INITIAL COMMENTS
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This report is a result of an on-site complaint investigation conducted on February 22, 2016, March 1, 2016, March 9, 2016 and March 10, 2016 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site complaint investigation, The Consortium was found not to be in compliance with the applicable chapters of 28 PA Code which pertain to the facility.
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Plan of Correction
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705.22 (2) LICENSURE Building exterior and grounds.
705.22. Building exterior and grounds.
The nonresidential facility shall:
(2) Keep the grounds of the facility clean, safe, sanitary and in good repair at all times for the safety and well being of clients, employees and visitors. The exterior of the building and the building grounds or yard shall be free of hazards.
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Observations
A Physical plant inspection was conducted on March 1, 2016.
#1 - Tiles that were stained, removed, water damaged.
1st floor
Dosing room
Hallway leading to the dosing area
Exit by the daycare room
Large waiting room
Hallway entrance
Rooms 121, 123, 136 (daycare), 152, 153
2nd floor
Male restroom
Female restrooms
Supervisors open conference area
Physician's waiting area
Lounge area in section 229-232
Rooms 201, 202, 205, 207, 216, 217, 225, 229, 233, 234, 236, 237, 244
#2 - Light fixtures not secured
1st floor
Room 136
2nd floor
Rooms 201, 236
#3 - Corrosion of pipes, a stove and sinks
Nurses' station (stove and sink)
Staff lounge on the first floor in room 154 (2 sinks)
Female restroom on the second floor (under one of the sinks)
Doctors exam room, room 205 (sink)
#4 - Exposed wires causing a tripping hazard
Dosing room by one of the dosing windows (dust build up on the wires)
#5 - Door knob not secured causing a cutting hazard for staff and patients
2nd floor
Doctor's office
#6 - Torn carpets that can cause a tripping hazard
1st floor
Hallway leading to the dosing area
Security office
Rooms 109, 152, 153, 158
Nurses' office
2nd floor
Supervisors open conference area
Physician's waiting area
Rooms 202, 225 and 236
#7 - Stained or dirty carpets
1st floor
Rooms 123, authorized personnel room (room number
not listed), carpets by the water fountain (large waiting area)
2nd floor
Room 225
#8 - Mold and standing water from water damage
1st floor
Two small buckets of dirty water located by two water fountains on the first floor.
One water fountain located in the large group room was dripping water on the carpet.
2nd floor
Lounge area 229-232 closet (major water damage and mold observed in that closet and two trash cans with standing water that hadn ' t been removed).
#9 - Exposed wires
1st floor
Hallway entrance on the first floor (wire hanging down where anyone can pull on)
Hallway leading to the dosing area (an outlet that had a mechanism plugged in, but the wires were sticking out)
Room 158 (wires pulled out from the wall that was located behind patients chairs)
2nd floor
Supervisors open conference room on the second floor
Rooms 202, 207 and 213
#10 - Fan guard removed exposing blades
Room 157
#11 - Cove base pulling away from the walls
Hallway leading to the dosing area,
Female restroom on the 2nd floor
Rooms 121 and 157
#12 - Peeling paint from water damage
Large waiting area on the first floor
Hallway entrance
Rooms 201, 202, 216, 237, 242, 249
Basement wall at exit door leading directly outside
#13 - Broken thermostat
Room 158
#14 - Exposed live wires by water
1st floor
Large waiting area by the water cooler.
#15 - Dirty water coolers with no cups to get the water
Two coolers on the 1st floor and one on the second floor
#16 - Hole in wall
1st floor
Outside the male restroom by the hallway leading to the dosing area.
#17 - Filters that had dirt build up that was not cleaned
Observed throughout the facility
#18 - Exposed electrical box
1st floor
Door of the alarm system was open and not locked exposing the inner wiring system.
#19 - Rodent droppings
Observed rodent dropping in the staff lounge room 154 in the bottom cabinet under the sink.
#20 - Crack in wall, mouse traps, dirty floor, ladder leading to the roof old shirt hanging on the top of the ladder and light issue.
Room located on the 2nd floor off from the elevator.
#21 - Exposed light fixture that seemed to been burnt out
Elevator
#22 - Areas of roof in disrepair and/or not properly sealed
Roof drains
Air Handling Unit
Vent Pipes
Sections where the roof meets the parapet.
#23 - Sections of railing pulling away from ramp railing balusters exposing nails
Exit ramp leading to Children's exterior play area and front of building.
#24- Section of parapet pulling away from the building due to erosion of mortar
Front right corner of building
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Plan of Correction
Plan of Correction:
#1 - Tiles that were stained, removed, water damaged.
All ceiling tiles in the identified areas of the building will be removed/replaced by 6/11/16.
#2 - Light fixtures not secured
All light fixtures in the identified areas will be repaired/replaced by 5/11/16.
