INITIAL COMMENTS
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This report is a result of an on-site licensure renewal and methadone monitoring inspection conducted on October 27, 2021 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-PA, 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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704.11(c)(1) LICENSURE Mandatory Communicable Disease Training
704.11. Staff development program.
(c) General training requirements.
(1) Staff persons and volunteers shall receive a minimum of 6 hours of HIV/AIDS and at least 4 hours of tuberculosis, sexually transmitted diseases and other health related topics training using a Department approved curriculum. Counselors and counselor assistants shall complete the training within the first year of employment. All other staff shall complete the training within the first 2 years of employment.
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Observations
Based on a review of personnel records and the facility's Staffing Requirement Facility Summary Report (SRFSR) form, the facility failed to ensure that employee #4 received the minimum of 6 hours of HIV/AIDS training and at least four hours of TB/STD and other health related topics within the regulatory timeframe.
Employee #4 was hired as a counselor on February 17, 2020 and was due to have the communicable disease trainings no later than February 17, 2021. There was no documentation in the personnel file of the completion of the trainings as of the date of the inspection.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The facility will provide the 6 hours of HIV/AIDS training and 4 hours TB/STD training with Employee #4 to meet regulations. This training will occur and be completed by December 17th. Clinical Supervisor will monitor training requirements to ensure regulation is upheld and Clinic Director will perform audits to monitor. |
715.13(a) LICENSURE Patient identification
(a) A narcotic treatment program shall use a system for patient identification for the purpose of verifying the correct identity of a patient prior to administration of an agent.
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Observations
Based on observation during methadone dosing, the facility failed to follow their policy and procedures manual regarding properly identification of patient prior to administration of an agent. Policy 6.1.1 #7d states "Patients will present at the dispensing window without hats or sunglasses." One patient was dosed without being asked to remove their hat.
The findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
Policy 6.1.1 #7d was reviewed with nursing on 10/27/21 to ensure proper identification of all patients before administering an agent. Nursing supervisor will ensure policy is followed daily and Clinic Director will perform spot checks to monitor. |