INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on November 18, 2015 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Caron Treatment Centers - Detox Unit, 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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704.11(b)(1) LICENSURE Individual training plan.
704.11. Staff development program.
(b) Individual training plan.
(1) A written individual training plan for each employee, appropriate to that employee's skill level, shall be developed annually with input from both the employee and the supervisor.
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Observations
Based on a review of the Staffing Requirements Facility Summary Report, the facility failed to provide documentation of individual training plans in three of seven employees.
The findings include:
Seven employees reviewed on the Staffing Requirements Facility Summary Report requiring documentation of individual training plans were reviewed on November 18, 2015.
Employee #5 was hired as an RN on February 28, 2012. The facility failed to provide documentation of an individual training plan.
Employee #6 was hired as an RN on October 17, 2011. The facility failed to provide documentation of an individual training plan.
Employee #7 was hired as an RN on June 27, 2011. The facility failed to provide documentation of an individual training plan.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Effective December 14th we will change our process for performance evaluations for per diem staff to include a training plan. We will also ensure that a training plan is developed for all those staff who currently don't have one as well as establish a training plan for all new hires.
The Senior Director of HR and the Senior Director of Nursing are responsible for compliance. |
715.9(a)(1) LICENSURE Intake
(a) Prior to administration of an agent, a narcotic treatment program shall screen each individual to determine eligibility for admission. The narcotic treatment program shall:
(1) Verify that the individual has reached 18 years of age.
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Observations
Based on the review of patient records, the facility failed to document verification that the individual has reached 18 years of age in one of three patient records.
The findings include:
Three patient records were reviewed November 18, 2015. Three patient records were reviewed for documentation of verification that the individual had reached 18 years of age. Prior to administration of an agent, a narcotic treatment program shall screen each individual to determine eligibility for admission. One patient record did not include the documentation.
Patient #1 was admitted May 31, 2015, transferred to the Inpatient Treatment Program on June 2, 2015 during his taper, and discharged August 27, 2015. The initial dose of Suboxone was given to the patient on June 1, 2015. The facility failed to document verification that the individual had reached 18 years of age prior to administration of Suboxone.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Effective December 14th the
following process will take effect:
1) Admission staff processing an admission will document via admission summary note and place phone call to Charge Nurse when a driver?s license (or another form of photo ID) is not obtained during the admission process.
2) The Charge Nurse during the admission process will check for a driver?s license (or another form of photo ID). This is located in Document Imaging.
3) This check for photo ID by the Charge Nurse will be added to the ?Admission Check List? to assure that this is done.
The Supervisor of Admission and the Senior Director of Nursing is responsible for compliance. |
715.9(a)(2) LICENSURE Intake
(a) Prior to administration of an agent, a narcotic treatment program shall screen each individual to determine eligibility for admission. The narcotic treatment program shall:
(2) Verify the individual 's identity, including name, address, date of birth, emergency contact and other identifying data.
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Observations
Based on the review of patient records, the facility failed to document verification of the individuals identity, including name, address, date of birth, emergency contact and other identifying data, in one of three patient records.
The findings include:
Three patient records were reviewed on November 18, 2015 for compliance in the Buprenorphine waiver, and were required to document verification of the individuals identity. One patient record did not include the documentation.
Patient record #1 was admitted on May 31, 2015, was transferred to the Inpatient Treatment Program on June 2, 2015 during his taper, and was discharged on August 27, 2015. The initial dose of Suboxone was given to the patient on June 1, 2015. The facility failed to document verification of the individuals identity prior to the first administration.
The findings were reviewed with the director and were not disputed.
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Plan of Correction
Effective December 14th the following process will take effect:
1) Admission staff processing an admission will document via admission summary note and place phone call to Charge Nurse when a driver?s license (or another form of photo ID) is not obtained during the admission process.
2) The Charge Nurse during the admission process will check for a driver?s license (or another form of photo ID). This is located in Document Imaging.
3) This check for photo ID by the Charge Nurse will be added to the ?Admission Check List? to assure that this is done.
The Supervisor of Admissions and the Senior Director of Nursing is responsible for compliance. |