INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on November 16 - 18, 20, 2020 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, Snug Harbor Rehabilitation and Recovery LLC. 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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704.11(f)(2) LICENSURE Trng Hours Req-Coun
704.11. Staff development program.
(f) Training requirements for counselors.
(2) Each counselor shall complete at least 25 clock hours of training annually in areas such as:
(i) Client recordkeeping.
(ii) Confidentiality.
(iii) Pharmacology.
(iv) Treatment planning.
(v) Counseling techniques.
(vi) Drug and alcohol assessment.
(vii) Codependency.
(viii) Adult Children of Alcoholics (ACOA) issues.
(ix) Disease of addiction.
(x) Aftercare planning.
(xi) Principles of Alcoholics Anonymous and Narcotics Anonymous.
(xii) Ethics.
(xiii) Substance abuse trends.
(xiv) Interaction of addiction and mental illness.
(xv) Cultural awareness.
(xvi) Sexual harassment.
(xvii) Developmental psychology.
(xviii) Relapse prevention.
(3) If a counselor has been designated as lead counselor supervising other counselors, the training shall include courses appropriate to the functions of this position and a Department approved core curriculum or comparable training in supervision.
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Observations
Based on a review of the personnel training records, the facility failed to have each counselor complete at least 25 clock hours of training annually. One counselor was applicable for the training year reviewed, and did not have the required hours. Employee #3 documented seven hours of training for the October 1, 2019 to September 30, 2020 training year.The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Snug Harbor has contracted with Relias for educational trainings, in addition to DDAP and on site (in house) trainings we will adhere to the training requirements.
Staff holding positions requiring minimal training hours will complete those training hours each training year.
This will be implemented by January 24, 2021. The clinical Supervisor and Program Manager will ensure this is managed. |
709.25 LICENSURE Fiscal Management
§ 709.25. Fiscal management.
The project shall obtain the services of an independent certified public accountant for an annual financial audit of activities associated with the project ' s drug/alcohol abuse services, in accordance with generally accepted accounting principles which include reference to the drug and alcohol treatment activities.
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Observations
Based on a review of the administrative information, the facilty failed to document an annual financial audit for 2019. The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Snug Harbor will request from our private accountant a formal annual audit at year end.
The Executive Director will ensure this is completed on an annual basis. Arrangements will be made for this process by January 24, 2021
We have filed for an exception to this regulation due to the hardship Covid has imposed on everyone and the unavailability of office information to the accountant due to working from home.
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709.28 (c) (1) LICENSURE Confidentiality
§ 709.28. Confidentiality.
(c) The project shall obtain an informed and voluntary consent from the client for the disclosure of information contained in the client record. The consent must be in writing and include, but not be limited to:
(1) Name of the person, agency or organization to whom disclosure is made.
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Observations
Based on a review of the client records, the facility failed to include the name of the person, agency or organization on the release of information forms for funding in ten of ten client records reviewed.The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
A new form has been developed which prompts the Intake Coordinator to list the exact name of the funding source per client. The staff has been educated on the new forms and how to use them and have signed acknowledgement of the education and understanding of this requirement.
All current clients will be asked to sign the new form.
Executive Director will provide education. Proper use of this form will be monitored by Intake Coordinator and overseen by Program Manager. The use of this form was immediate after survey. |
709.30 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.
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Observations
Based on a review of the client records, the facility failed to document written acknowledgement in ten of ten client records reviewed that clients have been notified of all their rights.All clients reviewed had signed off as receiving the client handbook. In a review of the client handbook, the handbook did not include (2) the facility will not discriminate based on color, and (3) the facility or clinical director may temporarily remove portions of the records prior to the inspection by the client if the director determines that the information may be detrimental if presented to the client. The findings were reviewed with facility staff during the licensing process.This is a repeat citation from the January 22-24, 29, 2020 inspection.
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Plan of Correction
The client rights portion of the client handbook has been updated to ensure it contains a complete listing of all client rights. The content of the client handbook is explained to the client initially upon intake and then again later it is discussed and explained thoroughly in detox and in residential. The explanation is done by the Intake coordinator and then the counselor on duty in residential. This review is signed off by the clients each time it is offered in an attempt to clearly explain the client rights.
