INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on April 22, 2019 by staff from the Department of Drug and Alcohol Programs, Bureau of Quality Assurance for Prevention and Treatment. Based on the findings of the on-site inspection, Ambrosia of Philadelphia 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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704.9(a) LICENSURE Counselor Asst Supervision
704.9. Supervision of counselor assistant.
(a) Supervision. A counselor assistant shall be supervised by a full-time clinical supervisor or counselor who meets the qualifications in 704.6 or 704.7 (relating to qualifications for the position of clinical supervisor; and qualifications for the position of counselor).
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Observations
The facility failed to have employee #3, a counselor assistant hired on March 1, 2019, properly supervised by a full-time clinical supervisor or qualified counselor.
The findings were discussed with facility staff during the licensing process.
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Plan of Correction
Facility has recruited and hired a Full-Time Clinical Supervisor/Lead Therapist effective start date May 13th, 2019 in order to fulfill supervisory regulations. Employee #3 will be reassigned to the Clinical Supervisor effective May 13th, 2019. Program Manager is responsible for implementation of POC and will continue to oversee all supervisory requirements. POC is effective immediately, 5/9/2019.
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705.10 (d) (4) LICENSURE Fire safety.
705.10. Fire safety.
(d) Fire drills. The residential facility shall:
(4) Maintain a written fire drill record including the date, time, the amount of time it took for evacuation, the exit route used, the number of persons in the facility at the time of the drill, problems encountered and whether the fire alarm or smoke detector was operative.
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Observations
The facility failed to document on the March 2019 fire drill log the time of the fire drill and the amount of time it took to evacuate.
The findings were discussed with facility staff during the licensing process.
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Plan of Correction
Form for documentation of Fire Drills includes space for date and time of drill. All future fire drills will be completed appropriately per Fire Drill Form. Facility Director will be responsible for the implementation of POC and ongoing supervision of Fire Drills, effective immediately, Thursday, 5/9/2019. |
709.28 (a) (1) LICENSURE Confidentiality
§ 709.28. Confidentiality.
(a) A written procedure shall be developed by the project director which shall comply with 4 Pa. Code § 255.5 (relating to projects and coordinating bodies: disclosure of client-oriented information). The procedure must include, but not be limited to:
(1) Confidentiality of client identity and records. Procedures must include a description of how the project plans to address security and release of electronic and paper records and identification of the person responsible for maintenance of client records.
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Observations
The facility failed to include documentation of compliance with 4 Pa. Code 255.5 in their current confidentiality policy and procedures.
The findings were discussed with facility staff during the licensing process.
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Plan of Correction
Policy and Procedure has been updated to include PA code 255.5 Confidentiality Policy. A separate Release of Information has been created for payers. Policy specifically details what can be released to payers as per PA code 255.5. Program Director is responsible for the implementation and ongoing supervision of POC. POC is effective immediately, Thursday, 5/09/2019. |
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 failed to include a policy and procedure regarding verbal telephone orders given by the facility doctor in the facility's current policy and procedures.
The findings were discussed with facility staff during the licensing process.
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Plan of Correction
Policy and Procedures have been revised and updated to indicate requirements that doctor will authenticate a verbal order within 24 hours of the verbal order. Program manager and Medical Director are responsible for implementation of POC and ongoing supervision of POC. POC is effective immediately, Thursday, May 9, 2019. |
709.32 (c) (3) (i) - (v) LICENSURE Medication control
§ 709.32. Medication control.
(3) Inspection of storage areas that ensures compliance with State and Federal laws and program policy. The policy must include, but not be limited to:
(i) What is to be verified through the inspection, who inspects, how often, but not less than quarterly, and in what manner it is to be recorded.
(ii) Disinfectants and drugs for external use are stored separately from oral and injectable drugs.
(iii) Drugs requiring special conditions for storage to insure stability are properly stored.
(iv) Outdated drugs are removed.
(v) Copies of drug-related regulations are available in appropriate areas.
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Observations
The facility failed to include in their current policy and procedure a specific policy and procedure for the inspection of all drug storage areas, which is to include what is to be verified through the inspection, who inspects, how often, how it is recorded, where disinfectants and drugs for external use are stored separately from oral and injectable drugs, the removal of outdated drugs, and where copies of drug-related regulations are kept.
The findings were discussed with facility staff during the licensing process.
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Plan of Correction
Policy and Procedure has been updated to include inspection process of all medication storage areas including documentation of what is to be inspected, who is responsible, how often, and how inspection is to be documented. Policy has also been updated to include process for separate storage of oral and injectable drugs, the removal of outdated drugs, and where copies of all drug related information will be kept. Program Manager and Medical Director are responsible to implement POC and ongoing supervision of POC. POC is effective immediately, Thursday, 5/9/2019. |