INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on February 19 - 20, 2020 by staff from the Department of Drug and Alcohol Programs, Bureau of Quality Assurance for Prevention and Treatment. Based on the findings of the on-site inspection, Resolution Recovery Center LLC 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(a) LICENSURE Staff Development Procedure
704.11. Staff development program.
(a) Components. The project director shall develop a comprehensive staff development program for agency personnel including policies and procedures for the program indicating who is responsible and the time frames for completion of the following components:
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Observations
The facility failed to document a policy and procedure addressing a comprehensive staff development program.
The policy and procedure manual was reviewed on February 19 - 20, 2020. The policy and procedure addresses individual training plans, not a comprehensive staff development program, and does not indicate time frames for completion for the assessment of needs, the overall plan, or the annual evaluation.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Program Director responsible comprehensive staff development plan.
Time Line: Start January and end December; based on one year.
Feedback: every staff that attends a training will complete an agency feedback form. The feedback form will be turned into the program director following each training.
An annual evaluation will take place. All agency feedback forms will be assessed to determine what trainings are appropriate for staff in the future, what trainings need to be added for the future and what trainings are of no use for staff development in the future.
During yearly individual evaluations training needs and future training/educational needs will be addressed with the staff. |
705.9 (4) (i) LICENSURE General safety and emergency procedures.
705.9. General safety and emergency procedures.
The residential facility shall:
(4) Provide written procedures for staff and residents to follow in case of an emergency which shall include provisions for:
(i) The evacuation and transfer of residents and staff to a safe location.
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Observations
The facility failed to document a complete procedure addressing the evacuation and transfer of residents and staff.
The procedure manual was reviewed on February 19 - 20, 2020, and does not include a meeting location or census taking. The procedure also includes references to utilizing an overhead paging system which is not installed in the facility.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Program Director will develop Policy and Procedures for RRC.
RRC will not have a overhead paging system. RRC will utilize walkie-talkies. There will be an adequate number of walkie-talkies for each staff member on each shift. There walkie-talkies will be rechargeable.
The nursing office and admissions office have mounted panic buttons. The nursing office panic button is mounted on the bottom of the table top area. The admissions room panic button is mounted on the bottom of the desk top.
Internal Disaster meeting place: main social area of building.
Incase of a server weather, tornado. Patients will be in the hallway to the left or right of their doors in the fetal position. There is no exposure to glass in the hallway. This will reduce exposure to other items that could cause harm to patients. Nurses, doctors, administrator and floor staff will take census of detox patients. Counselor, Counselor Assistants and Floor Staff will take census of residential patients. There is space available for all staff to protect themselves from exposure; they can also use the hallways with patients and use a fetal position till danger passes. Nurses, doctors, administrator and floor staff will assist in the evacuation and transfer(if necessary) of detox clients. Counselor, Counselor Assistants and Floor Staff will take census of residential patients. Counselor, Counselor Assistants and Floor Staff will assist in the evacuation and transfer(if necessary) of residential clients.
Flood emergency: The meeting place is the central social area for all staff and patients. Nurses, doctors, administrator and floor staff will take census of detox patients. Counselor, Counselor Assistants and Floor Staff will take census of residential patients. Nurses, doctors, administrator and floor staff will take census of detox patients. Nurses, doctors, administrator and floor staff will assist in the evacuation and transfer (if necessary) of detox clients. Counselor, Counselor Assistants and Floor Staff will take census of residential patients. Counselor, Counselor Assistants and Floor Staff will assist in the evacuation and transfer (if necessary) of residential clients.
External Disaster meeting place: The back left corner of the parking lot. This is a safe distance from the building if there is an issue inside the building. Nurses, doctors, administrator and floor staff will take census of detox patients. Counselor, Counselor Assistants and Floor Staff will take census of residential patients. Nurses, doctors, administrator and floor staff will take census of detox patients. Nurses, doctors, administrator and floor staff will assist in the evacuation of detox clients. Counselor, Counselor Assistants and Floor Staff will take census of residential patients. Counselor, Counselor Assistants and Floor Staff will assist in the evacuation of residential clients.