The staff has been educated on this procedure and it is monitored by the Program Manager regularly. |
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
Based on a review of the administrative information, the facility failed to document a quarterly inspection of the detoxification storage area and the residential treatment storage area. The following components were missing:(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. The findings were reviewed with facility staff during the licensing process.This is a repeat citation from the January 22-24, 29, 2020 inspection.
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Plan of Correction
Staff has been reeducated on the use of the correct form. The form was revised in March of 2020 and the staff failed to use the revised form. Staff has been re-education on its use this will be monitored by the Director of Nursing and overseen by the Program Manager.
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709.34 (c) (5) 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:
(5) Outbreak of a contagious disease requiring CDC notification.
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Observations
Based on a review of the administrative information, the facilty failed to file a written unusual incident report with the Department within 3 business days following an outbreak of a contagious disease requiring CDC notification.The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Nursing has been educated on the reportability of positive covid results and any outbreak of a contagious disease requiring CDC notification will be reported to Department of D and A.
This will be reported to the Department using the electronic reporting site within three business days of positive results.
All personnel are aware of this requirement. This will be monitored by the Director of Nursing and reviewed by the Program Manager quarterly. |
709.63(a)(5) LICENSURE Record of Services
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:
(5) Record of services provided.
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Observations
Based on a review of client records, the facility failed to document a record of service in six of six applicable client records reviewed for the detoxification activity.Client #1 was admitted to detoxification treatment on August 16, 2020 and was discharged on August 21, 2020. There was no documentation of a record of service.Client #2 was admitted to detoxification treatment on October 24, 2020 and was discharged on November 7, 2020. There was no documentation of a record of service.Client #3 was admitted to detoxification treatment on August 18, 2020 and was discharged on August 25, 2020. There was no documentation of a record of service.Client #5 was admitted to detoxification treatment on October 27, 2020 and was transferred to residential treatment on November 7, 2020. There was no documentation of a record of service while in detoxification treatment.Client #8 was admitted to detoxification treatment on October 3, 2020 and was discharged on October 8, 2020. There was no documentation of a record of service.Client #10 was admitted to detoxification treatment on September 25, 2020, transferred to residential treatment on October 2, 2020 and discharged on October 28, 2020. There was no documentation of a record of service while in detoxification treatment.The findings were reviewed with facility staff during the licensing process.This is a repeat citation from the January 22-24, 29, 2020 inspection.
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Plan of Correction
Snug Harbor has developed a record of service document with a schedule of when particular processes are to be performed and completed.
The staff has been educated on this new form and procedure and each employee signed off on the understanding and education of the form. This education was conducted by the Executive Director.
The program Manager will ensure through weekly random chart audits that this is utilized and retained within the client medical record. |
709.63(a)(7) LICENSURE Discharge summary
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:
(7) Discharge summary.
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Observations
Based on a review of client records, the facility failed to document a discharge summary in four of four applicable client records reviewed for the detoxification activity.Client #1 was admitted to detoxification treatment on August 16, 2020 and was discharged on August 21, 2020. There was no documentation of a discharge summary.Client #2 was admitted to detoxification treatment on October 24, 2020 and was discharged on November 7, 2020. There was no documentation of a discharge summary.Client #3 was admitted to detoxification treatment on August 18, 2020 and was discharged on August 25, 2020. There was no documentation of a discharge summary.Client #8 was admitted to detoxification treatment on October 3, 2020 and was discharged on October 8, 2020. There was no documentation of a discharge summary.The findings were reviewed with facility staff during the licensing process.This is a repeat citation from the January 22-24, 29, 2020 inspection.
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Plan of Correction
The discharge summary form has been updated to more clearly indicate the plans after discharge. It summarized treatment received and details instructions for discharge.
The staff has been re-educated on the proper use of the new form by the Executive Director. The monitoring of proper use of this form will be by the program manager and will be routinely reviewed during weekly random chart audits. |
709.63(a)(8) LICENSURE Follow-up Information
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:
(8) Follow-up information.