#3 - Corrosion of pipes, a stove and sinks
All pipes will be replaced/repaired by 5/27/16.
The stove will be removed by 5/27/16
#4 - Exposed wires causing a tripping hazard.
Dust on the exposed wire will be cleaned by 4/29/16
#5 - Door knob not secured causing a cutting hazard for staff and patients
The Door knob will be repaired by 5/4/16.
#6 - Torn carpets that can cause a tripping hazard
All torn carpeting will be replaced with flooring by 7/26/16
#7 - Stained or dirty carpets
Stained carpeting will be replaced with flooring by 7/26/16. Carpets that can be cleaned will be cleaned and restored by 7/26/16.
#8 - Mold and standing water from water damage
Buckets of water were removed 4/29/16. The roofing issues, which are causing the water damage will be repaired by 7/15/16. Assessment for possible mold will be completed by an external party by 6/30/16.
Fountains will be replaced with new fountains by 5/27/16.
#9 - Exposed wires
All exposed wires will be repaired/covered/or removed by 5/4/16
#10 - Fan guard removed exposing blades
Fan with exposed blades will be removed by 4/29/16
#11 - Cove base pulling away from the walls
Cove based in all areas identified will be repaired/replaced by 6/11/16
#12 - Peeling paint from water damage
Walls identified will be repainted after water damage resulting from roofing issues is completed. Painting will be completed by 7/15/16.
#13 - Broken thermostat
Thermostat will be repaired/replaced by 6/26/16.
#14 - Exposed live wires by water
Live wire will be covered by 4/29/16.
#15 - Dirty water coolers with no cups to get the water
Fountains will be replaced with new fountains by 5/27/16.
#16 - Hole in wall
Hole will be repaired by 5/27/16
#17 - Filters that had dirt build up that was not cleaned
All filters will be inspected. Those that have dirt build up will be thoroughly cleaned and/or replaced by 5/27/16
#18 - Exposed electrical box
Electrical box will be closed/covered by 4/29/16
#19 - Rodent droppings
Exterminator will provide service for rodents and droppings will be cleaned by 5/14/16
#20 - Crack in wall, mouse traps, dirty floor, ladder leading to the roof old shirt hanging on the top of the ladder and light issue.
All issues identified will be repaired/removed/cleaned by 5/27/16
#21 - Exposed light fixture that seemed to been burnt out
Light fixture will be covered and repaired by 6/11/16.
#22 - Areas of roof in disrepair and/or not properly sealed
Roofing repairs in all areas identified will be completed by 7/15/16.
#23 - Sections of railing pulling away from ramp railing balusters exposing nails
Railing will be repaired/replaced by 7/26/16. Children will engage in indoor activity until repairs are completed.
#24- Section of parapet pulling away from the building due to erosion of mortar
Repair will be completed by 6/26/16.
All issues that are caused by the roof, will be repaired by 7/15/16 to allow time to obtain funds and obtain a vendor to complete the job, as well as allow enough time to have the roof repaired correctly.
Responsible Party: The Facilities Department is responsible for ensuring that the facility keeps the grounds of the facility clean, safe, sanitary and in good repair at all times for the safety and well being of clients, employees and visitors.
They are also responsible for ensuring that the exterior of the building and the building grounds or yard is free of hazards.
Ongoing Monitoring:
The Facilities Department will conduct daily rounds of exterior and interior areas of the building to ensure reporting of safety hazards to the Facilities Director within 24 hours.
Facilities Director will ensure prompt repair of all issues identified through daily rounds and reports of safety hazards.
Facilities Director will maintain a log of daily round sheets.
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705.23 (2) LICENSURE Counseling or activity areas and office space
705.23. Counseling or activity areas and office space.
The nonresidential facility shall:
(2) Maintain counseling areas with furnishings which are in good repair.
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Observations
Based on a physical plant inspection conducted on March 1, 2016, the facility failed to maintain furnishings which are in good repair.
The waiting rooms had furniture that were either stained/dirty or torn. Waiting room 229-232 had two couches that were stained and dirty and the doctor's waiting room had two couches that had ripped cushions.
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Plan of Correction
Facilities Personnel will remove all stained/dirty and torn furniture in all rooms identified.
All furniture will be replaced with new or furniture in good repair.
Responsible Party: The Facilities Dept is responsible for maintaining counseling areas with furnishings which are in good repair.
Ongoing Monitoring: The Facilities Dept will ensure that all furniture in the building is assessed during daily rounds and if necessary, furniture removed within 48 hours if not in good repair.
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705.23 (4) LICENSURE Counseling or activity areas and office space
705.23. Counseling or activity areas and office space.
The nonresidential facility shall:
(4) Locate counseling areas so that noise does not disturb or interfere with counseling sessions.
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Observations
Based on observation during the physical plant inspection conducted on March 1, 2016, the facility failed to ensure that counseling sessions could not be heard outside of the counseling room and/or that noise does not disturb or interfere with counseling sessions.
