INITIAL COMMENTS
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Based on the concerns arising from COVID-19, The Department of Drug and Alcohol Programs, Bureau of Quality Assurance for Prevention and Treatment, has implemented temporary procedures for conducting an annual renewal inspection.
The inspection will be divided into two parts.
1, an abbreviated off-site inspection, will be conducted off site, and will require the submission of administrative information via email to a Licensing Specialist.
2, an abbreviated on-site inspection, will be conducted on-site at a later date and will include a review of client/patient records, and a physical plant inspection.
This report is a result of Part 2, an abbreviated on-site inspection, conducted on September 8, 2020 by staff from the Department of Drug and Alcohol Programs, Bureau of Quality Assurance for Prevention and Treatment. Not all regulations were reviewed, the remainder of the regulations were reviewed during Part 1.
Based on the findings of Part 2, an abbreviated on-site inspection, Spanish American Civic Association for Equality, 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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709.30 (2) LICENSURE Client rights
§ 709.30. Client rights.
The project shall develop written policies and procedures on client rights and document written acknowledgement by clients that they have been notified of those rights.
(2) The project may not discriminate in the provision of services on the basis of age, race, creed, sex, ethnicity, color, national origin, marital status, sexual orientation, handicap or religion.
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Observations
The project failed to document that the client acknoweldged that they were oriented to their clienr right that the project may not discriminate in the provision of services on the basis of age, creed, ethnicity, national origin, marital status and sexual orientation in one of seven client records reviewed.
Client #2 was admitted on December 11, 2019 and was discharged on January 20, 2020. There was no documentation in the client record that the client was notified of this client right.
These findings were reviewed with project staff during the licensing process.
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Plan of Correction
On September 9, 2020 all current client charts were audited by clinical supervisor to ensure current discrimination was present in charts and signed. Director removed all old forms from drawers and ensured the master chart had the correct from. Clinical supervisor will audit new client charts weekly to ensure compliance. Director retrained admission staff on forms |
709.32 (c) (1) (i) - (ii) LICENSURE Medication control
§ 709.32. Medication control.
(c) The project shall have and implement a written policy and procedures regarding all medications used by clients which shall include, but not be limited to:
(1) Administration of medication, including the documentation of the administration of medication:
(i) By individuals permitted to administer by Pennsylvania law.
(ii) When self administered by the client.
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Observations
The project failed to ensure that they implemented their written procedures regarding the documentation of the administration of all medications used by clients in five out of seven client records reviewed.
Client #1 was admitted on November 14, 2019 and was discharged on February 12, 2020. The client missed dosages of prescribed medications on February 13, 2020; however, the reasons for the missed dosages were not documented in the record. Additionally, one medication was prescribed three times a day; however, the administration of this medication was only signed off on by staff and the client two times a day. Facility staff also failed to sign off on another medication administered on November 18, 2019, November 19, 2019, November 20, 2019 and November 21, 2019.
Client #2 was admitted on December 11, 2019 and discharged on January 20, 2020. The client was prescribed medication #1 on December 4, 2019 and was to take this medication one time per day; however, it was documented that the client took medication #1 two times per day from December 28, 2020 through January 19, 2020. The client was prescribed medication #2 on December 4, 2019 and was to take this medication one time per day; however, it was documented that the client took medication #2 two times per day from December 17, 2019 through December 21, 2019. The client was prescribed medication #3 on December 27, 2019 and was to take this medication one time per day; however, it was documented that the client took medication #3 two times per day from December 29, 2019 through December 31, 2019. There was no documentation in the client's record that the dosages of these medications had been changed by a physician or pharmacist.
Client #3 was admitted on June 13, 2019 and discharged on September 11, 2019. The client missed dosages of prescribed medications from July 1, 2019 through July 26, 2019 and on August 10, 2019; however, the reasons for the missed dosages were not documented in the client record.
Client #6 was admitted on June 22, 2020 and was a current client at the time of the inspection. The client missed dosages of a prescribed medication from June 20, 2020 through August 6, 2020; however, the reasons for the missed dosages were not documented in the client record.
Client #7 was admitted on April 13, 2020 and was a current client at the time of the inspection. The client missed the second dosage of a prescribed medication on July 6, 2020, July 7, 2020, July 11, 2020, July 13, 2020, July 15, 2020, July 16, 2020, July 20, 2020, July 21, 2020, July 26, 2020, July 27, 2020, July 28, 2020 and July 29, 2020; however, the reasons for the missed dosages were not documented in the client record.
These findings were reviewed with project staff during the licensing process.
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Plan of Correction
LPN was called in to do medication training on 9/9/2020 at staff meeting. Staff understood even refusals need to be documented for follow up with prescribing doctor. Weekly medication chart audit will be completed by clinical supervisor weekly for the next 6 months then bi-weekly going forward. Monthly mini medication training by LPN will begin in October 2020 going forward |
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
The project failed to document follow-up information in two of seven client records reviewed.
Client #2 was admitted on December 11, 2019 and was discharged on January 20, 2020. There was no follow-up documentation in this client's record as of the date of the inspection.
Client #4 was admitted on May 14, 2019 and was discharged on July 5, 2019. There was no follow-up documentation in this client's record as of the date of the inspection.
These findings were reviewed with project staff during the licensing process.
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Plan of Correction
Support staff was informed at 9/9/20 meeting of the need to document follow up for ALL discharges no matter the status. Follow up forms will be reviewed for compliance weekly by clinical supervisor for the next 6 months.
Support person was instructed to make all follow up calls for documentation purposes from the last 3 months of discharges |