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Observations
Based on a review of client records, the facility failed to document follow-up information in four of four applicable client records reviewed for the detoxification activity. Per the agency policy, follow up is to be completed the first day after discharge, one week after discharge and one month, two months and three months.Client #1 was admitted to detoxification treatment on August 16, 2020 and discharged on August 21, 2020. There was no documentation that follow-up was completed the first day after discharge, one week after discharge, one month and two months.Client #2 was admitted to detoxification treatment on October 24, 2020 and discharged on November 7, 2020. There was no documentation that follow-up was completed the first day after discharge, and one week after discharge.Client #3 was admitted to detoxification treatment on August 18, 2020 and was discharged on August 25, 2020. There was no documentation that follow-up was completed the first day after discharge, one week after discharge, one month and two months.Client #8 was admitted to detoxification treatment on October 3, 2020 and was discharged on October 8, 2020. There was no documentation that follow-up was completed the first day after discharge, one week after discharge, and one month.The findings were reviewed with facility staff during the licensing process.This is a repeat citation from the January 22-24, 29, 2020 inspection.
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Plan of Correction
The discharge follow-up procedure has been updated to require follow-up within one week after discharge.
Policy has been updated to reflect this change and the new form states clearly that client follow-up takes place after discharge within 1 week from date of discharge.
This process is the responsibility of Case Manager.
This process will be monitored routinely during weekly random chart audits. |
715.9(a)(1) 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:
(1) Verify that the individual has reached 18 years of age.
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Observations
Based on a review of the patient records, the facility failed to verify the individual reached 18 years of age in two of four patient records reviewed for buprenorphine treatment. Patient #5 was admitted to treatment on October 27, 2020 and given the first dose of buprenorphine on October 28, 2020. There was no verification the client was 18 years of age.Patient #10 was admitted to treatment on September 25, 2020 and given the first dose of buprenorphine on October 1, 2020. There was no verification the client was 18 years of age.The findings were reviewed with facility staff during the licensing process.This is a repeat citation from the January 22-24, 29, 2020 inspection.
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Plan of Correction
Intake has been re-educated on the requirement to verify clients have reached the age of 18 yrs or more and to record the form of verification on the back of their photo taken upon admission.
This is the responsibility of the Intake Coordinator.
The process will be monitored by the program manager during routine weekly chart audits. |
715.9(d) LICENSURE Intake
(d) A narcotic treatment program shall explain to each patient treatment options; pharmacology of methadone, LAAM and other agents, including signs and symptoms of overdose and when to seek emergency assistance; detoxification rights; grievance procedures; and clinic charges, including the fee agreement signed by the patient.
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Observations
Based on a review of the patient records, the facility failed to document the items were explained to each patient in four of four patient records reviewed for buprenorphine treatment. Records # 2, 4, 5, and 10 did not document pharmacology of buprenorphine, detoxification rights; grievance procedures; and clinic charges, including the fee agreement signed by the patient.Patient #2 was admitted to detoxification treatment on October 24, 2020 and was discharged on November 7, 2020 and was given the first dose of buprenorphine on October 24, 2020.Patient #4 was admitted to residential treatment on September 14, 2020 and was given the first dose of buprenorphine on September 15, 2020.Patient #5 was admitted to treatment on October 27, 2020 and given the first dose of buprenorphine on October 28, 2020. Patient #10 was admitted to treatment on September 25, 2020 and given the first dose of buprenorphine on October 1, 2020. The findings were reviewed with facility staff during the licensing process.This is a repeat citation from the January 22-24, 29, 2020 inspection.
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Plan of Correction
The educational form used in detox to describe methods used for detoxification has been updated to include other methods of detoxification and potential complications.
The staff was re-educated on the correct use and design of new forms by the Executive Director and on the revised policy.
Staff has been re-educated by the executive director and understands that the Clients are to be educated on all forms of pharmacology used in detoxification especially buprenorphine, also the right of the client to choose other methods for detox and risks associated with each form. In addition any fees that may be associated with this treatment explained to the client along with their right to file a grievance.
