INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on April 11-12, 2019, by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, 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 inspection.
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Plan of Correction
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704.1-704.2(a) LICENSURE Staffing Compliance Plan
CHAPTER 704. STAFFING REQUIREMENTS FOR DRUG AND ALCOHOL TREATMENT ACTIVITIES
704.1. Scope.
This chapter applies to staff persons employed by drug and alcohol treatment facilities which are licensed or approved under Chapters 157, 709 and 711 (relating to drug and alcohol services; standards for licensure of freestanding treatment activities; and standards for certification of treatment activities which are a part of a health care facility) with the exception of staff persons employed in intake, evaluation and referral facilities as delineated in Chapter 709, Subchapter D (relating to standards for intake, evaluation and referral activities) and Chapter 711, Subchapter C (relating to standards for intake, evaluation and referral activities). Staff persons shall possess the qualifications set forth in this chapter and shall also participate in training as required in this chapter.
704.2. Compliance plan.
(a) The project's governing body shall approve a written compliance plan to insure that the staff persons affected by this chapter meet the appropriate educational and experiential qualifications and receive training as stipulated in this chapter.
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Observations
Based on a review of the project's policy and procedure manual, position descriptions, and an interview with facility staff, the project failed to ensure that the staff persons meet the educational and experiential qualification requirements of chapter 704.
The position description for the Director of Program Management, also known as the Facility Director, does not include the requirement that the person have experience in program planning.
The facility staff stated that their Counselor 2 position, was the equivalent of a counselor as per the Department of Drug and Alcohol Programs staffing regulations. However, the position description for a Counselor 2, only requires a high school diploma, and not an Associate degree or higher.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The HR department ensure the need for experience in program planning as a qualification for the Facility Director role will be added to the system's job description.
The line stating that a high school diploma is acceptable for a Counselor level position will be removed from the Counselor 2 job description by the HR manager. A line stating the education requirement for a counselor is a minimum of an associate's degree in chemical dependency, psychology, social work, counseling, nursing (with a clinical specialty in human services) or other related field.
The executive director's designee will review the project's policies and procedures against DDAP regulations annually to ensure compliance.
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705.7 (b) (6) LICENSURE Food service.
705.7. Food service.
(b) A residential facility may operate a central food preparation area to provide food services to multiple facilities or locations. A residential facility that operates an onsite food preparation area or a central food preparation area shall:
(6) Store all food items off the floor.
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Observations
There was a box filled with bottles of chocolate syrup stored on the floor of the dry food storage area during the physical plant inspection conducted on April 12, 2019.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
On April 15, 2019, the Program Director has trained and instructed all kitchen staff that all food items are to be stored of the floor. Weekly inspections of the kitchen and pantry are will be conducted by the Program Director and/or Maintenance Specialist to ensure compliance. |
709.26 (a) (1) LICENSURE Personnel management.
§ 709.26. Personnel management.
(a) The governing body shall adopt and have implemented written project personnel policies and procedures in compliance with State and Federal employment laws. In addition, the written policies and procedures must specifically include, but are not limited to:
(1) Utilization of volunteers.
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Observations
Based on a review of the project's policy and procedure manual, the project does not have a policy or procedure for utilization of volunteers.
These findings were reviewed with facility during the licensing inspection.
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Plan of Correction
The executive director will create a policy in relation to volunteers for the system.
The executive director's designee will review the project's policies and procedures annually against DDAP regulations to ensure ongoing compliance.
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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
Based on a review of the project's policy and procedure manual, the project's confidentiality policy does not include 4 Pa. 255.5(a)(6) identifying the limitation of information that may be disclosed to employers or prospective employers of the client. In addition, project's policy and procedure manual does not identify the person responsible for maintaining electronic records.
These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
The executive director will revise the confidentiality policy so it includes the limitation of information that may be disclosed to employers of the client.
The executive director will revise the confidentiality policy to include identification of the person responsible for maintaining electronic records.
The executive director's designee will review the project's policies and procedures annually against DDAP regulations to ensure ongoing compliance.
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709.28 (a) (2) 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:
(2) Identification of project staff having access to records, and the methods by which staff gain access.
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Observations
Based on a review of the project's policy and procedure manual, the project's procedures do not address the methods by which staff gain access to electronic records.
These findings were reviewed with facility staff during the licensing inspection
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Plan of Correction
The executive director will revise the confidentiality policy so it addresses the methods by which staff gain access to medical records.
