INITIAL COMMENTS
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This report is a result of an on-site complaint investigation conducted on March 3, 2020, by staff from the Department of Drug and Alcohol Programs, Bureau of Quality Assurance for Prevention & Treatment. 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 investigation.
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Plan of Correction
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709.26 (b) (4) LICENSURE Personnel management.
§ 709.26. Personnel management.
(b) The personnel records must include, but are not limited to:
(4) Disciplinary actions.
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Observations
The facility failed to document disciplinary actions in the personnel record in one applicable record.
Employee #1 was hired on November 3, 2017 and was terminated on January 22, 2018; On January 17, 2018 there was an incident report related to a theft of facility property involving employee #1, however there was no disciplinary action documented in the personnel record.
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Plan of Correction
All disciplinary records will be reviewed with Human Resources, signed and placed into the employee personnel file. The CEO will spot check personnel files monthly to ensure compliance. |
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
The facility failed to properly document medication administration.
On May 9, 2018 the quantity (2) Buprenorphine tables was dispensed at five different times, however the administering staff information is not documented.
On May 16, 2018 the quantity (2) Buprenorphine tables was dispensed, however the patient name, time and administering staff information are not documented.
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Plan of Correction
Nursing staff will be re-trained on proper documentation of medication administration per White Deer Run's policy including but not limited to including the patient and staff name during a nursing meeting on March 12, 2020. The Nurse Manager will review the medication administration records 2x/week to ensure compliance and will notify Program Director of any discrepancies to investigate. |
709.32 (c) (5) LICENSURE Medication control
§ 709.32. Medication control.
(5) Security of drugs, including, but not limited to, the loss, theft or misuse of drugs.
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Observations
The facility failed to properly document an investigation of a discrepancy in the count of controlled substances.
On January 17, 2018 there was a notation on the inventory sheet of a discrepancy in the Buprenorphine count from the previous shift; facility policy states " An investigation will be conducted and will be submitted to the Regional Administrator and the WDR/CFBHS/BGB Director of Quality and Nursing Services " , however there was no documentation that an investigation was conducted.
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Plan of Correction
The current Nurse Manager will be re-trained on the policy and resources available to complete a proper investigation when there is a discrepancy in the count of controlled substances. This training was completed on March 12, 2020. The Program Director will complete a review of the controlled substance count documentation once a month to ensure there are no discrepancies that were not investigated. |