INITIAL COMMENTS
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This report is a result of complaint investigation conducted on March 30, 2011, by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the complaint investigation, the allegations made against Parkside Recovery were substantiated. A plan of correction must be submitted by May 13, 2011.
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Plan of Correction
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704.3(c) LICENSURE Clerical/Support Staff
704.3. General requirements for projects.
(c) Clerical and other support staff shall be employed in sufficient numbers to insure efficient and safe operation of all of the services provided by the project.
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Observations
Based upon an interview with patient #1, and interviews with the Facility Director, Medical Director, Clinical Supervisor, Security Staff and the Quality Assurance Director, the facility failed to employ a sufficient number of support staff to ensure efficient and safe operation of all of the services provided by the project.
The findings include:
On March 28, 2011, a telephone interview was conducted with patient #1. Patient #1 stated that following dosing they proceeded to the side of the building with the elevator ramp to wait for the bus. While waiting for the bus a fight between patient 2 & 3 ensued. Patient #2 pulled out a box cutter and waved it around and subsequently cut patient #1 on the right hand. Patient #1 stated that although security was outside at the time of the incident, other patients were blocking security from intervening.
On March 30, 2011, Facility Director, Medical Director, Clinical Supervisor, Security Staff and the Quality Assurance Director were interviewed regarding the incident when patient #1 suffered a laceration of the hand inflicted by patient #2 while at the facility. The incident occurred on March 2, 2011. All staff interviewed confirmed that the incident did occur and that patient #1 did receive a laceration.
The Quality Assurance Director stated that patient #2 had arrived at the facility on 3/2/11, observed to be angry. The Quality Assurance Director expressed the opinion that it was over a movie that another client had sold to patient #2's Significant Other. The Quality Assurance Director stated that after patient #2 had walked out of the facility that day that the patient got into an altercation with another patient, patient #3. The Quality Assurance Director stated that the fight happened and patient #1 was put in the middle. Patient #1 got cut and went to the hospital and brought back paperwork.
The Head of Security stated that there were four people involved in the fight, patient #1 (the complainant), patient #2 (the patient with the box cutter), patient #3 (the patient that patient #2 first approached and patient #4 (patient #2's Significant Other). The Head of Security stated that patient #1 was standing outside when the fight began and the security tape shows that patient #1 voluntarily ran and joined the crowd that was watching/instigating the fight.
The Clinical Supervisor stated that the facility had a video of the fight and that if the Licensing Specialists wished to see the video of the fight they could. The Licensing Specialists asked to see the video, but the facility could not locate it. The facility director stated that they would send a copy of the video to the Licensing Specialists; however as of 4/21/11, the video has not yet been received.
The above mentioned facility staff confirmed that during the altercation between patient #2 & #3, patient #2 pulled out a box cutter and that patient #1 received a laceration of the hand. Furthermore, staff stated that another box cutter was confiscated from patient #2 on March 3, 2011.
Based on the evidenced inability for security to insure the safety of patient #1 so as to prevent patient #1 from receiving a laceration, and the inability for security to detect the presence of a box cutter on March 2, 2011, the facility lacks sufficient security staff to insure efficient and safe operation of all of the services provided.
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Plan of Correction
A security guard will remain outside walking the perimeter of Parkside Recovery at all times when the treatment facility is open. If the security guard needs to come into the building, he/she will call the security supervisor to provide outside coverage. The security supervisor will provide additional coverage during the times that groups leave the building to ensure this deficiency does not reoccur. All clients will go through the medical detector and will receive pat downs in the least restrictive manner in order ensure that all services are provided in a efficient and safe manner. The Program Director will meet with the security supervisor daily to ensure the deficiency's noted do not re-occur.
Completed: Immediately |
715.20 LICENSURE Patient transfers
A narcotic treatment program shall develop written transfer policies and procedures which shall require that the narcotic treatment program transfer a patient to another narcotic treatment program for continued maintenance, detoxification or another treatment activity within 7 days of the request of the patient.
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Observations
Based on an interview with the Clinical Supervisor, the Quality Assurance Director and patient #1's counselor, the facility failed to transfer patient #1 to another treatment facility within seven days of patient #1's request.
The findings include:
A review of documentation regarding a March 2, 2011 incident involving a patient's (#1) injury inflicted by another patient, while at the facility for the purpose of receiving medication., The injury required medical treatment. Upon returning to the clinic, patient #1 requested a transfer. As of March 30, 2011, patient #1 remained in treatment at the facility. The Clinical Supervisor, Counselor and Quality Assurance Director were all interviewed on March 30, 2011 and confirmed that patient #1 was no transferred within 7 days of the request. there was no documentation in the patient record that addressed efforts to resolve patient #1's request for transfer.
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Plan of Correction
Client #1 rescinded request to transfer within three days of incident to the counselor. Upon further discussion with client, the client reported to the supervisor that the client did inform DOH that the request for transfer was rescinded.The client also confirmed that the request to rescind was done three days after the incident.
Going forward to ensure this defiency does not re-occur Parkside Recovery will document not only requests for transfer within seven days as in the transfer policy (740.412) but will also document if a client rescinds a request for a transfer in the clients record.
Completed immediately |