The executive director's designee will review the project's policies and procedures annually against DDAP regulations to ensure ongoing compliance.
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709.28 (c) (2) 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. The consent must be in writing and include, but not be limited to:
(2) Specific information disclosed.
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Observations
The facility failed to ensure that it included all of the required information on its consent to release information forms.
A total of 11 patient records were reviewed during the on-site inspection.
A progress not for Patient #7 dated March 27, 2019, documents that the patient had a counseling session with his father. The patient's signed consent to release information form for the patient's father dated March 19, 2019, did not include counseling as part of the information to be disclosed.
Patient #6's signed consent to release information form for a specific individual dated November 20, 2018, did not include the information to be disclosed.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
On April 16, 2019 an updated Release of Information was initiated to include family counseling in the reason for information to be released when appropriate. On April 18th, Clinical Director reviewed the need for a family counseling release of information form and trained staff on the proper way to complete a Release of information in order to be in compliance of Regulation 709.28. Monthly chart reviews by the Clinical and Program Director are conducted to ensure compliance. |
709.28 (c) (3) 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. The consent must be in writing and include, but not be limited to:
(3) Purpose of disclosure.
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Observations
The facility failed to ensure that it included all of the required information on its consent to release information forms.
A total of 11 patient records were reviewed during the on-site inspection.
Patient #1's signed consent to release information form for another treatment provider dated September 16, 2018, did not include the purpose of the disclosure.
Patient #6's signed consent to release information form for a specific individual dated November 20, 2018, did not include the purpose of the disclosure.
The findings were reviewed with facility staff during the licensing process
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Plan of Correction
On April 18th, Clinical Director reviewed the updated release of information form and trained staff on the proper way to complete a Release of information in order to be in compliance of Regulation 709.28. Monthly chart reviews by the Clinical and Program Director are conducted to ensure compliance. |
709.28 (c) (4) 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. The consent must be in writing and include, but not be limited to:
(4) Dated signature of client or guardian as provided for under 42 CFR 2.14(a) and (b) and 2.15 (relating to minor patients; and incompetent and deceased patients).
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Observations
The facility failed to ensure that it included all of the required information on its consent to release information forms.
A total of 11 patient records were reviewed during the on-site inspection.
Patient #5's consent to release information form for the patient's funding source dated January 24, 2019, has the patient's printed name, but it does not have the patient's signature.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
On April 18th, Clinical Director reviewed the updated release of information form and trained staff on the proper way to complete a Release of information in order to be in compliance of Regulation 709.28. Monthly chart reviews by the Clinical and Program Director are conducted to ensure compliance. |
709.28 (c) (5) 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. The consent must be in writing and include, but not be limited to:
(5) Dated signature of witness.
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Observations
The facility failed to ensure that it included all of the required information on its consent to release information forms.
A total of 11 patient records were reviewed during the on-site inspection.
Patient #2's consent to release information form for the patient's funding source signed by the patient on October 24, 2018, does not have the date that the witness signed the release.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
On April 18th, Clinical Director reviewed the updated release of information form and trained staff on the proper way to complete a Release of information in order to be in compliance of Regulation 709.28. Monthly chart reviews by the Clinical and Program Director are conducted to ensure compliance |
709.30 (2) LICENSURE Client rights
§ 709.30. Client rights.
The project shall develop written policies and procedures on client rights and document written acknowledgement by clients that they have been notified of those rights.
(2) The project may not discriminate in the provision of services on the basis of age, race, creed, sex, ethnicity, color, national origin, marital status, sexual orientation, handicap or religion.
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Observations
Based on a review of the project's policy and procedure manual, the project failed to include in its policies that the project may not discriminate in the provision of services based on age, ethnicity, marital status and/or creed.
In the project's Rights Responsibilities and Ethics (RI), subject "Patients Rights" Policy and Procedure, Under Procedure: A. 1. "creed" is not included.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The executive director will revise the patient rights so they include that the project may not discriminate in the provision of services based on age, ethnicity, marital status and/or creed.
The executive director will add "creed" to the Rights Responsibilities and Ethics subject "Patient Rights" policy and procedure A.1. section.
The executive director's designee will review the project's policies and procedures annually against DDAP regulations to ensure ongoing compliance
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709.32 (c) (2) 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:
(2) Drug storage areas including, but not limited to, the secure storage of controlled substances and other abusable drugs in accordance with State and Federal regulations and program requirements.
