INITIAL COMMENTS
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This report is a result of an on-site complaint investigation conducted May 10-12, 2022, by staff from the Bureau of Program Licensure. Based on the findings of the on-site complaint investigation, Pennsylvania Adult and Teen Challenge 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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709.32 (c) (5) LICENSURE Medication control
§ 709.32. Medication control.
(5) Security of drugs, including, but not limited to, the loss, theft or misuse of drugs.
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Observations
Based on client and staff interviews, and a review of client charts, incident reports and client grievances, the facility failed to follow their policy regarding the security of drugs.
Documentation showed that client medication was missing in four out of the six client charts that were reviewed. In client charts #1, 2, 5, and 6 the MARS showed the medication was unavailable. There was no explanation provided for the medication being unavailable.
Documentation showed that clients #4 and #6 did not receive all of their medications when they were discharged from the facility. Client #4 client only received two out of three of his medications at discharge and client #6 medication (Wellbutrin) went missing.
Additionally, facility staff reported that there is a current investigation underway regarding the disappearance of client medication that was recently delivered by the pharmacy to the facility.
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Plan of Correction
The PAATC Medical Coordination Team has developed a procedure that ensures all clients that participates in programs continually receive their medications that are prescribed by their provider. Medication documentation training was conducted on 6/13/2022 by Medical Coordination Manager for all approved staff that oversee medication observation. This training reviewed documenting all medications that are self-administered. Any client medication that is "unavailable" will be logged as a progress note stating the reason for unavailability. The PAATC Medical Coordination Manager will oversee the team in conducting weekly chart audits to ensure approved medication observation staff are following PAATC approved procedures. Upon discharge, all patients that successfully complete our program will be supplied with 30-days of all current medications.
PAATC Human Resources and Medical Coordination Team immediately investigated the missing medication. Upon our findings during the investigation, the staff member that was responsible for signing and receiving all medications delivered from the pharmacy for our program was terminated from PAATC. Our findings concluded that he was the source of the missing medication. PAATC was in the process of getting a new script for that individual but he left prematurely from the program.
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709.34 (a) (1) LICENSURE Reporting of unusual incidents
§ 709.34. Reporting of unusual incidents.
(a) The project shall develop and implement policies and procedures to respond to the following unusual incidents:
(1) Physical assault or sexual assault by staff or a client.
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Observations
Based on staff and client interviews and a review of the facility's administrative documentation, the facility failed to report a physical assault to DDAP.
There was evidence of a physical altercation between a client and staff person on March 25, 2022. The incident was documented, but not reported to the DDAP.
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Plan of Correction
A training will be provided to the identified staff who are approved by PAAATC to submit incident reports to DDAP. Training will focus on circumstances necessitating submission of unusual incident reports and will be conducted on 06/22/2022. The Director, in coordination with the Quality Assurance department, will conduct weekly audits to ensure incident reports are submitted to DDAP in a timely manner according to internal policy and regulatory standards |