Responsibility of this education process will be done by the Director of Nursing with follow-up monitoring by the program Manager during routine weekly chart audits. |
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 the patient records, the facility failed to include all areas on the informed patient consent for the use of buprenorphine in two of four patient records reviewed for buprenorphine treatment. Patient records #2 and #5 did not document (1) That buprenorphine is a narcotic drug which can be harmful if taken without medical supervision, (4) That the possible risks and complications of treatment have been explained to the patient, and (5) That methadone is transmitted to the unborn child and will cause physical dependence on the patient consent for the use of buprenorphine. Patient #2 was given the first dose of buprenorphine on October 24, 2020.Patient #5 was given the first dose of buprenorphine on October 28, 2020.The findings were reviewed with facility staff during the licensing process.This is a repeat citation from the January 22-24, 29, 2020 inspection.
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Plan of Correction
The informed consent for detoxification has been revised to include ; Buprenorphine is a narcotic which can be harmful if taken without medical supervision, that the possible risks and complications of treatment have been explained to the client and that Buprenorphine is transmitted to the unborn child and will cause physical dependence.
Staff has been educated on this new form by the Executive Director.
This form will be reviewed with and signed by all current and future clients taking buprenorphine by Nursing Staff.
This process will be monitored by program manger during weekly random chart audits. |
715.17(c)(4)(i-viii) 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:
(4) Method for control and accountability of drugs. A narcotic treatment program shall develop and implement written policies and procedures regarding who is authorized to remove drugs from the storage area and the method for accounting for all stored drugs. An agent or other drug prescribed or administered shall be documented on an individual medication record or sheet in a manner sufficient to maintain an accurate accounting of medication at all times and shall include:
(i) The name of the medication.
(ii) The date prescribed.
(iii) The dosage.
(iv) The frequency.
(v) The route of administration.
(vi) The date and time administered.
(vii) The name of the person administering the medication.
(viii) The take-home schedule, if applicable.
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Observations
(vi) Based on a review of the patient records, the facility failed to document the time administered on the Buprenorphine Medication Administration Record (MAR) in three of four patient records, #2, 4, and 5.Patient #2 was given buprenorphine on October 24, 25, 26, 27, and 28, 2020, but no times were indicated on the MAR.Patient #4 was given buprenorphine on September 15, 16, 17, and 18, 2020, but no times were indicated on the MAR.Patient #5 was given buprenorphine on October 28, 29, 30, and 31, 2020, but no times were indicated on the MAR.The findings were reviewed with facility staff during the licensing process.This is a repeat citation from the January 22-24, 29, 2020 inspection.
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Plan of Correction
The staff has been re-educated on the use of the correct form to be for medication administration. Listing drug..dose..frequency..date and time.
A new RN DON has been hired and she will be responsible to ensure times are logged on this form.
The program manager will monitor this process ensuring it is completed properly during random weekly chart audits. |
709.52(a)(2) LICENSURE Tx type & frequency
709.52. Treatment and rehabilitation services.
(a) An individual treatment and rehabilitation plan shall be developed with a client. This plan shall include, but not be limited to, written documentation of:
(2) Type and frequency of treatment and rehabilitation services.
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Observations
Based on a review of client records, the facility failed to document the type and frequency of services on the treatment plans in four of five client records reviewed for the residential treatment activity. Client #4 was admitted to residential treatment on September 14, 2020. Treatment plans were completed on September 14, 2020 and September 23, 2020 and did not include the type and frequency of treatment.Client #7 was admitted to residential treatment on September 30, 2020 and was discharged on October 10, 2020. A treatment plan was completed on October 6, 2020 and did not include the type and frequency of treatment.Client #9 was admitted to residential treatment on October 8, 2020 and was discharged on October 23, 2020. A treatment plan was completed on October 8, 2020 and did not include the type and frequency of treatment.Client #10 was transferred from detoxification treatment to residential treatment on October 2, 2020 and was discharged on October 28, 2020. A treatment plan was completed on October 6, 2020 and did not include the type and frequency of treatment.The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The staff was re-educated to use proper documentation of all services client is receiving within the treatment plan by the Executive Director.
This education included the frequency of each service as indicated in the treatment plan and based on the needs of each individual client.
The Program Manager will ensure this complete documentation is occurring and contained within the treatment plan on weekly random chart audits. |
709.53(a)(3) LICENSURE Records of Service
709.53. 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:
(3) Record of services provided.
