INITIAL COMMENTS
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This report is a result of a complaint investigation conducted on June 28, 2020, by staff from the Department of Drug and Alcohol Programs, Bureau of Quality Assurance for Prevention & Treatment. Based on the findings of the on-site investigation, 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 investigation and a plan of correction is required.
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Plan of Correction
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709.24 (a) (3) LICENSURE Treatment/rehabilitation management.
§ 709.24. Treatment/rehabilitation management.
(a) The governing body shall adopt a written plan for the coordination of client treatment and rehabilitation services which includes, but is not limited to:
(3) Written procedures for the management of treatment/rehabilitation services for clients.
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Observations
The facility failed to conduct resident checks every 30 minutes according to facility procedure.
As a result of a fatality that occurred at the facility on July 3, 2020, an investigation was initiated. Based on a conversation with facility staff and a review of administrative documentation, resident checks are to be conducted every 30 minutes, and this is to be documented on the " Headcount " sheet, indicating the presence and location of each resident. The facility failed to complete this process for the 3:00 pm and 3:30 pm checks, specifically for client #1, who was on a bed-rest order and was discovered by staff in his dorm room, in an unresponsive state, at approximately 4:00 pm.
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Plan of Correction
The Program Director retrained all staff on the observation policy regarding the completion and documentation of client observation checks every 30 minutes. Staff will conduct the observation of clients every 30 minutes, or as ordered based on client's condition or need, and document on the head count sheet. This training occurred on 7/29/2020. All new staff will be trained during new hire orientation. The Program Director or designee will monitor and audit the roll call sheets. The audits will occur the morning following the day prior. Any discrepancies and/or lack of compliance will be addressed in supervision, which may result in disciplinary action, and up to termination. |
715.6(b)(1-9) LICENSURE Physician Staffing
(b) A narcotic treatment program may employ narcotic treatment physicians to assist the medical director. A narcotic treatment physician 's responsibilities include:
(1) Performing a medical history and physical exam.
(2) Determining diagnosis and determining narcotic dependence.
(3) Reviewing treatment plans.
(4) Determining dosage and all changes in doses.
(5) Ordering take-home privileges.
(6) Discussing cases with the treatment team.
(7) Issuing verbal orders pertaining to patient care.
(8) Assessing coexisting medical and psychiatric disorders.
(9) Treating or making appropriate referrals for treatment of these disorders.
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Observations
The facility failed to complete a history and physical for client #1.
Client #1 was admitted on June 9, 2020 and was discharged on July 3, 2020. The document Medical History and Physical Examination form, dated June 11, 2020, was contained in the patient record, however this document was incomplete; the physical exam biometrics and vital signs were left blank; Family Medical History was blank; Current Medications section was blank; Sections on the form for Skin, Head, Eyes, Ears, Nose/Sinuses, Mouth/Throat, Musculoskeletal, Chest, Lungs, Heart, Abdomen, Genitalia, and Rectal Exam are blank despite each area having an input box available to indicate no dysfunction in the areas identified.
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Plan of Correction
On July 22, 2020 the facility's Program Director met with the Medical Director regarding the facility's policy on the completion of the History and Physical exam. Medical Director was instructed to complete the History & Physical in its entirety. The Program Director has implemented a chart audit tool for Nursing to utilize to ensure thorough documentation on the History and Physical exam. All nursing staff were trained to utilize the chart audit tool on July 28, 2020.Any findings of noncompliance will result in disciplinary action. The Nurse Manager or designee will complete weekly chart reviews and document that the History and Physical exam was completed thoroughly. The Program Director will review charts on a monthly basis to ensure the Nurse Manager is reviewing charts and that the charts are compliant. Any instances of incomplete documentation on the History and Physical exam will be brought to the attention of the Medical Director and Program Director for review and determination of disciplinary action. |
709.53(a)(5) LICENSURE Progress Notes
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:
(5) Progress notes.
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Observations
The facility failed to complete progress notes for client #1.
Based on a review of administrative documentation, including the client record, it was observed that an individual progress not, dated 6/16/2020, had a ' data ' section that was copied and pasted verbatim from the document " WDR/Cove Forge Center for Recovery Diagnostic Summary " .
Additionally, a ' caseload group ' progress note dated 6/19/2020 had the clinicians signatures dated 5/22/2020.
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Plan of Correction
Clinical Director retrained clinical staff on the importance of individualizing group progress notes to the client's progress or lack thereof. This training included to sign and date notes correctly. This training occurred on 9/16/2020 and all new staff will be trained during the new hire orientation. The Clinical Director will complete weekly Compliance and Quality Chart Audits to ensure proper documentation.
The Program Director will complete random monthly chart audits to ensure compliance.
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