INITIAL COMMENTS
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This report is a result of an on-site inspection conducted for the licensure renewal and the approval to use a narcotic agent, specifically methadone, in the treatment of narcotic addiction. This inspection was conducted on November 24 - 25, 2015 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Discovery House HA 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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705.22 (2) LICENSURE Building exterior and grounds.
705.22. Building exterior and grounds.
The nonresidential 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 clients, 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 an observation during the physical plant inspection, the facility failed to ensure that the grounds of the facility were sanitary and in good repair.
The findings include:
A physical plant inspection was conducted on 11/25/2015. A Department licensing specialist observed multiple areas throughout the facility that were either unsanitary or in disrepair. The following deficiencies were found:
2' x1 ' section of the bottom of two ceiling tiles that were resting on the floor in the mechanical room were covered in mold.
lower level of the window next to the exit door that leads to the sidewalk on South Cameron Street had multiple holes and spider cracks that were sustained from gunfire.
metal latch faceplate on exit door that leads to the sidewalk on South Cameron Street was protruding from the door as it was only being held in place by one loose screw.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Facility Director has removed old ceiling tiles, lower level window has been replaced, and door has been repaired as of 12/11/15. Program Manager will complete a quarterly walk through of all areas of Discovery House on a quarterly basis to ensure the facility and grounds are in good repair. Program Director to review walk through inspection on a quarterly basis to ensure compliance. This was effective as of 12/11/15. |
715.14(a) LICENSURE Urine testing
(a) A narcotic treatment program shall complete an initial drug-screening urinalysis for each prospective patient and a random urinalysis at least monthly thereafter.
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Observations
Based on review of the patient records, the facility failed to ensure that a random urinalysis was completed at least monthly in one of twenty-one patient records reviewed.
The findings include:
Twenty-one patient records requiring monthly urinalysis drug screenings were reviewed on 11/24/2015 - 11/25/2015. The facility failed to ensure that urinalysis drug screenings were completed at least monthly in patient records # 3, 5 and 13.
Patient # 3 was admitted into the methadone clinic on 2/6/2015 and was still an active patient at the time of the inspection. A urinalysis drug screening was not completed in August 2015 for patient # 3.
Patient # 5 was admitted into the methadone clinic on 2/20/2015 and was still an active patient at the time of the inspection. A urinalysis drug screening was not completed in June 2015 for patient # 5.
Patient # 13 was admitted into the methadone clinic on 2/12/2014 and was still an active patient at the time of the inspection. A urinalysis drug screening was not completed in September 2015 for patient # 13.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Discovery House nursing staff were provided a training on required monthly random urinalysis on 12/29/15. Charge Nurse will run urinalysis reports to identify any patients that have not provided or are scheduled for a urinalysis and ensure all patients have minimally provided the required one random monthly urinalysis. This will take place during the last week of every month. Program Director and Clinical supervisors will monitor via chart reviews. This took effect on 12/29/15. |
715.17(c)(1)(i-vi)) LICENSURE Medication control
(c) A narcotic treatment program shall develop and implement written policies and procedures regarding the medications used by patients which shall include, at a minimum:
(1) Administration of medication.
(i) A narcotic treatment physician shall determine the patient 's initial and subsequent dose and schedule. The physician shall communicate the initial and subsequent dose and schedule to the person responsible for the administration of medication. Each medication order and dosage change shall be written and signed by the narcotic treatment physician.
(ii) An agent shall be administered or dispensed only by a practitioner licensed under the appropriate Federal and State laws to dispense agents to patients.
(iii) Only authorized staff and patients who are receiving medication shall be permitted in the dispensing area.
(iv) There shall be only one patient permitted at a dispensing station at any given time.
(v) Each patient shall be observed when ingesting the agent.
(vi) Administering and dispensing shall be conducted in a manner that protects the patient from disruption or annoyance from other individuals.
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Observations
Based on a review facility policies and an observation of the dispensing unit, the narcotic treatment facility failed to ensure that only authorized personnel were permitted within the dispensing unit.
The findings include:
An inspection of dispensing unit was conducted on 11/25/2015 between 8:12 AM - 8:30 AM. At 8:19 AM, a Department licensing specialist observed a clinical supervisor enter the secured dispensing area, provide a brief verbal statement to nursing staff regarding a patient, and then exit the secured dispensing area. The facility's policy regarding authorized personnel that are permitted within the dispensing unit did not list a clinical supervisor as authorized personnel.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Program Director provided a training to staff on 12/29/2015 which reviewed dispensary access regulations. Program Director also updated the dispensary access form to correctly identify those allowed access. Program Director to monitor on ongoing basis to ensure compliance. This took effect on 12/29/2015 |