INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection and buprenorphine monitoring inspection conducted on December 15-16, 2016 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Pocono Mountain Recovery Center, LLC. was found to be not in compliance with the applicable chapters of 28 PA Code which pertain to the facility. The following deficiencies were identified during this inspection:
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Plan of Correction
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704.11(c)(1) LICENSURE Mandatory Communicable Disease Training
704.11. Staff development program.
(c) General training requirements.
(1) Staff persons and volunteers shall receive a minimum of 6 hours of HIV/AIDS and at least 4 hours of tuberculosis, sexually transmitted diseases and other health related topics training using a Department approved curriculum. Counselors and counselor assistants shall complete the training within the first year of employment. All other staff shall complete the training within the first 2 years of employment.
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Observations
Based on a review of the facility's Staffing Requirements Facility Summary Report and employee records, the facility failed to ensure that employees, #10 and #11 received the required trainings.
The TB/STD training was due to be completed by 8/27/2016 but was not documented as completed as of the date of the licensing inspection for employee #10.
The TB/STD training was due to be completed by 10/17/2016 but was not documented as completed as of the date of the licensing inspection for employee #11.
This information was reviewed with the facility staff during the licensing inspection.
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Plan of Correction
Employees #10 and #11 in fact did not attend the required training's within their first 2 years of hiring. These include TB/STD for both. These training's have been scheduled and employee #10 and #11 will attend TB/STD on 1/31/17. The Clinical Director and Human Resource Director will assume the role of auditing employee's training manuals. These manuals will be audited once every 2 months. Therefore, training manuals will have been inspected 6 times annually. This will ensure that all employees have attended not only the necessary training's but also training's required for new employees. |
705.6 (3) LICENSURE Bathrooms.
705.6. Bathrooms.
The residential facility shall:
(3) Have hot and cold water under pressure. Hot water temperature may not exceed 120F.
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Observations
The facility failed to ensure hot water temperatures did not exceed 120 degrees in all bathrooms.
A physical plant inspection was conducted on December 16, 2016. The water temperatures in the follow rooms exceeded 120 degrees:
Restroom located in the nursing station sick-bay water temperature was 131.2 #11 bathroom water temperature was 136.5
Room #14 bathroom water temperature was 143.3 #20 bathroom water temperature was 143 #21 bathroom water temperature was 144.1 #23 bathroom water temperature was 140 #26 bathroom water temperature was 130 #1 on the female wing bathroom water temperature was 129.2 #2 on the female wing bathroom water temperature was 130.3 #4 on the female wing bathroom water temperature was 129.2 information was reviewed with facility staff during the licensing process.
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Plan of Correction
The Executive Director and Clinical Director met with maintenance supervisor regarding the hot water situation. A licensed HVAC contractor was hired to repair the hot water that is inclusive of installing hot water holding tanks between rooms. These holding tanks will monitor the hot water by either decreasing or increasing the temperature before entering the rooms. Until this is accomplished, maintenance supervisor will monitor hot water in all rooms especially rooms 11, 14, 21, 26, 29 to ensure the proper 120 degree temperature is maintained. Maintenance supervisor will report his finding 2 times weekly to the Executive Director of Clinical Director. |
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
Based on a review of client records conducted on December 15-16, 2016, the facility failed to limit the disclosure of information to an employer or employer-affiliated EAP (Employee Assistance program) to what is permitted in 4 PA Code 255.5 in the following client records.
Client #1 was admitted on 12/14/16 and was still an active client at the time of the inspection. A consent form to an employer, dated 12/4/16, permitted the release of the client's "Preliminary treatment plan, Medical history, Diagnosis, Progress, discharge summary and Aftercare plan".
Client #12 was admitted on 8/3/16 and was still an active client at the time of the inspection. A consent form to an employer-affiliated EAP, dated 8/3/16, permitted the release of the client's "Preliminary treatment plan, Medical history, Diagnosis, Progress, discharge summary and aftercare plan".
This information was reviewed with the facility staff during the licensing process.
