INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on August 27-28, 2019 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, WPIC Center for Psychiatric and Chemical Dependency Services 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(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
The facility facility to document that staff persons received and at least 4 hours of tuberculosis, sexually transmitted diseases and other health related topics training within the first year of employment in one of three personnel records.
Thirteen personnel records were reviewed on August 27-28, 2019. Three required STD/TB training.
Employee # 10 was hired as a counselor on June 11, 2018. The training was due to be completed by June 11, 2019. There was no documentation provided that the training had been completed as of August 28, 2019.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
CPCDS Director or designee will ensure that all new staff receive mandatory trainings within one year of hire.
Supervisors shall report on a monthly basis to the Director regarding required trainings and staff progress with this.
All new staff will be made aware of this expectation at orientation.
Employee #10 completed training on 9/11/19. |
715.28(a)(1-10) LICENSURE Unusual incidents
(a) A narcotic treatment program shall develop and implement policies and procedures to respond to the following unusual incidents:
(1) Physical assault by a patient.
(2) Inappropriate behavior by a patient causing disruption to the narcotic treatment program.
(3) Selling of drugs on the premises.
(4) Complaints of patient abuse (physical, verbal, sexual and emotional).
(5) Death or serious injury due to trauma, suicide, medication error or unusual circumstances.
(6) Significant disruption of services due to disaster such as fire, storm, flood or other occurrence.
(7) Incident with potential for negative community reaction or which the facility director believes may lead to community concern.
(8) Theft, burglary, break-in or similar incident at the facility.
(9) Drug related hospitalization of a patient.
(10) Other unusual incidents the narcotic treatment program believes should be documented.
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Observations
The policy and procedures manual was reviewed on August 27-28, 2019. The facility failed to document policies and procedures to respond to unusual incidents.
These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
CPCDS Director will develop and implement policies and procedures by 10/1/19 to respond to the following unusual incidents: (1) Physical assault by a patient, (2) Inappropriate behavior by a patient causing disruption to the program, (3) Selling of drugs on the premises, (4) Complaints of patient abuse (physical, verbal, sexual and emotional, (5) Death or serious injury due to trauma, suicide, medication error or unusual circumstance, (6) Significant disruption of services due to disaster such as fire, storm, flood or other occurrence, (7) Incident with potential for negative community reaction or which facility director believes may lead to community concern, (8) Theft, burglary, break-in or similar incident at the facility, (9) Drug related hospitalization of a patient, (10) Other unusual incidents the narcotic treatment program believes should be documented.
This will be housed in the Program Manual and Director or designee will review with all CPCDS staff by 10/15/19.
Director or designee will review program manual annually to ensure all required policies & procedures are in place. |
711.42(a) LICENSURE Communication w/Law Enforcement
711.42. Client management.
(a) The intake project shall have written policies and procedures for communication with law enforcement authorities, local or State health or welfare authorities, as appropriate, regarding clients whose condition or its cause is reportable; for example, persons having contagious diseases or victims of suspected criminal acts such as rape or gunshot wounds, 18 Pa. C.S. 5106 (relating to failure to report injuries by firearm or criminal act) and child abuse under the Child Protective Services Law (11 P. S. 2201-2224).
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Observations
The policy and procedure manual was reviewed on August 27-28, 2019. The facility failed to document written policies and procedures which included procedures for communicating with law enforcement authorities and procedures for reporting incidents of victims of suspected criminal acts such as rape or gunshot wounds.
The findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
CPCDS Director will develop written policies and procedures by 10/1/19 for communication with law enforcement authorities, local or State health of welfare authorities where appropriate regarding clients whose condition or its cause is reportable; for example persons having contagious diseases, or victims of suspected criminal acts such as rape or gunshot wounds and child abuse under Child Protective Services Law.
This will be housed in the Program Manual and Director or designee will review with CPCDS staff by 10/15/19.
Director or designee will review program manual annually to ensure all required policies & procedures are in place. |
711.42(b) LICENSURE Special Issues Regarding Treatment
711.42. