INITIAL COMMENTS
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This report is a result of an on-site provisional license follow-up inspection and complaint investigations conducted on November 12-15, 2024 by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, Angel's Light Addiction Specialists, 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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705.10 (d) (4) LICENSURE Fire safety.
705.10. Fire safety.
(d) Fire drills. The residential facility shall:
(4) Maintain a written fire drill record including the date, time, the amount of time it took for evacuation, the exit route used, the number of persons in the facility at the time of the drill, problems encountered and whether the fire alarm or smoke detector was operative.
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Observations
Based on a review of fire drill logs, the facility failed to maintain fire drill records which included accurate times it took for evacuation.
The fire drill logs for July 2024 - October 2024 were reviewed. The time for evacuation documented for the fire drill conducted on October 9, 2024 was inaccurate. An evacuation time of one hour, from 3:30 PM - 4:30 PM was documented on the fire drill log.
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Plan of Correction
The clinical supervisor and behavioral technician supervisor educated staff on the proper way to document fire drill logs and accurate evacuation times and why this is important.
This will be audited quarterly by the Behavioral Technician Supervisor
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709.28 (c) LICENSURE Confidentiality
§ 709.28. Confidentiality.
(c) The project shall obtain an informed and voluntary consent from the client for the disclosure of information contained in the client record.
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Observations
Based on a review of client records, the facility failed to obtain informed and voluntary consent from the client for the disclosure of information contained in the client record in one of eight client records.
Client #4 was admitted on July 30, 2024 and discharged on August 27, 2024. There was no documentation of a signed informed and voluntary consent to disclose information to a funding source in client record #4. It was confirmed that services were billed for this client.
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Plan of Correction
Effective immediately the admissions department will ensure that accurate ROI will be obtained for the funding source. The assigned primary counselor will audit the chart for the proper ROI documentation for the funding source. |
709.31 (a) LICENSURE Data collection system
§ 709.31. Data collection system.
(a) A data collection and recordkeeping system shall be developed that allows for the efficient retrieval of data needed to measure the project ' s performance in relationship to its stated goals and objectives.
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Observations
Based on a review of client records, the facility failed to develop a data collection and recordkeeping system that allows for the efficient retrieval of data in three of eight client records.
Client #4 was admitted on July 30, 2024 and discharged on August 27, 2024. The client record did not contain documentation of physician medication orders. These medication orders could not be located.
Client #5 was admitted on July 3, 2024 and discharged on August 13, 2024. Client record #5 did not include a medication administration record for the month of July 2024. This medication administration record could not be located.
Client #6 was admitted on August 5, 2024 and discharged September 10, 2024. Client record #6 did not include medication administration records for the month of August and September 2024. These medication records could not be located.
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Plan of Correction
Effective immediately the facility nurse will ensure the scanning of all physician medication orders into client EMR.
Effective immediately the facility nurse will ensure the scanning of all medication administration records into client EMR. The nurse will complete this at the end of each month to ensure a complete client record
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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
Based on a review of client records, the facility failed to document that medications were administered as prescribed in six of eight client records.
Client #2 was admitted on September 21, 2024 and was active at the time of the inspection.
Client #2 was prescribed 100 mg of Gabapentin on October 15, 2024 with instructions to take three times daily. There was no documentation that the client had the 8:00 PM dose of this medication on November 8, 10 and 14, 2024.
Client #2 was prescribed 100 mg of Trazadone on October 15, 2024 with instructions to take once daily at bedtime. There was no documentation that the client had the 8:00 PM dose of this medication on Novenber 1, 2, 13 & 14, 2024.
Client #2 was prescribed 25 mg of Sertraline on September 21, 2024 with instructions to take three tabs daily. There was no documentation that the client was given the medication on September 25-30, 2024.
Client #3 was admitted on October 14, 2024 and was active at the time of the inspection.
Client #3 was prescribed 20 mg of Escitalopram on October 15, 2024 with instructions to take once daily. There was no documentation that the client was given the medication on October 25 & 31, 2024.
Client #4 was admitted on July 30, 2024 and discharged on August 27, 2024.
Client #4 was prescribed 4 mg of Ondansetron to be taken once every six hours, per the medication administration record. The date of the prescription/order is unknown as it was not documented in the client record. There is no docuementation that the client was given the medication every six hours on August 1-9, 2024.
Client #4 was prescribed 20 mg Dicyclomine to be taken three times per day, per the medication administration record. The date of the prescription/order is unknown as it was not documented in the client record. There is no docuementation that the client was given the medication three times per day on August 2-6, 2024.
Client #5 was admitted on July 3, 2024 and discharged on August 13, 2024. It was confirmed that the client was prescribed and taking medications during his treatment stay. There was no medication administration record documented for client #5 for the month of July 2024.
Client #6 was admitted on August 5, 2024 and discharged on September 13, 2024. It was confirmed that the client was prescribed and taking medications during his treatment stay. There was no medication administration records documented for client #6 for the months of August and September 2024.
Client #7 was admitted on August 10, 2024 and discharged on September 13, 2024. Client #7 was prescribed 25 mg of Spironolactone on August 9, 2024 with instructions to take two tabs daily, one at 8:00 AM and one at 4:00 PM. There was no documentation that the client was given the PM dose of the medication August 11-30, 2024.
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Plan of Correction
The facility nurse has educated medication administration staff on proper MAR documentation including all situations such as client refusal of medication, client no show for medication pass, client temporarily admitted to a higher level of care, and client received medication. The Clinical Supervisor has met with the nurse to designate certain medication administration staff for each shift when the nurse is not on shift.
