INITIAL COMMENTS
|
This report is a result of an on-site licensure renewal, buprenorphine monitoring inspection and complaint investigation conducted on November 6-8, 2023 by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, Millerton Acquisition Sub, LLC DBA 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:
|
Plan of Correction
|
705.4 (3) LICENSURE Counseling areas.
705.4. Counseling areas.
The residential 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.
|
Observations
Based on a physical plant inspection, it was observed that the facility failed to ensure privacy so that counseling sessions cannot be seen or heard outside of the counseling room as cameras were operating in the group counseling/dining room.
This finding was reviewed with facility staff during the licensing process.
This is a repeat citation from the December 8, 2022 licensing inspection.
|
Plan of Correction
POC: Bradford Recovery Center has submitted the clearance form from DDAP to request permission for recording in the cafeteria and group room.
The facility director will ensure completion of the submission. Corrective Action Date: 1/9/2024
|
709.24 (a) (3) LICENSURE Treatment/rehabilitation management.
§ 709.24. Treatment/rehabilitation management.
(a) The governing body shall adopt a written plan for the coordination of client treatment and rehabilitation services which includes, but is not limited to:
(3) Written procedures for the management of treatment/rehabilitation services for clients.
|
Observations
Based on a review of inpatient client records, the facility failed to notify the emergency contact of the client leaving the facility against medical advice.
Client #30 was admitted on October 23, 2023 and discharged on October 27, 2023.
This finding was reviewed with facility staff during the licensing inspection.
|
Plan of Correction
Clinical Supervision will be conducted for all clinical staff to include making proper notifications to emergency contacts in the instance a client leaves against medical advice/against clinical advice and it will be documented in the client's EMR. If the client refuses to sign for Emergency contact upon admission, a note will be entered into the client's EMR. In the instance that a client leaves treatment prematurely (notification through email), the clinical director will review individual's EMR to ensure that emergency contact was notified within 12 hours of client discharge. This will be conducted as often as notifications are made of clients leaving treatment prematurely.
The clinical director will audit ten charts for the next four months beginning 1/15/2024 through 5/15/2024 to ensure compliance. |
709.33 (a) LICENSURE Notification of termination.
§ 709.33. Notification of termination.
(a) Project staff shall notify the client, in writing, of a decision to involuntarily terminate the client ' s treatment at the project. The notice shall include the reason for termination.
|
Observations
Based on the review of partial hospitalization client records, the facility failed to notify the client, in writing, of a decision to involuntarily terminate the client's treatment at the project in one out of two applicable client record.
Client #3 was admitted on September 13, 2023 and discharged on October 19, 2023.
This finding was reviewed with facility staff during the licensing inspection.
|
Plan of Correction
POC: A supervision will be conducted to ensure all clinical documentation will be entered into the client's EMR to include written notice of involuntary termination (Administrative Discharge) of treatment and with explanation for termination.
The clinical director will ensure compliance.
The clinical director and or counselor will ensure that all documentation (AD Notification Form) is entered into the EMR prior to the client being discharged from BRC by conducting daily chart audits.
The clinical director will audit ten charts for four months to ensure compliance starting 1/15/2024 and ending on 5/15/2024. |
709.81(b)(6) LICENSURE Intake and admission
709.81. Intake and admission.
(b) Intake procedures shall include documentation of:
(6) Psychosocial evaluation.
|
Observations
Based on the review of partial hospitalization client records, the facility failed to document a complete psychosocial evaluation in four out of ten applicable records.
Client #1 was admitted on August 9, 2023 and was discharged on September 15, 2023.
Client #2 was admitted on August 16, 2023 and was discharged on September 18, 2023.
Client #6 was admitted on October 3, 2023 and was still active at the time of the inspection.
Client #8 was admitted on August 15, 2023 and was discharged on September 29, 2023.
These findings were reviewed with facility staff during the licensing inspection.
This is a repeat citation from the December 8, 2022 licensing inspection.
|
Plan of Correction
POC: We created a policy change to reflect the proper time for the psychosocial to be completed within 72 hours of a client's admission into the PHP 2.5 level of care.
The clinical director will conduct a group supervision with the clinical team. The clinical director will audit ten charts for four months to ensure compliance starting 1/15/2024 and ending on 5/15/2024.
