INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on November 28-30, 2011 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Gaudenzia Erie, Inc - Crossroads 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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709.24(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.
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Observations
Based on a review of client records and the policy and procedure manual, the facility failed to document a clear, single policy and procedure in regards to case consultations.
The findings include:
A review of client records and the policy and procedure manual took place on November 28-30, 2011. Based on a policy dated July 1, 2011, "case consults will be completed by the first 30 days and each 30 days thereafter (long term); 14 days and each 14 days thereafter (short term)..." a second policy dated August 26, 2011 stated "counselors well be responsible for presenting a case consultation to the treatment team on a bi-weekly basis for each client." Due to the conflicting policies, the licensing specialist interviewed the clinical supervisor as to what policy/procedure is currently being used. During that interview, it was reported that case consultations are conducted within five days of admission, at the time of the treatment plan update and at discharge.
Client records were reviewed on November 29 & 20, 2011. It is unclear which policy is being followed by clinical staff as there is no uniform timeframe identified in the four client records reviewed.
Client # 5 was admitted to the short term residential program on November 8, 2011 and was discharged on November 25, 2011. No case consultations were completed while this client was in treatment; however, two case consultations dated December 1, 2011 were documented in the client record.
Client # 6 was admitted to the long term residential program on September 27, 2011 and was discharged on October 20, 2011. One case consultation dated October 6, 2011 was documented in the client record.
Client # 7 was admitted to the long term residential program on July 20, 2011 and was discharged August 16, 2011. Two case consultations dated August 11, 2011 and one dated September 22, 2011 were documented in the client record.
Client # 8 was admitted to the short term residential program on November 3, 2011. One case consultation dated November 17, 2011 was documented in the record.
Multiple interviews were conducted with the clinical supervisor on November 28, 29 & 30, 2011. The clinical supervisor was unaware of the conflicting policies and confirmed the aforementioned information.
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Plan of Correction
Division Director will correct Case Consutlation policies and ensure they reflect the same information. The Program Director of Residential will review policy with staff by 1/27/11 |
709.26(f) LICENSURE Personnel Management
709.26. Personnel management.
(f) There shall be written job descriptions for project positions which include, but are not limited to:
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Observations
Based on a review of personnel records, the facility failed to document a written job description for the position of facility director, which contained the employee's and supervisor's dated signatures in one of one personnel record.
The findings include:
One personnel record for the facility director was reviewed on December 2, 2011. This record required documentation of a signed job description. The facility did not document a signed job description for the position of facility director in personnel record #9.
Employee #9 is the Director of Finance and Operations and was hired on September 16, 1996. The previous facility director resigned on November 11, 2011. Per the Staffing Requirements Facility Summary Report, employee #9 assumed the duties of facility director as of November 11, 2011. There was no documentation of a signed job description for the position of facility director in personnel record #9.
The facility director was interviewed on December 2, 2011. It was confirmed that there was no signed job description in place which included the duties of facility director.
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Plan of Correction
A signed job description has placed in the "Interim" Facility Directors personnel file. Regional Director along with the Director of Finance & Operations (In charge of HR in Erie) will monitor employee files to ensure correct job descriptions are in the employee files. |
709.32(b) LICENSURE Medication Control
709.32. Medication control.
(b) Verbal medication orders may be accepted but shall be put in writing and signed within 24 hours thereafter by the prescribing physician.
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Observations
Based on a review of client records, the facility failed to ensure that verbal medication orders are put in writing and signed with 24 hours thereafter by the prescribing physician in four of eight client records.
The findings include:
Eight detoxification and residential treatment and rehabilitation client records were reviewed on November 29-30, 2011. All verbal medication orders are required to be signed within 24 hours by the prescribing physician. Patient records # 1, 2, 5 and 6 contained documentation of a verbal medication order that was not signed by the prescribing physician within 24 hours.
Client #1 was admitted on November 27, 2011. A verbal order dated November 27, 2011 did not have documentation of the physician's signature. In addition, the verbal order stated that the nurse can implement the opiate withdrawal protocol. The nurse then determined which medications the client needed based on symptoms.