It was observed that group sessions being conducted in group rooms located on the 1st and 2nd floors could clearly be heard in the hallways of the facility.
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Plan of Correction
Sound machines will be ordered for the rooms where sessions can be heard outside of the counseling office. To allow time for ordering and receipt of machines, all sound machines will be in use by 6/30/16. Until machines arrive, and are in place staff will be reminded to ensure sessions keep noise minimal, as to not be heard outside of the group and counseling session offices.
Counselors will also ensure that doors are closed during individual and group sessions.
Responsible Party: All staff is responsible for ensuring that noise cannot be heard outside of the counseling office.
Ongoing Monitoring:
Facilities and Security staff will conduct walk throughs of the hallways outside of the counseling areas daily to ensure noise cannot be heard outside of the session.
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705.24 (5) LICENSURE Bathrooms.
705.24. Bathrooms.
The nonresidential facility shall:
(5) Ventilate bathrooms by exhaust fan or window.
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Observations
Based on a physical plant inspection conducted on March 1, 2016, the facility failed to ventilate bathrooms by an exhaust fan or window.
During the physical plant inspection it was observed that the 10 restrooms inspected all failed to have working exhaust fans.
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Plan of Correction
Exhaust fans in all 10 bathrooms will be repaired or removed. Due to the size and cost of this job,the agency will need until 7/30/16 to have repairs completed.
Responsible Party:
The Facilities Dept is responsible for ensuring ventilation is present in all bathrooms by exhaust fan or window.
Ongoing Monitoring:
Facilities Staff will ensure fans are working properly daily as part of their daily rounds.
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705.24 (7) LICENSURE Bathrooms.
705.24. Bathrooms.
The nonresidential facility shall:
(7) Maintain each bathroom in a functional, clean and sanitary manner at all times.
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Observations
Based on the physical plant inspection conducted on March 1, 2016, the facility failed to maintain each bathroom to be functional, clean and sanitary at all times.
The male restroom located on the first floor by the large waiting room: urinals were dirty, urine was seen on the floor and trash was also located on the floor.
The handicapped restroom located by the elevator had missing tiles which is a cutting hazard for clients and staff.
The female restroom located in the hallway by the dosing room had a sink that was pulling away from the wall.
The female restroom located on the 2nd floor had a sink that was pulling away from the wall, a hole located on the floor in the handicapped stall and eroding/corrode pipes under one of the sinks.
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Plan of Correction
Bathrooms identified were cleaned on 3/23/16. Thereafter, bathrooms will be cleaned 1-2 times daily as part of the Facilities' staff daily rounds.
Sinks that are not attached to the wall will be fixated to the wall by 5/30/16.
Missing floor tiles will be repaired by 6/11/16.
Piping issues will be repaired by 5/27/16.
Responsible Party:
The Facilities Dept is responsible for maintaining each bathroom in a functional, clean and sanitary manner at all times.
Ongoing Monitoring:
Facilities Staff will ensure bathrooms are thoroughly cleaned as part of their daily rounds.
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705.26 (1) LICENSURE Heating and cooling.
705.26. Heating and cooling.
The nonresidential facility:
(1) Shall have a heating and cooling ventilation system that is adequate to maintain an indoor temperature of at least 65F in the winter. When indoor temperatures exceed 90F, mechanical ventilation such as fans or air conditioning shall be used.
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Observations
Based on interviews with facility staff on March 1, 2016, the facility failed to ensure that the heating system was adequate to maintain an indoor temperature of a least 65 F in the winter.
This Licensing Specialist Supervisor talked with staff and was informed that the heating system had not been working for the past few weeks.
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Plan of Correction
The Heating system was repaired on 3.11.16. Additionally, the timer will be modified during the winter months of Oct 1st to April 31st every year to ensure an indoor temperature of 65 degrees.
Additionally, if the heating system malfunctions, the program will take all measures to ensure that system is functional by the end of the next business day.
Responsible Party:
The Facilities Dept is responsible for ensuring that facility has a heating and cooling ventilation system that is adequate to maintain an indoor temperature of at least 65 F in the winter.
Ongoing Monitoring:
The Facilities staff will check temperatures on a daily basis to ensure accurate temperatures during the winter and summer months.
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705.26 (2) LICENSURE Heating and cooling.
705.26. Heating and cooling.
The nonresidential facility:
(2) May not permit in the facility heaters that are not permanently mounted or installed.
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Observations
Based on a physical plant inspection conducted on February 22, 2016 and March 1, 2016, the facility failed to ensure that there were no heaters that were not permanently mounted or installed within the facility.
Security office
Rooms 111, 122, 136 (daycare room), 157, 213, 215, 217, 227, 229 and 244
This is a repeat citation from the licensing renewal/monitoring inspection conducted on July 21, 2015.