Fire meeting location: The back left corner of the parking lot. This is a safe distance from the building if there is a fire. Staff on shift will take census of patients. Nurses, doctors, administrator and floor staff will take census of detox patients. Counselor, Counselor Assistants and Floor Staff will take census of residential patients.Nurses, doctors, administrator and floor staff will take census of detox patients. Nurses, doctors, administrator and floor staff will assist in the evacuation of detox clients. Counselor, Counselor Assistants and Floor Staff will take census of residential patients. Counselor, Counselor Assistants and Floor Staff will assist in the evacuation and of residential clients.
This would also include natural gas. The back left corner of the parking lot. This is a safe distance from the building if there was a leak of natural gas. Staff on shift will take census of patients. Nurses, doctors, administrator and floor staff will take census of detox patients. Counselor, Counselor Assistants and Floor Staff will take census of residential patients. Nurses, doctors, administrator and floor staff will take census of detox patients. Nurses, doctors, administrator and floor staff will assist in the evacuation of detox clients. Counselor, Counselor Assistants and Floor Staff will take census of residential patients. Counselor, Counselor Assistants and Floor Staff will assist in the evacuation of residential clients.
If displaced for more than 2 hours all patients will be escorted by all shift staff to locale hospital. Hospital is locate adjacent to Resolutions Recovery Center, walking distance of approximately 150 yards. Nurses, doctors, administrator and floor staff will take census of detox patients. Nurses, doctors, administrator and floor staff will assist in the evacuation and transfer of detox clients. Counselor, Counselor Assistants and Floor Staff will take census of residential patients. Counselor, Counselor Assistants and Floor Staff will assist in the evacuation and transfer of residential clients. |
705.10 (a) (1) (iv) LICENSURE Fire safety.
705.10. Fire safety.
(a) Exits.
(1) The residential facility shall:
(iv) Clearly indicate exits by the use of signs.
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Observations
The facility failed to clearly indicate exits by the use of signs.
The physical plant inspection was conducted on February 19, 2020. The exit from the kitchen is not clearly indicated by a sign. That exit leads to another external exit which is not clearly indicated by a sign.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
2 Signs were ordered on 2.19.20. The signs will be up and installed on 2.29.20.
Exit sign in kitchen area, a vinyl exit sign will be placed above door.
A lighted emergency exit sign will be installed above the external door in storage area.
This will be completed by Program Director.
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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
The facility failed to document fire drill records that included all required information.
The fire drill record from July 2019 to February 2020 was reviewed on February 19, 2020. The records do not include exit used or whether the fire alarm or smoke detector was operable.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
There are 2 Fire Logs.
The first log: Live Fire Drill Log. Changes that were made; the documentation now in log indicates which fire alarm was pulled for the testing. The documentation now in the log indicated which exit(s) are being utilized and how many staff and patients exited the building.
The second log: Farrell Fire Department Live Fire Drill Log. Changes that were made; the documentation now in log indicates which fire alarm was pulled for the testing. The documentation now in the log indicated which exit(s) are being utilized and how many staff and patients exited the building.
Program Director is responsible |
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 document a written procedure for the management of treatment services for clients.
The procedure manual was reviewed on February 19 - 20, 2020.
The procedure does not indicate the time frames for completion or who is responsible for psychosocial evaluation, treatment plan, treatment plan update, and progress notes.
The procedure does not include a record of service or a case consultation.
There are two follow-up procedure time frames which are not consistent and do not include who is responsible.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Program Director is responsible for policy and procedure.
Responsible for Psychosocial Evaluation: Program Director, Doctor, Facility Director, RN, LPN, Counselor and Counselor Assistant. This will completed in the intact process; when patient arrives at the facility. All clients complete a psychosocial evaluation at intake.
Responsible for Treatment Plan: Program Director, Doctor, Facility Director, RN, LPN, Counselor and Counselor Assistant. Treatment Plan is developed during the intake process; EMR system generates a treatment plan through the information gathered during the psychosocial evaluation. All patients do a psychosocial evaluation at intake.
Responsible for Treatment Plan Update: Program Director, Doctor, Facility Director, RN, LPN, Counselor and Counselor Assistant. Treatment plan updates will take place every 15 days. If moving from detox to short term stay the update will take place the day of transfer. Interns and volunteers can participate in a treatment plan updates.