Bradford created a policy change 1/9/24 to reflect the proper time for the psychosocial to be completed within 72 hours of a client's admission into the PHP 2.5 level of care. Beginning 1/9/24 clinical director will be actively auditing all new admissions to the PHP LOC to ensure that the policy is being upheld. Daily and weekly audits will continue throughout the year.
|
709.81(b)(7) LICENSURE Intake and admission
709.81. Intake and admission.
(b) Intake procedures shall include documentation of:
(7) Preliminary treatment and rehabilitation plan.
|
Observations
Based on a review of partial hospitalization client records, the facility failed to document a preliminary treatment plan according to the facilities policy and procedure manual in seven out of ten records reviewed. The facility's policy and procedures manual states that the preliminary treatment plan must be completed at intake.
Client #1 was admitted on August 9, 2023 and was discharged on September 15, 2023.
Client #2 was admitted on August 16, 2023 and was discharged on September 18, 2023.
Client #4 was admitted on October 12, 2023 and was still active at the time of the inspection.
Client #5 was admitted on September 1, 2023 and was discharged October 10, 2023.
Client #6 was admitted on October 3, 2023 and was still active at the time of the inspection.
Client #8 was admitted on August 15, 2023 and was discharged on September 29, 2023.
Client #9 was admitted on August 16, 2023 and was discharged October 3, 2023.
These findings were reviewed with facility staff during the licensing inspection.
|
Plan of Correction
A policy change was created on 1/8/2024 to reflect Nursing staff will complete the Preliminary Treatment Plan for all incoming clients upon admission. The nursing director will conduct a supervision with the medical team to reflect the changes in policy. This change will reflect in the completion of the Nursing Assessment completed in BestNotes. Nurse Manager will continue auditing all new admission charts daily to ensure treatment plans for all new admissions are documented in the EMR.
|
709.82(a)(3) LICENSURE Treatment and rehabilitation services
709.82. 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:
(3) Proposed type of support service.
|
Observations
Based on a review of partial hospitalization client records, the facility failed to document proposed type of support service on individual treatment plans in ten out of ten records reviewed.
This finding was reviewed with facility staff during the licensing inspection.
This is a repeat citation from the December 8, 2022 licensing inspection.
|
Plan of Correction
POC: Clinical staff will be educated on the importance on educating clients on their individual treatment plans. The clinical director will review ten charts per month for the next four months to ensure treatment plans are being completed correctly and support services are added to the treatment plans starting 1/15/2024 and ending on 5/15/2024.
The clinical director will ensure compliance.
Updated POC: The clinical director will audit all incoming PHP Client charts for the next 90 days to ensure that the Treatment plans include recommended support services. We will also be following up with the clinicians on a daily basis during FLASH Meeting to ensure proper documentation is being entered into the EMR.
Daily and weekly chart audits will continue throughout the year.
|
709.83(a)(11) LICENSURE Client records
709.83. 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.
|
Observations
Based on a review of partial hospitalization client records, the facility failed to document follow up information within guidelines established by the facility's policy and procedures manual in eight out of eight applicable records reviewed. The facility's policy and procedures manual states the that follow up must be completed seven days following discharge.
Client #1 was admitted on August 9, 2023 and was discharged on September 15, 2023.
Client #2 was admitted on August 16, 2023 and was discharged on September 18, 2023.
Client #3 was admitted on September 13, 2023 and was discharged October 19, 2023.
Client #5 was admitted on September 1, 2023 and was discharged October 10, 2023.
Client #7 was admitted on July 13, 2023 and was discharged August 8, 2023.
Client #8 was admitted on August 15, 2023 and was discharged on September 29, 2023.
Client #9 was admitted on August 16, 2023 and was discharged October 3, 2023.
Client #10 was admitted on September 27, 2023 and was discharged October 3, 2023.
This finding was reviewed with facility staff during the licensing process.
|
Plan of Correction
POC: The policy has been reviewed and changed that Bradford Recovery Center will contact the client within 30 days of the client's discharge.
A Salesforce report will be created by the Pennsylvania Access Center and will be sent to our Admissions Department daily to monitor progress.