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Plan of Correction
The Facility Director will do a walk through of all offices/rooms to ensure that there are no portable heaters on site. All heaters will be removed by those staffs that are found to have heaters that are not mounted.
Responsible Party:
The Facility Director is responsible for ensuring that heaters that are not permanently mounted or installed are not permitted in the building.
Ongoing Monitoring:
The Facilities Staff will check for heaters not permanently installed or mounted as part of their daily rounds.
They will report non compliance to the Facility Director within 1 hour of identification, which will then follow up with staff and ensure removal within the same work day.
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705.27 (3) LICENSURE General safety and emergency procedures.
705.27. General safety and emergency procedures.
The nonresidential facility shall:
(3) Limit smoking to designated smoking areas.
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Observations
Based on a complaint investigation follow-up conducted on March 1, 2016, the facility failed to ensure that patients smoked in a designated smoking area.
The entrance of the building is located on the side of the building and the designated smoking area is located away from that entrance. When entering the front entrance this Licensing Specialist Supervisor had to go around several patients who were either smoking or congregating around the entrance door.
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Plan of Correction
The facility will designate a specific smoking area, which is away from any of the facility entrances to the building, for members and staff to smoke.
Responsible Party:
Facility Director and Security staff are responsible for limiting smoking to designated smoking areas
Ongoing Monitoring: Security Staff will monitor smoking activity to ensure smoking does not occur around any of the facility entrances. Additionally, they will ensure that smoking activity is limited only to the designated smoking area on a daily basis.
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705.28 (c) (3) LICENSURE Fire safety.
705.28. Fire safety.
(c) Fire extinguishers. The nonresidential facility shall:
(3) Ensure fire extinguishers are inspected and approved annually by the local fire department or fire extinguisher company. The date of the inspection shall be indicated on the extinguisher or inspection tag. If a fire extinguisher is found to be inoperable, it shall be replaced or repaired within 48 hours of the time it was found to be inoperable.
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Observations
Based on the physical plant inspection conducted on March 1, 2016, the facility failed to ensure that fire extinguishers were inspected and approved annually.
Room 121, listed as a group room, had a fire extinguisher on the wall near the door and the last time the fire extinguisher was inspected was dated April 2013.
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Plan of Correction
The fire extinguisher in room 121 will be inspected and approved by the local fire dept or extinguisher company.
Responsible Party:
Facilities staff is responsible for ensuring that fire extinguishers are inspected and approved annually by the local fire department or fire extinguisher company.
Ongoing Monitoring. Fire extinguisher tags will be reviewed monthly by the Facilities staff to ensure that the date inspection date is met prior to its expiration.
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705.28 (c) (4) LICENSURE Fire safety.
705.28. Fire safety.
(c) Fire extinguishers. The nonresidential facility shall:
(4) Instruct staff in the use of the fire extinguisher upon staff employment. This instruction shall be documented by the facility.
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Observations
Based on a review of personnel records on March 9, 2016, the facility failed to document the instruction of staff in the use of a fire extinguisher upon staff employment, in personnel record, #1.
Employee # 1 was hired on January 4, 2016. Employee #1's training did not take place until January 28, 2016.
This is a repeat citation from the licensing renewal/monitoring inspection conducted on July 21, 2015.
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Plan of Correction
Staff #1 is no longer with the agency.
Responsible Party: The Facility Director/Supervisor is responsible for ensuring and documenting that staff is trained in the use of the fire extinguisher upon staff employment.
Ongoing Monitoring: The Clinical Supervisor will train new staff within 1 day of hire date. This shall be documented and kept on file by the respective Supervisor.
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705.28 (d) (3) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(3) Ensure that all personnel on all shifts are trained to perform assigned tasks during emergencies.
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Observations
Based on a review of personnel records on March 9, 2016, the facility failed to ensure that all personnel on all shifts were trained to perform assigned tasks during emergencies, personnel record #1.
Employee # 1 was hired on January 4, 2016. The training for assigned tasks during emergencies was documented on January 28, 2016
This is a repeat citation from the licensing renewal/monitoring inspection conducted on July 21, 2015.
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Plan of Correction
Staff #1 is no longer with the agency.
Responsible Party: The Facility Director/Supervisor is responsible for ensuring and documenting that all personnel on all shifts are trained to perform assigned tasks during emergencies
Ongoing Monitoring: The Clinical Supervisor will train new staff within 1 day of hire date. This shall be documented and kept on file by the respective Supervisor.
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705.29 (1) (i) LICENSURE Child care.
705.29. Child care.
When a nonresidential facility admits children for services or for custodial care, the following requirements apply:
(1) Building exterior and grounds. The nonresidential facility shall:
(i) Fence off or have natural barriers to protect children from all areas determined to be unsafe including steep grades, open pits, swimming pools, high voltage boosters or roads.