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Observations
Based on a review of client records, the facility failed to document a record of service in five of five client records reviewed for the residential treatment activity. Records # 4, 6, 7, 9 and 10 did not document a record of service.Client #4 was admitted to residential treatment on September 14, 2020. Client #6 was admitted to residential treatment September 9, 2020 and was discharged on October 1, 2020. Client #7 was admitted to residential treatment on September 30, 2020 and was discharged on October 10, 2020. Client #9 was admitted to residential treatment on October 8, 2020 and discharged on October 23, 2020. Client #10 was admitted to detoxification treatment on September 25, 2020, transferred to residential treatment on October 2, 2020 and discharged on October 28, 2020. The findings were reviewed with facility staff during the licensing process.This is a repeat citation from the January 22-24, 29, 2020 inspection.
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Plan of Correction
A record of service document has been developed for residential.
This form details services rendered.
The staff was educated on the proper use of this form and time frames for completion by the Executive Director.
Proper use of this form will be monitored by the Program Manager during random weekly chart audits. |
709.53(a)(10) LICENSURE Discharge Summary
709.53. 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:
(10) Discharge summary.
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Observations
Based on a review of client records, the facility failed to document a discharge summary in four of four applicable client records reviewed for the residential treatment activity. Records # 6, 7, 9 and 10 did not document a discharge summary.Client #6 was admitted to residential treatment September 9, 2020 and was discharged on October 1, 2020. Client #7 was admitted to residential treatment on September 30, 2020 and was discharged on October 10, 2020. Client #9 was admitted to residential treatment on October 8, 2020 and discharged on October 23, 2020. Client #10 was admitted to detoxification treatment on September 25, 2020, transferred to residential treatment on October 2, 2020 and discharged on October 28, 2020. The findings were reviewed with facility staff during the licensing process.This is a repeat citation from the January 22-24, 29, 2020 inspection.
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Plan of Correction
The discharge summary form has been updated to include a more specific listing of services rendered to a client while in treatment.
The staff was re-educated on proper use of this form by the Executive Director.
Proper use of this form will be monitored by the program manager during random weekly chart audits. |
709.53(a)(11) LICENSURE Follow-up information
709.53. 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:
(11) Follow-up information.
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Observations
Based on a review of client records, the facility failed to document follow-up information in two of four applicable client records reviewed for the residential treatment activity. Per the agency policy, follow up is to be completed the first day after discharge, one week after discharge, one month, two months and three months.Client #9 was admitted to residential treatment on October 8, 2020 and discharged on October 23, 2020. There was no documentation that follow-up was completed the first day after discharge, and one week after discharge.Client #10 was admitted to detoxification treatment on September 25, 2020, transferred to residential treatment on October 2, 2020 and discharged on October 28, 2020. There was no documentation that follow-up was completed the first day after discharge, and one week after discharge.The findings were reviewed with facility staff during the licensing process.This is a repeat citation from the January 22-24, 29, 2020 inspection.
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Plan of Correction
The follow-up policy and procedure has been revised.
The policy and procedure states a follow-up phone call to be made within 1 week after discharge by the Case Manager.
The staff was educated on this revision by the Executive Director.
This process will be monitored to ensure proper documentation by the program manager during random weekly chart audits. |
709.53(a)(12) LICENSURE Work as treatment
709.53. 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:
(12) Verification that work done by the client at the project is an integral part of his treatment and rehabilitation plan.
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Observations
Based on a review of client records, the facility failed to verify that any work done by the client at the project is an integral part of his treatment and rehabilitation plan in five of five client records reviewed for the residential treatment activity.Records # 4, 6, 7, 9 and 10 did not verify this information on the treatment plan.Client #4 was admitted to residential treatment on September 14, 2020. Client #6 was admitted to residential treatment September 9, 2020 and was discharged on October 1, 2020. Client cord #7 was admitted to residential treatment on September 30, 2020 and was discharged on October 10, 2020. Client #9 was admitted to residential treatment on October 8, 2020 and discharged on October 23, 2020. Client #10 was admitted to detoxification treatment on September 25, 2020, transferred to residential treatment on October 2, 2020 and discharged on October 28, 2020. The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Treatment plans will reflect chores completed by client along with the skills learned while completing this assignment.
The staff was educated on this procedure by the Executive Director.
The program Manager will monitor proper documentation of this procedure during random weekly chart audits. |