INITIAL COMMENTS
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Based on the concerns arising from COVID-19, The Department of Drug and Alcohol Programs, Bureau of Quality Assurance for Prevention and Treatment, has implemented temporary procedures for conducting an annual renewal inspection.
The inspection will be divided into two parts.
1, an abbreviated off-site inspection, will be conducted off site, and will require the submission of administrative information via email to a Licensing Specialist.
2, an abbreviated on-site inspection, will be conducted on-site at a later date and will include a review of client/patient records, and a physical plant inspection.
This report is a result of Part 2, an abbreviated on-site inspection, conducted on September 15, 2020 by staff from the Department of Drug and Alcohol Programs, Bureau of Quality Assurance for Prevention and Treatment. Not all regulations were reviewed, the remainder of the regulations were reviewed during Part 1.
Based on the findings of Part 2, an abbreviated on-site inspection, Silver Pines Treatment Center 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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705.10 (c) (2) (i) LICENSURE Fire safety.
705.10. Fire safety.
(c) Fire extinguisher. The residential facility shall:
(2) Maintain at least one portable fire extinguisher with a minimum of an ABC rating in each kitchen.
(i) This fire extinguisher shall meet the requirement of one portable fire extinguisher for a 2,000 square foot area.
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Observations
Based on a physical site inspection on September 15, 2020, the facility failed to maintain at least one portable fire extinguisher with a minimum of an ABC rating in the kitchen.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Facility Manager will purchase an ABC rated fire extinguisher that meets the minimum requirement for a 2,000 square foot area.
The Property Manager will install the fire extinguisher on 9/25/20.
The Director of Quality Assurance and Facility Manager will ensure that the fire extinguisher is inspected and inventoried on a monthly basis.
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709.30 (2) LICENSURE Client rights
§ 709.30. Client rights.
The project shall develop written policies and procedures on client rights and document written acknowledgement by clients that they have been notified of those rights.
(2) The project may not discriminate in the provision of services on the basis of age, race, creed, sex, ethnicity, color, national origin, marital status, sexual orientation, handicap or religion.
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Observations
Based on a review of 15 client records on September 15, 2020, the project failed to notify clients of all their civil rights in nine out of fifteen records reviewed.
Client # 1 was admitted on September 11, 2020 and was current at the time of the inspection. The project failed to notify the client that the project may not discriminate on the basis of sex, creed, color, national origin, marital status, handicap and religion.
Client # 2 was admitted on September 14, 2020 and was current at the time of the inspection. The project failed to notify the client that the project may not discriminate on the basis of sex, creed, color, national origin, marital status, handicap and religion.
Client # 3 was admitted on September 13, 2020 and was current at the time of the inspection. The project failed to notify the client that the project may not discriminate on the basis of sex, creed, color, national origin, marital status, handicap and religion.
Client # 4 was admitted on September 12, 2020 and was current at the time of the inspection. The project failed to notify the client that the project may not discriminate on the basis of sex, creed, color, national origin, marital status, handicap and religion.
Client # 8 was admitted on August 21, 2020 and was current at the time of the inspection. The project failed to notify the client that the project may not discriminate on the basis of sex, creed, color, national origin, marital status, handicap and religion.
Client # 9 was admitted on September 1, 2020 and was current at the time of the inspection. The project failed to notify the client that the project may not discriminate on the basis of sex, creed, color, national origin, marital status, handicap and religion.
Client # 10 was admitted on August 28, 2020 and was current at the time of the inspection. The project failed to notify the client that the project may not discriminate on the basis of sex, creed, color, national origin, marital status, handicap and religion.
Client # 13 was admitted on August 14, 2020 and was discharged on August 29, 2020. The project failed to notify the client that the project may not discriminate on the basis of sex, creed, color, national origin, marital status, handicap and religion.
Client # 15 was admitted on July 16, 2020 and was discharged on August 15, 2020. The project failed to notify the client that the project may not discriminate on the basis of sex, creed, color, national origin, marital status, handicap and religion.
These findings were reviewed with project staff during the licensing process.
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Plan of Correction
The Director of Quality Assurance created a form for the client to sign in the electronic medical record. Upon intake all clients will sign off on this form, acknowledging that they are aware that Silver Pines Treatment Center will not discriminate on the basis of sex, creed, color, national origin, martial status, handicap and religion. The form was created on 9/21/20
All staff was trained on the new form and expectations on 9/22/20.
Director of Quality Assurance will routinely audit client records to ensure that documentation is being completed.
Clients 1, 2, 3, 4, 8, 9, 10, 13, 15 were no longer in services and could not sign the form.
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715.9(a)(2) LICENSURE Intake
(a) Prior to administration of an agent, a narcotic treatment program shall screen each individual to determine eligibility for admission. The narcotic treatment program shall:
(2) Verify the individual 's identity, including name, address, date of birth, emergency contact and other identifying data.
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Observations
Based on a review of 15 client records on September 15, 2020, the narcotic treatment program failed to verify the individual's identity, including name, address, date of birth, and other identifying data in three out of four clients reviewed.
Client # 1 was admitted on September 11, 2020 and was still current at the time of the inspection. The program failed to verify the individual's identity including name, address and date of birth.
Client # 2 was admitted on September 14, 2020 and was still current at the time of the inspection. The program failed to verify the individual's identity including name, address and date of birth.
Client # 15 was admitted on February 7, 2020 and was discharged on March 4, 2020. The program failed to verify the individual's identity including name, address and date of birth.
These findings were reviewed with program staff during the licensing process.
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Plan of Correction
Moving forward, upon intake a photo will be taken and uploaded to the EMR of the client's photo ID.
Staff was trained on the new procedure on 9/24/20
Director of Quality Assurance will routinely audit to ensure that photo identification is being obtained upon admission.
Clients 1, 2 and 15 were no longer in services.
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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 four client records on September 15, 2020, the narcotic treatment program failed to obtain an informed, voluntary, written consent before an agent was administered to the patient for either maintenance or detoxification treatment.
Client # 1 was admitted on September 9, 2020 and was current at the time of the inspection. The narcotic treatment program failed to obtain an informed, voluntary, written consent before an agent was administered
These findings were reviewed with program staff during the licensing process.
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Plan of Correction
Medical staff was retrained on the consent form on 9/24/20.
Director of Quality Assurance will weekly audit client records to ensure that all clients that are receiving an agent for maintenance or detoxification are signing the consent form.
Client 1 is no longer in services at this time.
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715.24(3) LICENSURE Narcotic detoxification
If a narcotic treatment program provides narcotic detoxification services, the narcotic treatment program shall develop and implement narcotic detoxification policies and procedures which include the following:
(3) A 1-year physiologic dependence is not required for narcotic detoxification although documentation of current dependency is required.
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Observations
During a review of four client records on September 15, 2020, the narcotic treatment program failed to document in two of the client records whether the individual was currently physiologically dependent upon a narcotic drug.
Client # 1 was admitted on September 11, 2020 and was current at the time of the inspection. The narcotic treatment program failed to document whether the individual was currently physiologically dependent upon a narcotic drug
Client # 2 was admitted on September 14, 2020 and was current at the time of the inspection. The narcotic treatment program failed to document whether the individual was currently physiologically dependent upon a narcotic drug
These findings were reviewed with program staff during the licensing process.
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Plan of Correction
Director of Quality Assurance revised the current intake assessment to include a question is the client is currently physiologically dependent upon a narcotic drug on 9/23/20.
Staff was trained on this form on 9/24/20.
Client 1 and 2 are no longer in services at this time.
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