The facility director will ensure compliance by auditing Salesforce every 72 hours to ensure compliance. The facility CEO and Admissions Director will continue to hold weekly meetings with the Pennsylvania Call Center's Director to ensure compliance.
|
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.
|
Observations
Based on the review of buprenorphine patient records, the facility failed to verify an emergency contact in two out of nine records reviewed.
Patient #21 was admitted on October 27, 2023 and was still active at the time of the inspection.
Patient #26 was admitted on September 21, 2023 and was discharged on September 26, 2023.
These findings were reviewed with facility staff during the licensing inspection.
|
Plan of Correction
POC: All clients during the admissions/intake process will sign a consent for an emergency contact. All refusals will be properly documented into the EMR. A supervision will be completed with intake/admissions to ensure compliance. Clients will have Emergency contact entered during admission assessment. If client refuses, admissions department will enter a note in EMR immediately upon client's refusal. Prior to administration of agent, nursing staff will verify there is an emergency contact or refusal note in client's chart.
The Intake Coordinator will notify all staff through email via Bradford208 if a client refuses to sign for an emergency contact. The Clinical Director and Nurse Manager will ensure compliance by conducting daily and weekly audits of incoming client's charts. |
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.
|
Observations
Based on the review of buprenorphine detox patient records, the facility failed to complete an initial drug screening urinalysis for each prospective patient in one out of eight records reviewed.
Patient #26 was admitted on September 21, 2023 and was discharged on September 26, 2023. A urinalysis was completed on September 23, 2023 and the patient was administered buprenorphine on September 22, 2023.
This finding was reviewed with facility staff during the licensing inspection.
This is a repeat citation from the December 8, 2022 licensing inspection.
|
Plan of Correction
POC: Nursing staff will randomly select clients for urine drug screens throughout their course of treatment and Bradford Recovery Center.
Nursing staff will perform urinalysis upon admission for all clients. Nursing staff will ensure urinalysis is entered in clients EMR prior to administration of buprenorphine, if not completed on admission, one will be completed prior to administration of Buprenorphine. Nurse Manager will ensure random urinalysis are being performed on 10 clients weekly starting on 1/9/2024. Daily auditing will be completed to ensure treatment plans for all new admissions are completed. |
715.23(b)(4) LICENSURE Patient records
(b) Each patient file shall include the following information:
(4) The results of an initial intake physical examination.
|
Observations
Based on a review of buprenorphine detox patient records, the facility failed to complete a physical within guidelines established by the facility's policy and procedures manual in three out of nine applicable records reviewed. The facility's policy and procedures manual states the that physical must be completed within 24 hour of admission.
Patient #24 was admitted on September 20, 2023. A physical was due no later than September 21, 2023. However, it was not completed until September 22, 2023.
Patient #28 was admitted on September 28, 2023. A physical was due no later than September 29, 2023. However, it was not completed until October 4, 2023.
Patient #29 was admitted on September 29, 2023. A physical was due no later than September 30, 2023. However, it was not completed until October 4, 2023.
These findings were reviewed with facility staff during the licensing inspection.
|
Plan of Correction
POC: A supervision was completed with our medical providers to ensure completion of the physical examinations.
Providers will ensure initial intake physical is being completed per BRC policy timeframe. Nurse Manager will ensure daily that initial physicals are completed per policy and will provide direct supervisions with providers when needed. Daily auditing will be completed to ensure treatment plans for all new admissions are completed.
A policy change was created on 1/8/2024 to reflect that all History and Physicals will be completed within 48 hours of admission into the program.
|
709.51(b)(6) LICENSURE Psychosocial evaluation
709.51. Intake and admission.
(b) Intake procedures shall include documentation of:
(6) Psychosocial evaluation.
|
Observations
Based on the review of inpatient client records, the facility failed to document a complete psychosocial evaluation in four out of twelve applicable records.
Client #11 was admitted on October 23, 2023 and was still active at the time of the inspection.
Client #15 was admitted on July 26, 2023 and was discharged on September 6, 2023.
Client #16 was admitted on August 5, 2023 and was discharged on September 5, 2023.
Client #18 was admitted on August 15, 2023 and was discharged on September 18, 2023.
These findings were reviewed with facility staff during the licensing inspection.
This is a repeat citation from the December 8, 2022 licensing inspection.
|
Plan of Correction
POC: The policy has been changed to reflect that psychosocials will be completed within 72 hours of a client's transfer into the 3.5 level of care. The clinical director will conduct a group supervision with the clinical team to ensure the psychosocial evaluations are being completed within the 72-hour timeframe when a client transitions into the 3.5 level of care.
