/1/20 and discharged 9/7/20.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
Clinical Director met the clinical administrative assistant to ensure proper completion and filing of the follow up forms for all clients in a timely manner. Clinical Director will monitor compliance on a monthly basis through chart audits. |
709.53(a)(8) LICENSURE Case Consultation Notes
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:
(8) Case consultation notes.
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Observations
Based on a review of client records during the licensing inspection conducted May 24, 2021 through May 26, 2021, the facility failed to document that case consultations were conducted with more than one staff member. In 3 of 6 records, the case consultations is signed by a single staff member and verification that other staff were present in the consultation is not documented.
Client # 1 - case consultation dated 5/13/21
Client # 11 - case consultation dated 1/22/21
Client # 12 - case consultation dated 3/24/21
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Clinical Director met with the clinical and admission staff on June 23, 2021 and proper documentation and completion of the case consultation forms. Clinical Director will monitor proper documentation of case consultations on a monthly basis through chart audits. All deficiencies will be addressed through individual supervisions |