Client #2 was admitted on August 11, 2011 and discharged on August 12, 2011. A verbal order dated August 11, 2011 did not have documentation of the physician's signature. In addition, the verbal order stated that the nurse can implement the opiate withdrawal protocol. The nurse then determined which medications the client needed based on symptoms.
Client #5 was admitted on November 5, 2011 and discharged on November 25, 2011. Verbal orders dated November 5 & 8, 2011 did not have documentation of the physician's signatures. In addition, the verbal order stated that the nurse can implement the opiate withdrawal protocol. The nurse then determined which medications the client needed based on symptoms.
Client #6 was admitted on September 22, 2011 and discharged on October 20, 2011. Verbal orders dated September 22 & 24, 2011 did not have documentation of the physician's signature. In addition, the verbal order stated that the nurse can implement the opiate withdrawal protocol. The nurse then determined which medications the client needed based on symptoms.
Interviews with the clinical supervisor and nurse manager took place several times on November 30, 2011. The aforementioned information was confirmed.
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Plan of Correction
All verbal orders will be put in writing and signed by the physician within 24 hours. Nurses' will no longer continue to circle the medications on the protol. The Nurse Manager will monitor to ensure proper protcol and that the Physician's verbal medication order is signed within twenty-four hours. |
715.15(b) LICENSURE Medication dosage
(b) The narcotic treatment physician shall determine the proper dosage level for a patient, except as otherwise provided in this section. If the narcotic treatment physician determining the initial dose is not the narcotic treatment physician who conducted the patient examination, the narcotic treatment physician shall consult with the narcotic treatment physician who performed the examination before determining the patient 's initial dose and schedule.
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Observations
Based on a review of patient records, the facility failed to document that the narcotic treatment physician shall determine the proper dosage level for a patient in two of eight patient records.
The findings include:
Eight patient records were reviewed on November 29 & 30, 2011. The narcotic treatment physician was required to determine the proper dosage level for the patient in all eight patient records reviewed. The facility failed to document that the narcotic treatment physician determined the proper dosage level for the patient in patient records # 1 and 4.
Patient #1 was admitted to treatment on November 27, 2011. A physician order dated November 27, 2011 included Suboxone on day 4 & 5 if needed, PRN.
Patient # 4 was admitted on November 28, 2011. A physician order dated November 28, 2011 included Suboxone on day 4 & 5, PRN.
An interview with the nurse manager took place on November 30, 2011. It was reported that the narcotic treatment physicians typically order day 4 and 5 as PRN so the medication can be obtained by the pharmacy. Based on symptoms, the nurse makes a determination if the medication is needed. If so, it is administered to the patient. If not, the medication is destroyed.
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Plan of Correction
Nurse Manager will monitor that the physicians are documenting the entire protol dosages levels needed by the client. The Nurse will follow the physcian's orders on the administration of suboxone and that suboxone will not be left to a PRN basis. Nurse Manager will report any problems to the Program Director. |
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 client record review, the facility failed to document a discharge summary within seven days of discharge in two of three client records.
The findings include:
Three discharged residential treatment and rehabilitation client records were reviewed on November 30, 2011. A discharge summary, which is to be completed within seven days of discharge, per facility policy, was required in all three client records. The facility did not document a discharge summary within seven days of discharge in client records # 6 and 7.
Client #6 was admitted to residential treatment and rehabilitation on September 27, 2011 and was discharged on October 20, 2011. A discharge summary was due to be completed by October 27, 2011. The discharge summary was completed on October 28, 2011.
Client #7 was admitted to residential treatment and rehabilitation on July 20, 2011 and was discharged on August 16, 2011. A discharge summary was due to be completed by August 23, 2011. The discharge summary was completed on September 18, 2011.
An interview with the clinical supervisor took place on November 30, 2011. The aforementioned dates and information was confirmed at that time.
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Plan of Correction
Program Director of Residential will review/train staff on agency policies in regards to time frames of documentation of discharge summaries. Training will be completed on 1/27/12 and will be monitored by the Program Director during UR/QI process |