The clinical director will continue with daily and weekly audits to ensure compliance. |
709.52(a) LICENSURE Individual TX and REHAB Plan
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:
|
Observations
Based on a review of inpatient client records, the facility failed to complete treatment plans according to the facilities policy and procedure manual in seven out of twelve records reviewed. The facility's policy and procedures manual states that the treatment plan must be completed within 72 hours of intake.
Client #13 was admitted on July 20, 2023 and was still active at the time of the inspection. A treatment plan was due no later than July 23, 2023; however, it was not completed until August 13, 2023.
Client #15 was admitted on July 26, 2023 and was discharged on September 6, 2023. A treatment plan was due no later than July 29, 2023; however, it was not completed until August 11, 2023.
Client #16 was admitted on August 5, 2023 and was discharged on September 5, 2023. A treatment plan was due no later than August 8, 2023; however, it was not completed until August 28, 2023.
Client #18 was admitted on August 15, 2023 and was discharged on September 18, 2023. A treatment plan was due no later than August 18, 2023; however, it was not completed until August 21, 2023.
Client #19 was admitted on August 16, 2023 and was discharged on September 13, 2023. A treatment plan was due no later than August 19, 2023; however, it was not completed until August 31, 2023.
Client #20 was admitted on August 16, 2023 and was discharged on August 29, 2023. A treatment plan was due no later than August 19, 2023; however, it was not completed until August 21, 2023.
Client #21 was admitted on October 27, 2023 and was still active at the time of the inspection. A treatment plan was due no later than October 30, 2023; however, it was not completed until October 31, 2023.
These findings were reviewed with facility staff during the licensing inspection.
|
Plan of Correction
POC: A policy change was created on 1/9/2024 to reflect the Treatment Plan will be completed within 72 hours upon admission into the detox component of the facility. Daily auditing will be completed to ensure treatment plans for all new admissions are completed.
A supervision will be conducted will all nursing staff to address the necessity of the treatment plan being completed within 72 hours. |
709.52(a)(3) LICENSURE Support service type
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:
(3) Proposed type of support service.
|
Observations
Based on a review of inpatient client records, the facility failed to document proposed type of support service on individual treatment plans in twelve out of twelve client records reviewed.
This finding was reviewed with facility staff during the licensing inspection.
This is a repeat citation from the December 8, 2022 licensing inspection.
|
Plan of Correction
POC: Clinical staff will be educated on the importance on educating clients on their individual treatment plans. Clinical Director has conducted a documented group supervision on documenting the Treatment Plan within 72 hours of the client being admitted into PHP2.5 Level of Care. Clinical director will continue to audit all PHP new admissions charts to ensure the Treatment Plan is being completed within the 72-hour timeframe outlined in the policy. Daily and weekly auditing will continue throughout the year. |
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.
|
Observations
Based on a review of inpatient client records, the facility failed to document follow up information within guidelines established by the facility's policy and procedures manual in eight out of eight applicable records reviewed. The facility's policy and procedures manual states the that follow up must be completed seven days following discharge.
Client #13 was admitted on July 20, 2023 and was discharged on September 8, 2023.
Client #14 was admitted on July 26, 2023 and was discharged on August 4, 2023.
Client #15 was admitted on July 26, 2023 and was discharged on September 6, 2023.
Client #16 was admitted on August 5, 2023 and was discharged on September 5, 2023.
Client #17 was admitted on August 3, 2023 and was discharged on August 6, 2023.
Client #18 was admitted on August 15, 2023 and was discharged on September 18, 2023.
Client #19 was admitted on August 16, 2023 and was discharged on September 13, 2023.
Client #20 was admitted on August 16, 2023 and was discharged on August 29, 2023.
This finding was reviewed with facility staff during the licensing process.
|
Plan of Correction
POC: The policy has been reviewed and changed that Bradford Recovery Center will contact the client within 30 days of the client's discharge.
The facility CEO and Intake Coordinator will ensure compliance by auditing Salesforce every 72 hours to ensure calls have been placed. Weekly meetings will be held with the Director of the Pennsylvania Call Center to ensure compliance. |