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Observations
Based on observation during a physical plant inspection conducted on March 9, 2016, the facility failed to provide fencing or barriers to areas determined to be unsafe for children.
The facility lacked a fence or gate from the children's exterior play area leading to the front visitors' parking lot. This parking lot also would allow access to the road.
The facility left the gate opened from the children's play area to the employee parking lot during the entire inspection. This parking lot also would allow access to the road.
The facility had two gas grills located in the children's play area at the time of the inspection.
The facility had a portable basketball hoop and pole that was in disrepair located in the children's play area.
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Plan of Correction
The gate will begin being closed daily on 5/16/16. Additionally a gate in the rear of the children's outdoor play area will be added by 8/25/16.
The outdoor play area will not be utilized until after the gate is added.
The grills in the play area have been removed.
The basketball hoop and pole will be removed by 5/27/16.
Responsible Party:
The Facilities Dept is responsible for ensuring the fencing off or natural barrier to protect children from all areas determined to be unsafe including steep grades, open pits, swimming pools, high voltage boosters or roads.
Ongoing Monitoring:
The childcare staff and the Facilities Dept will assess outdoor grounds daily to ensure that the gates are closed daily and that the area is safe for the children to be outdoors.
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705.29 (2) (i) LICENSURE Child care.
709.29. Child care.
When a nonresidential facility admits children for services or for custodial care, the following requirements apply:
(2) Interior space. The nonresidential facility shall:
(i) Provide an interior play area which meets the developmental and recreational needs of the children in care.
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Observations
Based on the physical plant inspection conducted on March 1, 2016, the facility failed to provide an interior play area which meets the development and recreational needs of the children in care.
The child care room 135, had several items stored in this room that was a safety concern. There was a toaster located on a cart, a vacuum cleaner, bags, an air conditioner and other stored items in this room. The Licensing Specialist Supervisor asked facility staff if children played in this room and the Licensing Specialist Supervisor was told yes the children play in this room.
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Plan of Correction
The Facility Staff will review room 135 for all items identified, as well as any other unsafe items, and ensure all items are removed.
Responsible Party: The Facilities Dept/Child care staff are responsible for
providing an interior play area which meets the developmental and recreational needs of the children in care.
Ongoing Monitoring: The Facilities staff will review room for safety daily as part of their daily rounds. All unsafe items will be removed by the close of business on the same day identified.
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705.29 (2) (ii) LICENSURE Child care.
705.29. Child care.
When a nonresidential facility admits children for services or for custodial care, the following requirements apply:
(2) Interior space. The nonresidential facility shall:
(ii) Maintain security screens or safety locks for all operable windows.
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Observations
Based on a physical plant inspection conducted on March 9, 2016, the facility failed to maintain security screens or safety locks for all operable windows.
The large waiting room, located by the daycare room, had a play area located in the back of the room. There were four operable windows located in the play area. The facility failed to maintain a security screen or safety locks on one of the windows.
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Plan of Correction
The Facilities Staff will add safety screens or safety locks for all windows in the children's section of the 1st floor lobby. The children will play inside of the child care room (#135) until windows are repaired.
Responsible Party: The Facilities staff is responsible for maintaining security screens or safety locks for all operable windows.
Ongoing Monitoring: Facilities will monitor all windows daily as part of their daily rounds to ensure that all locks are properly working, or that all safety screens are in place as required.
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705.29 (2) (iii) LICENSURE Child care.
705.29. Child care.
When a nonresidential facility admits children for services or for custodial care, the following requirements apply:
(2) Interior space. The nonresidential facility shall:
(iii) Maintain protective caps over each electrical outlet.
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Observations
Based on a physical plant inspection conducted on March 1, 2016, the facility failed to maintain protective caps over each electrical outlet.
The large waiting room, located by the daycare room, had a play area located in the back of the room. There were several electrical outlets in the room without protective caps.
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Plan of Correction
All outlets in the children's playroom in room 235, as well as the outlets in the child play area in the 1st floor lobby, will be covered by outlet covers.
Responsible Party:
The Facilities Staff is responsible for maintaining protective caps over each electrical outlet in areas designated as child play areas.
Ongoing Monitoring:
The Childcare staff will report any missing outlet covers within the same day identified.
The Facilities Staff will ensure covering of the outlet by the next business day.
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709.28 (b) LICENSURE Confidentiality
§ 709.28. Confidentiality.
(b) The project shall secure hard copy client records within locked storage containers. Electronic records must be stored on secure, password protected data bases.
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Observations
The physical plant inspections was conducted on February 22, 2016, March 1, 2016 and March 9, 2016. Based on the physical plant inspections, the facility failed to secure hard copy client records within locked storage containers in the Medical Records Room, Nurse Medical Records Room, the basement, the Client Records Room and rooms labeled #134 and #216.
In the Client Medical Records Room, client records were stored on top of file cabinets, inside unlocked opened file cabinets, on the floor and on a desk.