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Plan of Correction
The Medical Records Manager will implement standalone consent forms for employers and employer affiliated EAPs. The new consent form will limit the disclosure of information to an employer or employer affiliated EAP to what is permitted in the PA Code 255.5. The Clinical Director will train all staff on the differentiation between non-affiliated EAPs and employers and affiliated EAPs, disclosure is permitted, and how to complete the new consent form. This will be fully implement by 1/31/2017 which will permit the Clinical Director ample time to train all staff on the new procedure. Employer consents that were implemented for client #1 and client # 2 will be deemed invalid due to be improperly completed. Clients #1 and #2 will be contacted and informed. All consent forms will be monitored by the quality assurance department to ensure this procedure is being adhered to. Quality assurance will forward reports containing any deviations to this procedure to the Clinical Director and Executive Director for additional monitoring. |
715.9(a)(4) LICENSURE Intake
(a) Prior to administration of an agent, a narcotic treatment program shall screen each individual to determine eligibility for admission. The narcotic treatment program shall:
(4) Have a narcotic treatment physician make a face-to-face determination of whether an individual is currently physiologically dependent upon a narcotic drug and has been physiologically dependent for at least 1 year prior to admission for maintenance treatment. The narcotic treatment physician shall document in the patient 's record the basis for the determination of current dependency and evidence of a 1 year history of addiction.
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Observations
Based on a review of client records and a conversation with the facility staff conducted on December 15-16, 2016, the facility failed to comply with the regulation in the following record.
Client #23 was admitted to the detoxification unit on 7/14/16 and discharged on 7/20/2016. The Physician's Assistant conducted the initial assessment and physical examination, which documented the current opiate addiction, however there was no documentation that the narcotic treatment physician signed off on the assessment or physical exam.
This information was reviewed with the facility staff during the licensing inspection.
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Plan of Correction
The Medical Records Manger in conjunction with the Clinical Director and Director of Nursing has developed new documentation which identifies and documents current physiological addiction to opiates. The Medical Director will meet face-to-face with patients prior to prescribing buprenorphine for the purpose of opiate detoxification. Effective 1/23/2017, the Medical Director will sign as acknowledgement that he has assessed for indications of physiological dependence. All intake documentation will be monitored by the quality assurance department to ensure this procedure is being adhered to. Quality assurance will forward reports containing any deviations to this procedure to the Clinical Director and Executive Director for additional monitoring. |
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 a review of client records and a conversation with the facility staff conducted on December 15-16, 2016, the facility failed to comply with the regulation in the following record.
Client #23 was admitted to the detoxification unit on 7/14/16 and discharged on 7/20/2016.
This information was reviewed with the facility staff during the licensing inspection.
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Plan of Correction
The Clinical Director, and medical records manager reviewed the standards requiring facilities to acquire informed consent prior to administration of Buprenorphine. The medical records developed a new form entitled "Buprenorphine Informed Consent", which requires the patient, and nurse's signature. Nurses on all shifts were trained and educated about providing the proper information to patients prior to taking Buprenorphine, and receiving signed consent from each patient prior to administering the medication. The medical records manager entered the new form in the system on 10/10/2016, and the new procedure for obtaining informed consent started 10/10/2016. The quality assurance manager will monitor case records on a weekly basis to ensure that written informed consent is received from each patient prior to administering the medication. The quality assurance manager will forward reports to the Clinical Director and Executive Director for additional monitoring. |
715.15(b) LICENSURE Medication dosage
(b) The narcotic treatment physician shall determine the proper dosage level for a patient, except as otherwise provided in this section. If the narcotic treatment physician determining the initial dose is not the narcotic treatment physician who conducted the patient examination, the narcotic treatment physician shall consult with the narcotic treatment physician who performed the examination before determining the patient 's initial dose and schedule.
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Observations
Based on a review of client records and a conversation with the facility staff conducted on December 15-16, 2016, the facility failed to comply with the regulation in the following record.
Client #23 was admitted to the detoxification unit on 7/14/16 and discharged on 7/20/16. The Physician's Assistant conducted the initial assessment and physical examination, however there was no documentation that the narcotic treatment physician consulted with the Physician's Assistant prior to the initial dose.
This information was reviewed with the facility staff during the licensing inspection.
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Plan of Correction
It is a facility policy for the medical director to conduct an assessment and physical examination prior to the determination of the initial dose of any medication. Effective 1/20/2017 if for any reason it must be conducted by the Physician's assistant, the Physician will review and countersign the assessment and physical examination as acknowledgement. All physical exams and initial assessment will be monitored by the quality assurance department to ensure this procedure is being adhered to. Quality assurance will forward reports containing any deviations to this procedure to the Clinical Director and Executive Director for additional monitoring. |