The facility nurse will review medication administration records weekly.
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709.34 (c) (4) 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:
(4) Event at the facility requiring the presence of police, fire or ambulance personnel.
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Observations
Based on a review of unusual incident reports, the facility failed to file a report with DDAP within 3 business days following an event at the facility requiring the presence of police, fire or ambulance personnel.
An incident occurred on September 7, 2024 in which the ambulance was contacted and reported to the facility. There was no documentation that an unusual incident report was filed with DDAP within 3 business days.
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Plan of Correction
The Clinical Supervisor and Project Director met with all staff to go over the protocol for notifying administrative staff of any unusual incident and all situations that would be considered an unusual incident. The Clinical Supervisor and/or Project Director will be responsible for reporting unusual incidents to the department. |
709.52(b) LICENSURE TX Plan update
709.52. Treatment and rehabilitation services.
(b) Treatment and rehabilitation plans shall be reviewed and updated at least every 30 days. For those projects whose client treatment regime is less than 30 days, the treatment and rehabilitation plan, review and update shall occur at least every 15 days.
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Observations
Based on a review of client records and facility policy and procedures, the facility failed to document treatment plan updates every fifteen days, as required by policy and regulation, in three of eight client records.
Client #1 was admitted on September 12, 2024 and was active at the time of the inspection. The individual treatment and rehabilitation plan was documented on September 19, 2024 and a treatment plan update was completed on October 2, 2024. Additional treatment plan updates were due to be completed by October 17 and November 1, 2024. There were no additional treatment plan updates documented in client record #1.
Client #7 was admitted on August 10, 2024 and discharged on September 13, 2024. The individual treatment and rehabilitation plan was documented on August 23, 2024. A treatment plan update was due to be completed by September 7, 2024. There were no additional treatment plan updates documented in client record #7.
Client #8 was admitted on August 29, 2024 and discharged on October 7, 2024. The individual treatment and rehabilitation plan was documented on September 3, 2024. A treatment plan update was completed on September 3, 2024. Additional treatment plan updates were due to be completed by September 18 and October 3, 2024. There were no additional treatment plan updates documented in client record #8.
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Plan of Correction
The Clinical Supervisor and Project Director met with the Clinical staff and reviewed required documentation timelines as well as provided the Clinical staff with a copy of the documentation timeframe policy and procedure.
This will be monitored by the Clinical Supervisor in the form of weekly chart audits.
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709.52(c) LICENSURE Provision of Counseling Services
709.52. Treatment and rehabilitation services.
(c) The project shall assure that counseling services are provided according to the individual treatment and rehabilitation plan.
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Observations
Based on a review of client records, the facility failed to provide counseling services as per the individual treatment and rehabilitation plan in two of seven client records.
Client #1 was admitted on September 12, 2024 and is currently active in treatment. The individual treatment and rehabilitation plan was documented on September 19, 2024, and included that the individual sessions were to be provided weekly and group sessions daily. There was no individual session documented for the week of October 20, 2024.
Client #6 was admitted on August , 2024 and discharged on September 10, 2024. The individual treatment and rehabilitation plan was documented on August 13, 2024, and included that the individual sessions were to be provided weekly and group sessions daily. There was no individual session documented for the week of September 1, 2024.
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Plan of Correction
The Clinical Supervisor and Project Director met with the Clinical staff and reviewed required documentation timelines as well as provided the Clinical staff with a copy of the documentation timeframe policy and procedure.
This will be monitored by the Clinical Supervisor in the form of weekly chart audits.
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709.53(a) LICENSURE Complete Client Record
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:
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Observations
Based on a review of client records, the facility failed to maintain complete client records which included all required documentation in three of eight client records.
Client #4 was admitted on July 30, 2024 and discharged on August 27, 2024. The client record did not contain documentation of physician medication orders.
Client #5 was admitted on July 3, 2024 and discharged on August 13, 2024. Client record #5 did not include a medication administration record for the month of July 2024.
Client #6 was admitted on August 5, 2024 and discharged September 10, 2024. Client record #6 did not include medication administration records for the month of August and September 2024.
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Plan of Correction
Effective immediately the facility nurse will ensure scanning of all physician medication orders and medication administration record into client EMR.
The Clinical Supervisor and Project Director met with staff to discuss the importance of maintaining complete client records
The facility nurse will review medication administration records weekly.
The Clinical Supervisor will monitor this in the form of weekly chart audits.
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709.53(a)(11) LICENSURE Follow-up information
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:
(11) Follow-up information.
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Observations
Based on a review of client records and facility policy and procedure, the facility failed to document follow up in three of four discharged records.
Per the facility policy, follow up is to be completed within twelve hours for against medical advice (AMA) discharged clients, within three days for unplanned discharges and within five days for planned discharges.
Client #4 was admitted on July 30, 2024 and successfully dischared on August 27, 2024. A follow up was due to be completed by September 2, 2024. There was no follow up documented in client record #4.
Client #5 was admitted on July 3, 2024 and successfully discharged on August 13, 2024. A follow up was due to be completed by August 18, 2024. There was no follow up documented in client record #5.
Client #7 was admitted on August 10, 2024 and medically discharged on September 13, 2024. A follow up was due to be completed by September 16, 2024. There was no follow up documented in client record #7.
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Plan of Correction
Effective immediately a lead behavioral technician has been designated to conduct and document all follow-ups.
This will be monitored weekly by the clinical supervisor in the form of supervisor sign-off of completion on the follow-ups.
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