INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on April 10-11, 2018, by staff from the Division of Drug and Alcohol Program Licensure. 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 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 facility records conducted during the on-site inspection, the facility failed to include all of the required information on its fire drill records.
The fire drill record for the fire drill conducted on 10/22/2017, did not document the number of persons in the building during the time of the drill.
These findings were reviewed with facility staff as part of the inspection process.
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Plan of Correction
All monthly fire drills and emergency drills will be thoroughly documented by the safety manager as to the number of people participating in the drill, number of people in the building, which exit is used, exit time and any unusual encounters. The safety manager will also make note if a smoke alarm or hard wired alarm was used. After each drill is completed the safety manager will document the event in the emergency/fire drill log. The facility director will review the documentation monthly. |
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 a review of patient records conducted during the on-site inspection, the facility failed to obtain the proper intake documentation for 2 of 3 narcotic treatment patient records reviewed.
Client #1 was admitted for narcotic treatment on 12/12/2017, and was dosed with a narcotic agent on 12/13/2017, but the facility did not obtain an acceptable form of identification for the patient.
Client #3 was admitted for narcotic treatment on 01/09/2018, and was dosed with a narcotic agent on 01/10/2018, but the facility did not obtain an acceptable form of identification for the patient.
These findings were reviewed with facility staff as part of the inspection process.
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Plan of Correction
All clients being admitted into this facility, regardless of level of care, must present upon admission, a state issued ID, passport or a photo ID with address and/or birth date. The admissions coordinator will make a copy of the ID and it will be available for review in the client's chart. Monthly chart checks, by the clinical supervisor , will verify that this process is being done. |
715.9(a)(4) 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:
(4) Have a narcotic treatment physician make a face-to-face determination of whether an individual is currently physiologically dependent upon a narcotic drug and has been physiologically dependent for at least 1 year prior to admission for maintenance treatment. The narcotic treatment physician shall document in the patient 's record the basis for the determination of current dependency and evidence of a 1 year history of addiction.
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Observations
Based on a review of patient records conducted during the on-site inspection, the facility failed to properly screen patients in 2 of 3 patient records reviewed.
Patient #1 was admitted for narcotic treatment on 12/12/2017, and was dosed with a narcotic agent on 12/13/2017, but the face-to-face determination of whether the individual was currently physiologically dependent upon a narcotic drug was performed by a certified nurse practitioner and not a narcotic treatment physician.
Patient #3 was admitted for narcotic treatment on 01/09/2018, and was dosed with a narcotic agent on 01/10/2018, but the face-to-face determination of whether the individual was currently physiologically dependent upon a narcotic drug was performed by a certified nurse practitioner and not a narcotic treatment physician.
These findings were reviewed with facility staff as part of the inspection process.
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Plan of Correction
Upon admission for narcotics treatment clients will be thoroughly screened thru a face to face review by the narcotics treatment physician. The narcotic treatment physician shall document in the patients record the basis for the determination of the current dependency and evidence of a one year addiction history.
This will be monitored by the Director of Medicine for the facility. |
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 facility records conducted during the on-site inspection, the facility failed to document treatment plan updates at least once every 15 days in 4 of 5 applicable client records reviewed. The facility's treatment regimen is less than 30 days.
Client #9 was admitted for treatment on 01/05/2018, and discharged on 1/29/2018. The client's individualized treatment plan was dated 01/08/2018, but the client's treatment plan was never updated.
Client #10 was admitted for treatment on 12/31/2017, and discharged on 1/28/2018. The client's individualized treatment plan was dated 01/06/2018, but the client's treatment plan was never updated.
Client #12 was admitted for treatment on 12/18/2017, and discharged on 1/15/2018. The client's individualized treatment plan was dated 12/21/2017, but the client's treatment plan was never updated.
Client #13 was admitted for treatment on 11/06/2017, and discharged on 12/20/2017. The client's individualized treatment plan was dated 11/13/2017, but the client's treatment plan was never updated.
These findings were reviewed with facility staff as part of the inspection process.
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Plan of Correction
Treatment plan updates will be completed at least once every 15 days as per DDAP regulations. This will be initiated by the primary therapist and review by the clinical supervisor for completion. Weekly clinical team meetings will review the treatment plan updates for content and timeliness. |
709.53(a)(10) LICENSURE Discharge Summary
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:
(10) Discharge summary.
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Observations
Based on a review of facility records conducted during the on-site inspection, the facility failed to document complete client records in 2 of 5 applicable records reviewed.
Client #9 was discharged from treatment on 01/29/2018, but there was no discharge summary for the client.
Client #10 was discharged from treatment on 01/28/2018, but there was no discharge summary for the client.
These findings were reviewed with facility staff as part of the inspection process.
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Plan of Correction
Primary therapists will document the completion of a clients treatment by including a discharge summary for each closed chart.
The clinical supervisor will review and audit each closed chart making sure there is a complete record of the client's treatment history, including but not limited to, the discharge summary. |