INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on January 4, 2024, by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, Treatment Trends, Inc. 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, the facility failed to follow their written procedures for the management of treatment/rehabilitation services for clients in one of two applicable records reviewed.
Client #7 was admitted to the residential rehabilitation level of care on April 18, 2023 and discharged against facility advice on July 21, 2023. The facility failed to follow their policy to contact the emergency contact within twelve hours of the client leaving the facility against facility advice.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
To ensure compliance with Act 41, all staff members will notify the emergency contact if a client leaves the facility against medical advice (AMA), provided the client has not revoked consent to notify the emergency contact if one is on file. Notification shall occur immediately and in no event later than
12 hours of a patient leaving against medical advice. A training, facilitated by the Facility Director, is scheduled for 01/17/2024 at 9:00am to address the 12-hour time frame and review (1) where to find an emergency contact in the file, (2) what to say to the emergency contact in the event that an AMA occurs, (3) and how to document that the notification occurred. Signage has been hung in the BHT and counselors' offices that outlines this directive for new employees. The Clinical Supervisor or designee will review each chart within 14 days of discharge, and/or while reviewing the discharge summary, to ensure that notification has occurred within the specified time frame. In the specific case of Client #7, the emergency contact was notified on Monday morning, despite his AMA occurring on Friday evening. Due to the emergency contact being notified of Client #7's discharge, we will not take further action to rectify the situation.
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709.28 (d) LICENSURE Confidentiality
§ 709.28. Confidentiality.
(d) A copy of a client consent shall be offered to the client and a copy maintained in the client record.
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Observations
Based on a review of the client records, the facility failed to document that a copy of a client consent was offered to the client and a copy maintained in the client record in seven out of seven client records reviewed.
There was no documentation that a copy was offered for any of the releases of information located in each of records reviewed.
These findings were reviewed with the facility staff during the licensing process.
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Plan of Correction
To address this deficiency, The Quality Assurance Coordinator will alter the electronic releases of information to include an area that illustrates that clients are offered a copy of this documentation at time of signature and upon request. The Quality Assurance Coordinator will submit these amendments to the contracted electronic medical record (EMR) company utilized by the facility. This submission will occur within 30 days. Until this submission, staff will write a note in the client's chart indicating that copies of the signed releases of information were offered to the client at time of signature. The Facility Director will ensure there is a note in each chart during inspection of the initial encounter, or within 14 days of admission. |
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 January 4, 2024, the facility failed to ensure that drugs for external use were stored separately from oral drugs as two cans of foot spray was store with the oral medication in the med cart.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
To ensure compliance with the medication storage policy, the Facility Director will create a checklist for medication storage which will be reviewed with the Medical Service Specialists (MSS) and the Behavioral Health Technician (BHT) staff. This checklist will be reviewed during a whole-staff training scheduled for 01/17/2024 at 9:00am and immediately implemented thereafter. The checklist will be posted in the medication room and the Lead MSS or designee will check the med cart weekly and sign off on the storage and location of medication. |