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Observations
Based on a review of the project's policy and procedure manual, the project does not have a policy or procedure for documentation of medication administration when self-administered by the client.
These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
The executive director will revise the current policy that exists on medication administration and self-administration so it includes reference to the current self medication documentation form.
The executive director's designee will review the project's policies and procedures annually against DDAP regulations to ensure ongoing compliance.
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709.32 (c) (3) (i) - (v) LICENSURE Medication control
§ 709.32. Medication control.
(3) Inspection of storage areas that ensures compliance with State and Federal laws and program policy. The policy must include, but not be limited to:
(i) What is to be verified through the inspection, who inspects, how often, but not less than quarterly, and in what manner it is to be recorded.
(ii) Disinfectants and drugs for external use are stored separately from oral and injectable drugs.
(iii) Drugs requiring special conditions for storage to insure stability are properly stored.
(iv) Outdated drugs are removed.
(v) Copies of drug-related regulations are available in appropriate areas.
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Observations
Based on a review of the project's policy and procedure manual, the project does not have a policy relating to maintaining copies of drug-related regulations being available in appropriate areas.
These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
The executive director will add a policy that addresses the need to maintain copies of drug-related regulations in appropriate areas to the regional policy and procedure manual.
The executive director's designee will review the project's policies and procedures annually against DDAP regulations to ensure ongoing compliance.
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709.62(c)(v) LICENSURE Physical Examination
709.62. Intake and admission.
(c) Intake procedures shall include documentation of the following:
(5) Physical examination.
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Observations
The facility failed to document a complete physical examination in 3 of 6 detoxification patient records reviewed during the on-site inspection.
The physical examinations for Patient #3, Patient #4 and Patient #5 did not document the patients' vital signs.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
On April 16, 2019 Program Director reviewed with the nursing and medical staff the required documentation of vital signs on the physical examination forms of each patient. Nursing Manager and Clinical Director will review charts on a monthly basis to ensure compliance. |
715.22(b) LICENSURE Patient grievance procedures
(b) The procedure shall permit aggrieved patients a full and fair opportunity to be heard, to question and confront persons and evidence used against them and to have a fair review of their grievances by the narcotic treatment program director. If the grievance is filed against the narcotic treatment program director, the review of the case shall be conducted by either a multi-representative group of the narcotic treatment program or a subcommittee of the governing body instituted for the express purposes of grievance adjudication.
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Observations
Based on a review of the project's policy and procedure manual, the project ' s grievance procedure does not address permitting patients a full and fair opportunity to be heard, to question and confront persons and evidence used against them and to have a fair review of their grievances by the narcotic treatment program director.
Based on a review of the project's policy and procedure manual, the project ' s grievance procedure does not address grievances filed by patients against the narcotic treatment program director.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The executive director will revise the current grievance procedure so it addresses permitting patients to have a full and fair opportunity to be heard, to question and confront persons and evidence used against them and to have a fair review of their grievances by the narcotic treatment program director and to address grievances filed by patients against the narcotic treatment program director.
The executive director's designee will review the project's policies and procedures annually against DDAP regulations to ensure ongoing compliance.
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715.22(c) LICENSURE Patient grievance procedures
(c) Penalties may not be initiated prior to final resolution with the exception that penalties may be initiated against patients who have committed acts of physical violence or who have threatened to commit acts of physical violence in or around the narcotic treatment program premises.
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Observations
Based on a review of the project's policy and procedure manual, the project ' s grievance procedure does not address penalties being initiated against patients prior to the final resolution of grievances.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The executive director will update the grievance procedure to address penalties being initiated against patients prior to the final resolution of grievances.
The executive director's designee will review the project's policies and procedures annually against DDAP regulations to ensure ongoing compliance.
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709.51(b)(5) LICENSURE Physical Examination
709.51. Intake and admission.
(b) Intake procedures shall include documentation of:
(5) Physical examination.
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Observations
The facility failed to document a complete physical examination in 2 of 6 residential and treatment patient records reviewed during the on-site inspection.
The physical examinations for Patient #6 and Patient #7 did not document the patients' vital signs.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
On April 16, 2019 Program Director reviewed with the nursing and medical staff the required documentation of vital signs on the physical examination forms of each patient. Nursing Manager and Clinical Director will review charts on a monthly basis to ensure compliance. |