INITIAL COMMENTS
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This report is a result of an on-site licensure renewal and methadone monitoring inspection conducted on March 9, 2022 by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, Center for Behavioral Health - HA, 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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705.28 (d) (1) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(1) Conduct unannounced fire drills at least once a month.
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Observations
Based on a review of fire drills from November 2020 through February 2022, the facility failed to conduct a monthly fire drill in April and June 2021.
The findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
Clinic Director has added reminders to her Outlook calendar for each month for the next year so that fire drills will be completed monthly as required. Clinic Director has ensured that reminders are entered for different days and times so that patients and staff alike are part of the drills. |
709.34 (c) (1) LICENSURE Reporting of unusual incidents
§ 709.34. Reporting of unusual incidents.
(c) To the extent permitted by State and Federal confidentiality laws, the project shall file a written unusual incident report with the Department within 3 business days following an unusual incident involving:
(1) Physical or sexual assault by staff or a client.
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Observations
Based on a review of patient records, unusual incident reports and communication with staff, the facility failed to file a written report to DDAP within three business days following an incident involving physical assault. The client-on-client physical assault occurred on December 20, 2021 and at the time of the incident, no report have been filed with the Department.
The finding was reviewed with facility staff during the licensing inspection.
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Plan of Correction
Clinic Director will ensure that all DDAP required incident reports are submitted within 3 business days as per policy. Clinic Director will review each incident report as they are completed to determine if it is a DDAP-reportable incident. Clinical Supervisor will be responsible for this in the event of Director's absence. |
715.17(c)(1)(i-vi)) LICENSURE Medication control
(c) A narcotic treatment program shall develop and implement written policies and procedures regarding the medications used by patients which shall include, at a minimum:
(1) Administration of medication.
(i) A narcotic treatment physician shall determine the patient 's initial and subsequent dose and schedule. The physician shall communicate the initial and subsequent dose and schedule to the person responsible for the administration of medication. Each medication order and dosage change shall be written and signed by the narcotic treatment physician.
(ii) An agent shall be administered or dispensed only by a practitioner licensed under the appropriate Federal and State laws to dispense agents to patients.
(iii) Only authorized staff and patients who are receiving medication shall be permitted in the dispensing area.
(iv) There shall be only one patient permitted at a dispensing station at any given time.
(v) Each patient shall be observed when ingesting the agent.
(vi) Administering and dispensing shall be conducted in a manner that protects the patient from disruption or annoyance from other individuals.
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Observations
Based on direct observation of medication administration, the facility failed to follow the facility's policy and procedures manual 6.1.1.7i by requiring patients to speak to the nurse to assure medication has not been diverted. One patient did not speak following medication administration.
The finding was reviewed with facility staff during the licensing inspection.
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Plan of Correction
Clinic Director and Nurse Manager reviewed Policy 6.1.17(i) with all nursing staff upon completion of inspection on 3/10/22. Supervisors have reinforced the importance of making sure that all patients speak to the nursing staff after medicating. Nurse Manager will monitor compliance with this policy on a daily basis. |