In the Nurse Medical Records Room, there were client records in storage boxes.
In the basement, there in unlocked cabinets, in boxes and trash bags.
Facility employees who should not have access to client records had access to client records located in the basement and rooms labeled #134 and #216.
In addition to storing unsecured client records the following rooms were used for storage:
Room #134: There were Christmas items located in this room.
Room #216: There were air conditioners, a desk, coffee pot, chalk board, electronic equipment, and chairs located in this room. Additionally, the facility director informed this Licensing Specialist Supervisor, during the physical plant inspection, that there were administrative documentation stored in this room.
Basement: Christmas decoration and other miscellaneous items located in this room.
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Plan of Correction
All areas identified that have records stored outside of locked storage containers will have all records stored and locked appropriately.
Responsible Party: The Facility Director/Medical Records Supervisor/Facilities Staff is responsible for ensuring that all records are stored in a locked storage container, while limiting access to unauthorized staff.
Ongoing Monitoring: All rooms will be checked daily by the Facilities staff as part of the daily rounds. Any records not locked in storage containers will be reported as identified to the Facility Director who will resolve the issue within 2 business days.
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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
Ten client records were reviewed on March 9, 2016 and March10, 2016. Of the ten records reviewed the facility released information that exceeded the limitations imposed under 4 Pa. Code 255.5 in one record (Client #1).
Client #1 - There was one letter that was sent out dated January 26, 2016 addressed "to whom it may concern" with identifying client information with no consent to release on file.
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Plan of Correction
The Facility Director will retrain Staff completing releases. Training will focus on the proper completion of treatment consents, as well as non disclosure without the proper signed releases.
Responsible Party: Program Staff of the project are responsible for obtaining an informed and voluntary consent from the client for the disclosure of information contained in the client record.
Ongoing Monitoring: Proper completion of releases will be reviewed by the Clinical Supervisor through the chart review process at least quarterly.
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709.28 (d) LICENSURE Confidentiality
§ 709.28. Confidentiality.
(d) A copy of a client consent shall be offered to the client and a copy maintained in the client record.
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Observations
Ten client records were reviewed on March 9, 2016 and 10, 2016. The facility failed to document whether or not client #7 was offered a copy of the consent to release dated January 11, 2016 for the PCP.
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Plan of Correction
The Facility Director will retrain Staff completing releases. Training will focus on the proper completion of treatment consents, including ensuring that it is evident whether or not the client was offered a copy.
Chart 7 will be reviewed, and will have an updated release completed ensuring that it is evident whether or not the client was offered a copy.
Responsible Party: Program Staff of the project are responsible for ensuring that a copy of client consent is offered to the client and a copy maintained in the client record.
Ongoing Monitoring: Proper completion of releases will be reviewed by the Clinical Supervisor through the chart review process at least quarterly.
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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 the review of the facility's unusual incident reports for the week of March 14, 2016, the facility failed to notify the Department within 3 business days following the unusual incident.
The incident dates are as followed:
February 26, 2016 - Police presence requested
January 5, 2016 - Fire presence requested
October 30, 2015 - Fire presence requested
September 28, 2015 - Police presence requested
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Plan of Correction
The Facility Manager will retrain staff responding to incidents around the timelines of reporting unusual incidents to the Department.
Responsible Party: The Facility Director/Incident Manger are responsible for filing a written unusual incident report with the Department within 3 business days following an unusual incident involving an event at the facility requiring the presence of police, fire or ambulance personnel.
Ongoing Monitoring: The Facility Director will receive all unusual incidents by the close of business for each occurrence to ensure that they are submitted to the Department within 3 days.
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715.12(1-5) LICENSURE Informed patient consent
A narcotic treatment program shall obtain an informed, voluntary, written consent before an agent may be administered to the patient for either maintenance or detoxification treatment. The following shall appear on the patient consent form:
(1) That methadone and LAAM are narcotic drugs which can be harmful if taken without medical supervision.
(2) That methadone and LAAM are addictive medications and may, like other drugs used in medical practices, produce adverse results.
(3) That alternative methods of treatment exist.
(4) That the possible risks and complications of treatment have been explained to the patient.
(5) That methadone is transmitted to the unborn child and will cause physical dependence.
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Observations
Based on the review of patient records on March 9, 2016 and March 10, 2016, the facility failed to ensure the patient signed the informed consent prior to the administration of a narcotic agent in patient record #9.
Patient #9 was admitted October 9, 2015 and a signed consent to administer an agent was not documented in the patient record.
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Plan of Correction
The Facility Director will reiterate to the Narcotic Treatment Physicians, the importance of the patient signing the informed consent prior to the administration of a narcotic agent.
Chart #9 will be reviewed. If the consent is not present, that person will be scheduled to see the onsite physician for review and execution of consent.