Responsible for Progress Note: Program Director, Doctor, Facility Director RN, LPN, Counselor, Counselor Assistant and Floor Staff. Progress Notes completed in all patients daily; each shift provides a progress note on each patient. Interns and volunteers can complete a progress note.
Record of Service is compiled in the EMR system for each patient. All patients information is kept in the EMR system.
Case Consultation will be completed on each patient. Case consults to be completed by Program Director, Doctor, Facility Director RN, LPN, Counselor, Counselor Assistant and Floor Staff. Interns and volunteers can participate in a case consultation. At least one case consultation will take place.
Discharge Planning: all patients that successfully completes the program will have a discharge meeting; increase success after discharge.
Patients leaving AMA will not have a discharge meeting.
Follow Up Procedures: attempted contact with the patient will be completed by:Program Director, Doctor, Facility Director RN, LPN, Counselor, Counselor Assistant and Floor Staff. Interns and volunteers can complete follow up's. Follow up's will take place 3 to 5 days after successful discharge.
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709.24 (a) (4) 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:
(4) Written procedures for referral outlining cooperation with other service providers including, but not limited to, provisions for access to emergency services.
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Observations
The facility failed to document a written procedure for referrals which includes access to emergency services.
The procedure manual was reviewed on February 19 - 20, 2020. The procedure for incoming referrals does not indicate who is responsible, and how it will be documented. The procedure does not include outgoing referrals or the provisions for access to emergency services.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Program Director responsible for policy and procedure.
Incoming Referrals: Program Director, Facility Director, Doctor, RN, LPN, Counselor, Counselor Assistant and Floor Staff can take phone call or address a referral source or future patient in person on the standards to become a patient at RRC. All staff will be trained on interactions, steps and standards that need to take place for a possible referral. Interns and volunteers can participate in referral process.
All referrals will be entered into the EMR system to determine if RRC is an appropriate detox or short term stay program for the referral.
If referral does not meet RRC standard for treatment Program Director, Facility Director, Doctor, RN, LPN, Counselor, Counselor Assistant and Floor Staff may provide possible solutions to the referral. This could be providing direction to a possible treatment facility that will meet the referral needs. Interns and volunteers can participate in this process. Program Director, Facility Director, Doctor, RN, LPN, counselor and counselor assistant will determine if referral in not a good fit for RRC program.
If referral is admitted to RRC and it is later determined that the referral in not a good fit for the Program Director, Facility Director, Doctor, RN, LPN, Counselor, Counselor Assistant and Floor Staff may provide possible solutions to the referral. This could be providing direction to a possible treatment facility that will meet the referral needs. Program Director, Facility Director, Doctor , RN, LPN, Counselor, Counselor Assistant will make phone calls in an attempt to place patient at the best treatment facility that best meets the patients needs. Interns and volunteers can participate in this process. Program Director, Facility Director, Doctor, RN, LPN, counselor and counselor assistant will determine if referral in not a good fit for RRC program.
Access to Emergency Services: For patients having issues related to flu, tooth aches, ear aches and other basic issues a doctor is on call for RRC 24/7. Also, a RN or LPN is on sight 24/7. Physical health issues/needs can be addressed by the doctor and nurses of RRC. Program Director, Doctors, RN and LPN will determine the appropriate level of care for all emergencies.
Health issues that require more than a doctor and nurses care can be addressed by a local emergency room. RRC is located next to UPMC Horizon, Shenango Valley; this is within walking distance. If UPMC Horizon, Shenago Valley cannot provide the services needed Sharon Regional Medical Center is located 1.2 miles from RRC. Transportation by RRC to be provided to any location deemed necessary. Located at Sharon Regional Medical Center is an adult psychiatric unit that will accept adults with mental health needs. Program Director, Doctors, RN and LPN will determine the appropriate level of care for all emergencies. |
709.28 (a) (1) LICENSURE Confidentiality
§ 709.28. Confidentiality.
(a) A written procedure shall be developed by the project director which shall comply with 4 Pa. Code § 255.5 (relating to projects and coordinating bodies: disclosure of client-oriented information). The procedure must include, but not be limited to:
(1) Confidentiality of client identity and records. Procedures must include a description of how the project plans to address security and release of electronic and paper records and identification of the person responsible for maintenance of client records.
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Observations
The facility failed to document a written procedure for the confidentiality of client identity and electronic client records.
