INITIAL COMMENTS
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This report is a result of an on-site licensure renewal and methadone monitoring inspection conducted on November 15-17, 2016, by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Parkside 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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705.24 (3) LICENSURE Bathrooms.
705.24. Bathrooms.
The nonresidential facility shall:
(3) Have hot and cold water under pressure. Hot water temperature may not exceed 120F.
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Observations
At the time of the onsite inspection, the facility failed to ensure the hot water temperature in all of the bathrooms was 120 degrees Fahrenheit or lower.
The hot water temperature of the second floor women's bathroom was tested at 132 degrees Fahrenheit.
These findings were reviewed with facility staff as part of the inspection process.
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Plan of Correction
The hot water heater for the building was found to be faulty on the day of the inspection. A new hot water heater was installed within 24 hours. Ongoing maintenance will be monitored by Facilities Department in accordance to vendor recommendations. |
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
The facility failed to instruct all of the staff in the use of fire extinguishers upon employment.
Staff Person #6 was hired on 02/22/2016. At the time of the onsite inspection, the facility did not have documentation the staff person was trained in the use of fire extinguishers.
These findings were reviewed with the facility staff as part of the inspection process.
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Plan of Correction
Verification of staff person #6 having training on the use of fire extinguishers prior to the inspection date was submitted within 24 hours of the inspection.
Effective immediately, verification of fire extinguisher safety will be collected by the staff member's assigned hiring manager within 30 days of any new staff members training. |
705.28 (d) (4) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential 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 the facility records during the onsite inspection, the facility failed to ensure all of the required information was documented in the fire drill record.
The exit routes for the fire drill conducted on 07/30/2016, were not documented on the facility's fire drill log.
These findings were reviewed with facility staff as part of the inspection process.
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Plan of Correction
Proper documentation of exit routes used during fire drills was reviewed with the security staff within 24 hours of the inspection date. The Program Director will review all monthly fire drill logs for proper documentation to ensure compliance. |
715.20(1) 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.
(1) The transferring narcotic treatment program shall transfer patient files which include admission date, medical and psychosocial summaries, dosage level, urinalysis reports or summary, exception requests, and current status of the patient, and shall contain the written consent of the patient.
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Observations
The facility failed to ensure the required information from patient records for patients transferring out of the facility were sent to the receiving narcotic treatment facility in 2 of 3 patient records reviewed during the onsite inspection.
Patient #1 was admitted for narcotic treatment on 03/25/2015, and was transferred to another narcotic treatment facility on 11/01/2016, but the patient's file did not contain documentation the required information from the client's file was sent to the other facility.
Patient #2 was admitted for narcotic treatment on 05/27/2016, and was transferred to another narcotic treatment facility on 10/25/2016, but the patient's file did not contain documentation the required information from the client's file was sent to the other facility.
These findings were reviewed with facility staff as part of the inspection process.
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Plan of Correction
Required information for patients transferring out of the facility was reviewed with the clinical staff within 48 hours of the inspection date. Charts will be reviewed in clinical supervision with the Clinical Supervisor to ensure ongoing compliance. |
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
The facility failed to send the required information for patients being transferred in from other narcotic treatment programs, to the facilities where the patients were transferring from in 4 of 4 patient records reviewed during the onsite inspection.
Patient #2 was transferred in from another narcotic treatment program on 05/27/2016, and was discharged 10/25/2016. The facility did not document that it notified the sending narcotic treatment program of the patient's admission or initial dose date.
Patient #8 was transferred in from another narcotic treatment program on 05/18/2016, and was discharged 09/13/2016. The facility did not document that it notified the sending narcotic treatment program of the patient's initial dose date.
Patient #10 was transferred in from another narcotic treatment program on 01/05/2016, and was an active patient at the time of the onsite inspection. The facility did not document that it notified the sending narcotic treatment program of the patient's admission or initial dose date.
Patient #11 was transferred in from another narcotic treatment program on 03/23/2016, and was an active patient at the time of the onsite inspection. The facility did not document that it notified the sending narcotic treatment program of the patient's admission or initial dose date.
These findings were reviewed with facility staff as part of the inspection process.
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Plan of Correction
Required information for patients being referred in to the facility from another narcotic treatment program was reviewed with the clinical staff within 48 hours of the inspection date. Documentation will be reviewed in clinical supervision with the Clinical Supervisor to ensure compliance. |
715.23(c)(1-7) LICENSURE Patient records
(c) An annual evaluation of each patient 's status shall be completed by the patient 's counselor and shall be reviewed, dated and signed by the medical director. The annual evaluation period shall start on the date of the patient 's admission to a narcotic treatment program and shall address the following areas:
(1) Employment, education and training.
(2) Legal standing.
(3) Substance abuse.
(4) Financial management abilities.
(5) Physical and emotional health.
(6) Fulfillment of treatment objectives.
(7) Family and community supports.
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Observations
The facility failed to ensure the annual evaluations for patients were signed by the medical director in 4 of 4 patient records reviewed during the onsite inspection.
Patient #1 was admitted for narcotic treatment on 03/25/2015, and was discharged on 11/01/2016. The patient's annual evaluation for the year 2016 was signed by a staff physician on 03/17/2016, but the evaluation was not signed by the medical director.
Patient #5 was admitted for narcotic treatment on 06/08/2015, and was an active patient at the time of the onsite inspection. The patient's annual evaluation for the year 2016 was signed by a staff physician on 06/02/2016, but the evaluation was not signed by the medical director.
Patient #6 was admitted for narcotic treatment on 05/06/2014, and was an active patient at the time of the onsite inspection. The patient's annual evaluation for the year 2016 was signed by a staff physician on 04/07/2016, but the evaluation was not signed by the medical director.
Patient #9 was admitted for narcotic treatment on 05/07/2013, and was discharged on 10/27/2016. The patient's annual evaluation for the year 2016 was signed by a staff physician on 04/25/2016, but the evaluation was not signed by the medical director.
These findings were reviewed with facility staff as part of the inspection process.
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Plan of Correction
In order to meet the standard there is a two-fold approach:
1. An exception request is being submitted for review to support on-site program physicians to sign the annual evaluation.
2. Until a decision is rendered on the exception request, the Chief Medical Officer will sign any annual evaluations.
This will be monitored by the Program Director and Executive Director to ensure compliance. |
715.24 LICENSURE Narcotic detoxification
If a narcotic treatment program provides narcotic detoxification services, the narcotic treatment program shall develop and implement narcotic detoxification policies and procedures which include the following:
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Observations
The facility failed to provide narcotic detoxification policies and procedures during the annual licensing and methadone monitoring inspection conducted on November 15 - 17, 2016. The facility license includes an Outpatient Detoxification activity, but the facility was not able to provide policy and procedures for that service.
These findings were reviewed with facility staff as part of the inspection process.
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Plan of Correction
The program policy is being revised to clarify the outpatient detoxification activity procedures. Until the policy is approved internally, no short-term detoxification activities will be provided. An anticipated date of policy update is 2/17/2017. |