Responsible Party:
The Narcotic Treatment Physician is responsible for ensuring that the patient signs the informed consent prior to the administration of a narcotic agent.
Ongoing Monitoring:
The Nurse Manager will review admission charts to ensure that the physician has executed consent prior to receiving the first medication dosage.
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715.19(1) LICENSURE Psychotherapy services
A narcotic treatment program shall provide individualized psychotherapy services and shall meet the following requirements:
(1) A narcotic treatment program shall provide each patient an average of 2.5 hours of psychotherapy per month during the patient 's first 2 years, 1 hour of which shall be individual psychotherapy. Additional psychotherapy shall be provided as dictated by ongoing assessment of the patient.
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Observations
Based on a review of patient records on March 9, 2016 and March 10, 2016, the facility failed to provide each patient an average of 2.5 hours of psychotherapy per month during the patient's first 2 years of treatment in patient records #3, 8 and 10.
Patient #3 was admitted on February 3, 2016. The patient's record only showed documentation of a 1 hour individual session since admission. There was no documentation of a group session since admission.
Patient #8 was admitted on November 10, 2015. The facility failed to document any individual sessions for the month of February 2016.
Patient #10 was admitted on October 20, 2015. The facility failed to document any individual sessions for the month of February 2016.
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Plan of Correction
The Facility Director will retrain staff on psychotherapy service schedules for those who are in treatment 2 years or less. Additionally, members will be notified of the regulation as well to ensure they are attending as scheduled.
Responsible Party:
The Clinical Counseling Staff is responsible for ensuring that those enrolled in treatment for 2 years or less receive at least 2.5 hours of psychotherapy per month during the patient's first 2 years, 1 hour of which shall be individual psychotherapy.
Ongoing Monitoring: Clinical Supervisors will monitor their respective counselor's treatment schedules weekly to ensure that all who are admitted within 2 years are receiving the appropriate amount of service.
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715.20(4) LICENSURE Patient transfers
A narcotic treatment program shall develop written transfer policies and procedures which shall require that the narcotic treatment program transfer a patient to another narcotic treatment program for continued maintenance, detoxification or another treatment activity within 7 days of the request of the patient.
(4) The receiving narcotic treatment program shall document in writing that it notified the transferring narcotic treatment program of the admission of the patient and the date of the initial dose given to the patient by the receiving narcotic treatment program.
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Observations
Based on a review of patient records on March 9, 2016 and March 10, 2016, the facility failed to document, in writing, that it notified the transferring narcotic treatment program of the admission of the patient and the initial dose given in patient record, #9.
Patient #9 was admitted on October 9, 2015 and their initial dose was October 10, 2015.
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Plan of Correction
The Nursing Supervisor will review chart #9. If verification has not yet been made to the transferring clinic that we have admitted their patient, it will be done and documented.
Responsible Party: The Nursing Dept is responsible for documenting in writing that it notified the transferring narcotic treatment program of the admission of the patient and the date of the initial dose given to the patient by the receiving narcotic treatment program.
Ongoing Monitoring: The Nursing Supervisor will review all charts of transferring in members, to ensure verification of enrollment and first dose has been made and documented in the client record.
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715..23(b)(1) LICENSURE Patient records
(b) Each patient file shall include the following information:
(1) A complete personal history.
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Observations
Based on the review of patient records on March 9, 2016 and March 10, 2016, the facility failed to document during the intake process the patient's personal history in patient record #9.
Patient #9 was admitted on October 9, 2015 and the facility did not document their personal history until December 3, 2015 after intake.
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Plan of Correction
Record # 9 will be reviewed by the respective Clinical Supervisor. If the personal history is not documented, the Clinical Supervisor will ensure that the counselor of record completes it as required.
Responsible Party: The Counselor of record is responsible for ensuring that each patient file includes a complete personal history.
Ongoing Monitoring: The Clinical Supervisor will increase monitoring of time sensitive documentation to ensure it is completed as required by the Department.
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715.23(b)(2) LICENSURE Patient records
(b) Each patient file shall include the following information
(2) A complete drug and alcohol history.
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Observations
Based on the review of patient records on March 9, 2016 and March 10, 2016, the facility failed to document during the intake process the patient's drug and alcohol history in patient record #9.
Patient #9 was admitted on October 9, 2015 and the facility did not document their drug and alcohol history until December 3, 2015 after intake.
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Plan of Correction
Record # 9 will be reviewed by the respective Clinical Supervisor. If the complete drug and alcohol history is not documented, the Clinical Supervisor will ensure that the counselor of record completes it as required.
Responsible Party: The Counselor of record is responsible for ensuring that each patient file includes a complete drug and alcohol history.
Ongoing Monitoring: The Clinical Supervisor will increase monitoring of time sensitive documentation to ensure it is completed as required by the Department.