The procedure manual was reviewed on February 19 - 20, 2020. The procedure does not address the security of electronic records, or the person responsible for maintenance of the client records.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Program Director responsible for the policy and procedure.
EMR system will be utilized by RRC. The EMR company is compliant with HIPPA, JACHO, CARF and various state agencies. It is a cloud based system. The system if back up daily.
Assess to the EMR system is based upon one's job title. Program Director will have full access to the system. Program Director will determine all RRC employees level of access to the system. Each RRC employee will only have access to the system depending on their job title and responsibilities. Each employee will have his or her own individualized password to the system according to their level of access.
Confidentiality: all patient records are password protected. Depending on job title and responsibilities employees will have limited access to patients records.
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709.32 (c) LICENSURE Medication control
§ 709.32. Medication control.
(c) The project shall have and implement a written policy and procedures regarding all medications used by clients which shall include, but not be limited to:
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Observations
The project shall have and implement a written policy and procedure regarding all medications used by clients.
The policy and procedure manual was reviewed on February 19 - 20, 2020, and does not completely address medications for residential treatment clients. In addition, the policy and procedure states verbal medication orders for detoxification clients will be signed by the physician within 48 hours.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Program Director is responsible for the policy and procedure.
Medication for Residential Treatment Patients: Doctor and nurses are available for residential treatment patients 24/7. A doctor is on call 24/7. Nurses are present at RRC 24/7. If a residential treatment patient is having a physical ailment or issue the doctor can prescribe the correct medication for that ailment. The nurse can provide the patient the medication. No patient will take medication on their own; only provided by the doctor and nurse. The patient is supervised when taking the medication by the doctor or nurse. Program Director will also be notified of physical ailments of the patient. Program Director, Doctor, Nurse, Counselor, Counselor Assistant and Floor Staff can also supervise to make sure the medication was properly taken.
Medication is supplied to RRC through a Pharmacy. The Pharmacy is located 1.0 miles from RRC; they will delivery medication daily or on a as needed basis to RRC. There are proper locking medication cart, refrigeration and security system in place to insure proper handling and distribution of all medication to all patients of RRC.
Verbal Orders: The ordering physician must authenticate the order(s) within 24 hours. Doctor is responsible for this. |
709.32 (c) (5) LICENSURE Medication control
§ 709.32. Medication control.
(5) Security of drugs, including, but not limited to, the loss, theft or misuse of drugs.
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Observations
The project shall have and implement a written policy and procedures regarding the security of drugs, including, but not limited to, the loss, theft or misuse of drugs.
The policy and procedure manual was reviewed on February 19 - 20, 2020, and does not include this policy and procedure.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Program Director is responsible for the policy and procedure.
Refrigeration: A locking refrigerator is placed in the nursing office for any medication needing refrigeration. Nothing else will be placed in the refrigerator beside medication. Program Director, Doctors and Nurses are responsible for the refrigerator and medication inside and distributed from the refrigerator.
Double Locking Medication Cart: A double locking medication cart was provided from the pharmacy to RRC. All medication will be stored in the locking medication cart (refrigerator medication are stored in a locking refrigerator). The medication cart is considered double locking as the first locking system locks the entire medication cart and the second locking devise (metal box) located inside the medication cart with hold the detoxification medication.
Only the nurse on shift will have the keys to access the medication cart for dispensing of the medication. Program Director has a spare set of keys locked in a lock box in his office. Incase of an issue.
The double locking medication cart is located in the nursing office. This is an office that will be locked at all times. One can only gain access to the nurses office with the key. Nurses, doctors and program director are the only staff permitted in the nursing office. A panic button is located in the nurses office. A surveillance camera is also located in the nurses office; these are additional security measures.
Medication will be dispensed through the window of the nursing station to residential treatment patients and detoxification patients. Only if necessary with the medication cart leave the nursing station to dispense medication to detoxification patients and residential treatment patients. There is a surveillance system in place throughout RRC; medication cart will be under video surveillance no matter location within the building.
Pharmacy: the pharmacy technician does an onsite inspection of the medication cart. the pharmacy technician also conduct a review of all medication; a medication count. The pharmacy keeps track of medication.
These checks will ensure of issues related to loss, theft and misuse of drugs.
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