INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection and methadone and buprenorphine monitoring inspection conducted on March 5, 2024, by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, Lehigh County Center for Recovery 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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709.28 (c) 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.
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Observations
Based on a review of client records, the facility failed to obtain a consent to release information form prior to releasing information in one out of twelve records reviewed.
Client #11 was admitted on September 14, 2023 and discharged on October 25, 2023. As part of aftercare planning, the facility contacted a drug and alcohol provider; however, the facility did not have a signed informed and voluntary consent to release information from the client.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
Clinical Director held a supervision/training on 3/13/24 how to complete a release of information, in its entirety, in our EMR system. This will be monitored by having the admissions coordinator review on a daily basis all releases of information for previous day admits monitoring that all are being completed in its entirety. Clinical Director will conduct weekly chart audits of all active clients that releases of information are complete and accurate. Program Director will conduct monthly chart audits to ensure compliance. |
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 physical plant inspection on March 5, 2024, the facility failed to ensure that drugs for external use were stored separately from oral drugs as there was medicated powder stored with the oral medication in the medication cart.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
Nurse Manager retrained staff on 3/11/24 on how to properly store medications in the medication cart. All staff were trained how to separate external use drugs from oral drugs. This will be monitored by the nurse manager conducting and documenting weekly cart audits. |
709.32 (c) (4) (i) - (ii) LICENSURE Medication control
§ 709.32. Medication control.
(4) Methods for control and accountability of drugs, including, but not limited to:
(i) Who is authorized to remove drug.
(ii) The program ' s system for recording drugs, which includes the name of the drug, the dosage, the staff person, the time and the date.
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Observations
Based on a review of client records, the facility failed to provide documentation of medication being provided as prescribed by a physician in two out of twelve client records.
Client #3 was admitted on March 1, 2024 and was still active at the time of the inspection. The client was prescribed two medications to be given in the morning. The medication administration records showed that the medications were not given on the morning of March 4, 2024. There was no additional documentation included indicating a reason why the medications were not given as prescribed.
Client #12 was admitted on February 8, 2024 and was still active at the time of the inspection. The client was prescribed one medication to be given at 1 PM. The medication administration records showed that the medications were not given on March 2, 2024. There was no additional documentation included indicating a reason why the medications were not given as prescribed.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
Nurse Manager conducted a training on the week of 3/11/24 for every nurse and shift. Staff were educated on the procedures we will be using in order to improve our MARS documentation. Each med pass the administrating nurse will be responsible for checking all MARS and documenting if the client refuses, no shows or the medication has not arrived from pharmacy.
Staff will also be required to document the order date on the MARS under the medication.
Nurse manager will do MARS checks weekly to ensure compliance.
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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 provide a complete client record, which is to include follow-up information in one out of one applicable record reviewed.
Client #7 was admitted on October 1, 2023 and discharged on October 4, 2023. A follow up was due per the facility ' s policy and procedure manual within 30 days of discharge; however, there is no documentation that one occurred.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
Program Director implemented a procedure on 3/11/24 for the Clinical Director and/or their designee to complete follow up calls on a weekly basis and that all calls are documented in the client's chart. Program Director will monitor and audit all charts on a bi-weekly basis that follow calls are being completed, documents and placed in the client's charts. |
709.52(b) LICENSURE TX Plan update
709.52. Treatment and rehabilitation services.
(b) Treatment and rehabilitation plans shall be reviewed and updated at least every 30 days. For those projects whose client treatment regime is less than 30 days, the treatment and rehabilitation plan, review and update shall occur at least every 15 days.
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Observations
Based on a review of client records, the facility failed to document treatment plan updates within the facility ' s policy and procedures manual of every 15 days in three out of six applicable records reviewed.
Client #9 was admitted on July 26, 2023 and discharged on Augst 24, 2023. A treatment plan was completed on August 3, 2023 and the next update was due no later than August 18, 2023, however, there is no documentation that one was completed.
Client #10 was admitted on July 20, 2023 and discharged on August 17, 2023. A treatment plan was completed on July 22, 2023 and the next update was due no later than August 6, 2023; however, there is no documentation that one was completed.
Client #11 was admitted on September 14, 2023 and discharged on October 25, 2023. A treatment plan was completed on September 26, 2023 and the next update was due no later than October 10, 2023; however, it was not completed until October 11, 2023.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
On 3/13/24 Clinical Director reviewed and re-educated the clinical staff on the procedure to complete Treatment Plan Updates (known as Treatment Concurrent Progress Forms) in our EMR system every 15 days. The clinical Director will complete weekly chart audits to ensure compliance. The Program Director will complete monthly chart audits to validate compliance. |
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 provide a complete client record, which is to include a follow up contact in two out of three applicable records reviewed. Per the facility ' s policy and procedure manual, follow up contacts are within 7 days if an aftercare appointment was made or within 30 days if no appointment was scheduled.
Client #9 was admitted on July 26, 2023 and discharged on Augst 24, 2023. There is no documentation that a follow up occurred.
Client #11 was admitted on September 14, 2023 and discharged on October 25, 2023. There is no documentation that a follow up occurred.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Program Director implemented a procedure on 3/11/24 for the Clinical Director and/or their designee to complete follow up calls on a weekly basis and that all calls are documented in the client's chart. Program Director will monitor and audit all charts on a bi-weekly basis that follow calls are being completed, documents and placed in the client's charts. |