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715.28(c)(1-5) LICENSURE Unusual incidents
(c) A narcotic treatment program shall file a written Unusual Incident Report with the Department within 48 hours following an unusual incident including the following:
(1) Complaints of patient abuse (physical, verbal, sexual and emotional).
(2) Death or serious injury due to trauma, suicide, medication error or unusual circumstances.
(3) Significant disruption of services due to a disaster such as a fire, storm, flood or other occurrence.
(4) Incidents with potential for negative community reaction or which the facility director believes may lead to community concern.
(5) Drug related hospitalization of a patient.
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Observations
Based on the review of the facility's unusual incident reports on March 14, 2016, the facility failed to notify the Department within 48 hours following the unusual incident.
The facility documented in one unusual incident that the facility was notified of the passing of a patient. That unusual incident was never received by the Department for review.
The incident date:
December 5, 2015
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Plan of Correction
Death incident report for patient deceased on 12/5/15 will be completed by the Facility Director.
Responsible Party:
The Facility Director is responsible for filing a written Unusual Incident Report with the Department within 48 hours following an unusual incident including death.
Ongoing Monitoring: The Facility Director will ensure that all death incident reports are completed within 48 hours of notification or verification
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709.91(b)(6) LICENSURE Intake and admission
709.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(6) Psychosocial evaluation.
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Observations
Ten client records were reviewed between March 9-10, 2016. The facility failed to provide documentation of a psychosocial evaluation in client records # 1, 3, 4 and 5.
Client #1 was admitted on August 17, 2015.
Client #3 was admitted on February 3, 2016
Client #4 was admitted on October 16, 2015
Client #5 was admitted on January 15, 2016. The psychosocial evaluation was in the client record and dated January 29, 2016, however, the psychical was incomplete. The facility failed to document the client's problems/needs, assets/strengths, support systems, coping mechanisms, negative factors that may inhibit treatment and/or counselor conclusions and impressions.
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Plan of Correction
Records # 1, 3, 4 and 5 will be reviewed by the respective Clinical Supervisor. If the completed Psycho-social evaluation is not documented, and/or completed fully, the Clinical Supervisor will ensure that the counselor of record completes it as required.
Responsible Party: The Counselor of record is responsible for ensuring that each patient file includes a complete Psycho-social evaluation.
Ongoing Monitoring: The Clinical Supervisor will increase monitoring of time sensitive documentation to ensure it is completed as required by the Department.
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709.92(a) LICENSURE Treatment and rehabilitation services
709.92. Treatment and rehabilitation services.
(a) An individual treatment and rehabilitation plan shall be developed with a client. This plan shall include, but not be limited to, written documentation of:
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Observations
Based on review of client records on March 9, 2016 and March 10, 2016, the facility failed to document an individual treatment and rehabilitation plan in client records, #3, 8, 9 and 10.
Client #3 was admitted on February 3, 2016.
Client #8's individual treatment and rehabilitation plan was not developed during the intake process. The individual treatment and rehabilitation plan was developed on December 28, 2015. Client #8 was admitted on November 10, 2015.
Client #9's individual treatment and rehabilitation plan was not developed during the intake process. The individual treatment and rehabilitation plan was developed on December 31, 2015. Client #9 was admitted on October 9, 2015.
Client #10's individual treatment and rehabilitation plan was not developed during the intake process. The individual treatment and rehabilitation plan was developed on December 1, 2015. Client #10 was admitted on October 20, 2015.
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Plan of Correction
The Intake Supervisor will increase monitoring of initial treatment plan submission to ensure they are being completed as required.
The Intake Worker will email completion of the initial treatment plan to the Intake Supervisor daily to ensure completion.
Responsible Party: The Intake Worker is responsible for completing initial treatment plans on the date of admission.
Ongoing Monitoring: The Intake Supervisor will track and monitor completion of initial treatment plans to ensure they are being done on the date of admission.
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709.92(b) LICENSURE Treatment and rehabilitation services
709.92. Treatment and rehabilitation services.
(b) Treatment and rehabilitation plans shall be reviewed and updated at least every 60 days.
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Observations
Based on a review of patient records on March 9, 2016 and March 10, 2016, the facility failed to document a treatment plan update per regulations in client records, #1 and 8 reviewed.
Client #1 was admitted on August 17, 2015. The last treatment plan update was documented on November 20, 2015.
Client #8 was admitted on November 10, 2015. The comprehensive treatment plan was completed on December 28, 2015.
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Plan of Correction
The Clinical Supervisors will increase monitoring of treatment plan due dates to ensure they are being completed as required.
Responsible Party: The Counselor of record is responsible for ensuring that each patient file includes updated treatment plans every 60 days.
Ongoing Monitoring: Clinical Supervisors will track and monitor completion of treatment plans to ensure they are being done as required.
Clinical Supervisors will review sampling of charts quarterly to ensure all treatment plans completed are in the client record as required.
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