INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection and complaint investigations conducted on January 29-31, 2020 by staff from the Department of Drug and Alcohol Programs, Bureau of Quality Assurance for Prevention and Treatment, Program Licensure Division. Based on the findings of the on-site inspection, Bradford Recovery 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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705.23 (3) LICENSURE Counseling or activity areas and office space
705.23. Counseling or activity areas and office space.
The nonresidential facility shall:
(3) Ensure privacy so that counseling sessions cannot be seen or heard outside the counseling room. Counseling room walls shall extend from the floor to the ceiling.
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Observations
Based on observation during a Physical Plant inspection conduced on January 30, 2020, the facility failed to ensure privacy so that counseling sessions could not be seen or heard outside of the counseling room.
The three individual counseling offices located in the modular addition had large transfer grilles (approximately 24" x 20") through the doors of the counseling offices allowing for the possibility of sessions to be heard in the outer office areas. While the Licensing Specialist could see into the counseling offices, the transfer grilles were located below the door knob limiting visibility into the office such that an individual could not be identified.
This was discussed with staff at the time of the inspection.
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Plan of Correction
Plan of Correction:
Facility Grounds Manager has installed all counseling doors with a nontransparent insert that was placed into the transfer grilles of each door to eliminate any visibility into the offices as well as to reduce the possibility of staff and/or patients being heard in outer areas of the clinical area. Facility will continue to utilize white noise machines for each individual office in the clinical area to increase privacy.
This correction has been fully implemented within the facility.
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709.34 (c) (4) LICENSURE Reporting of unusual incidents
§ 709.34. Reporting of unusual incidents.
(c) To the extent permitted by State and Federal confidentiality laws, the project shall file a written unusual incident report with the Department within 3 business days following an unusual incident involving:
(4) Event at the facility requiring the presence of police, fire or ambulance personnel.
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Observations
Based upon a discussion with facility staff on Jnauary 31, 2020, the facility failed to ensure that unusual incident reports involving the presence ot police, fire or ambulance personnel were reported to the Department within 3 business days following the incident.
Facility staff were asked to provide copies of incident reports form April 1, 2019 through January 31, 2020. Upon retrieving the reports, the facility noted that they had a number of incident reports where ambulance personnel had been called to the facility that had not been sent to the Department. Staff indicated that failure to send the incident reports was due to a change in how and who would follow through with the reporting process. Copies were provided and the faciltiy was advised to still submit them via the normal submission process.
This was discussed with facility staff at the time of the inspection.
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Plan of Correction
Plan of Correction:
The facility did not have one specific delegate submitting unusual incidents to the Department of Drug and Alcohol Programs. The facility Risk Manager has been delegated by the CEO to submit all unusual incidents to the Department of Drug and Alcohol Programs, in order to ensure all unusual incidents are reported to the Department of Drug and Alcohol Programs within 72 hours. The facility Risk Manager will maintain a binder of all unusual incidents reported.
All facility staff will be educated on Licensing Alert 02-2018, Reporting of Unusual Incidents to provide clarification and guidance regarding reporting of unusual incidents required by the Department of Drug and Alcohol Programs of all facilities as outlined in 709.34 ( c ) (4). All facility staff will be provided this education by March 8, 2020.
The facilities Leadership Team and Health and Safety Committee will review all unusual incidents at least monthly to ensure accuracy in reporting of unusual incidents to the Department of Drug and Alcohol Programs.
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709.63(a)(4) LICENSURE Medication records
709.63. Client records.
(a) There shall be a complete client record on an individual which includes information relative to the client's involvement with the project. This shall include, but not be limited to the following:
(4) Medication records.
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Observations
Based on a review of three detoxification client records and an interview with facility staff, the facility failed to document complete medication records in one of three records reviewed.
Client # 1 was admitted the eveing of June 13, 2019 and discharged on June 15, 2019 at 13:00 against staff advice.
The medication record for client #1 lacked documention to indicate the reason the client did not receive the following medications listed as being ordered in the client's medication record June 13, 2019.
Repatha injection 1 x 40mg/ml SQ
Meloxicam Tablets on 6/13/19 1 x 7.5 mg po
Additionally, the patient was not provided with their CPAP machine the night of June 13, 2019.
This was discussed with facility staff at the time of the inspection.
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Plan of Correction
Plan of Correction:
Upon review of the EMR of Client #1, it is noted that the facility failed to document medication that had been administered to Client #1. It is additionally noted that the facility did not provide Client #1 with his durable medical equipment on the day of admission.
The EMR will reflect any/all medications administered to all patients. The EMR will reflect if/when a patient misses a medication administration dose and the reasoning behind not receiving the medication. This will be documented in the MAR as well as in a progress note within the EMR. If a medication is withheld due to Medical Director orders and/or precautions due to medical complications, this too will be documented in the EMR within a progress note and the MAR.
Nursing manager will train/educate all nursing staff on entering medications ordered and administered into the MAR; reading/comprehending the MAR orders; administering medications listed in the MAR for each patient.
Nursing staff will ensure all medications are administered and documented as ordered.
Nursing Manager will provide nursing staff with "6 Rights of Medication Administration" and "10 Rights of Drug Administration" training by March 6, 2020.
All durable medical equipment that is brought to the facility by a patient will be requested for approval by the medical director, inspected for safety and proper functioning on the day of admission. Upon approval of the medical director, safety inspection and assessment for proper functioning on the day of admission, the patient will be given their durable medical equipment to utilize as ordered. |
715.1(a)(b) LICENSURE General Provisions
(a) An entity within this Commonwealth which uses agents for maintenance or detoxification of persons shall obtain the approval of the Department to operate a narcotic treatment program.
(b) The Department's approval of a narcotic treatment program shall be contingent upon the narcotic treatment program's compliance with the standards and conditions in this part. In addition, the program shall comply with applicable Federal laws and regulations.
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Observations
Based on an interview with facility staff on January 31, 2020, the facility failed to obtain approval from the Department to operate a Narcotic Treatmetn Program (NTP).
At the time of the inspection the facility was approved to provide detoxification and maintenance services using Buprenorphine under the Medical Director's DATA 2000 waiver. Facility staff stated that as of July 2019, they changed from using the Medical Director's DEA number to using the facility's DEA number to order the Buprenorphine. Because they were not approved as an Opioid Treatment Program by SAMHSA/CSAT and a Narcotic Treatment Program by the Commonwealth they had not yet receive approval from the Department.
Following a discussion regarding this the facility contacted the Medical Director and they were going back to the use of the DATA 2000 Waiver until they received Deparment approval to operate as an NTP.
This was discussed with faciity staff at the time of the inspection.
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Plan of Correction
Plan of Correction:
The facility does not have a current or valid OTP or NTP license; therefore, the facility will provide detoxification and Maintenance services using Buprenorphine under the Medical Director's DATA 2000 Waiver.
This correction has been fully implemented within the facility.
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