INITIAL COMMENTS
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This report is a result of an on-site complaint investigation conducted April 16, 2021 by staff from the Bureau of Program Licensure. Based on the findings of the on-site complaint investigation, Lebanon Treatment Center 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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715.7(b) LICENSURE Dispensing or Administering Staffing
(b) Dispensing time shall be prorated for patient census. There shall be sufficient dispensing staff to ensure that all patients are medicated within 15 minutes of arrival at the dispensing area.
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Observations
Based on dosing observation, client and staff interviews, and a review client grievance forms, the facility failed to medicate clients within the allowable timeframe. It was reported that clients waited over an hour to be medicated so they were late for work in June 2020.
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Plan of Correction
Wait times were identified as being problematic and a "work" line was implemented in July of 2020. Workline prioritizes dosing for patients who are actively employed between 5am and 5:45am Mon-Fri. Additional operational changes have also been implemented to reduce interruptions to dispensary, and ensure that patient dosing is streamlined and operated by two nurses daily. As a result, overall wait times have been significantly reduced. Average wait time for the month of April 2021 was 3.83 minutes.
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715.22(b) LICENSURE Patient grievance procedures
(b) The procedure shall permit aggrieved patients a full and fair opportunity to be heard, to question and confront persons and evidence used against them and to have a fair review of their grievances by the narcotic treatment program director. If the grievance is filed against the narcotic treatment program director, the review of the case shall be conducted by either a multi-representative group of the narcotic treatment program or a subcommittee of the governing body instituted for the express purposes of grievance adjudication.
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Observations
The facility failed to follow-up with clients regarding grievance resolutions. There was no
documented follow-up or information regarding a resolution for the issues on the following grievances: client #1: 3/19/2020, client #2 6/13/2020, and client #3 6/19/2020.
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Plan of Correction
Patient concerns were actively addressed. However, documentation of completion was not done. Clinical director will ensure that any and all grievances are followed up with and documented within appropriate timeframes moving forward.
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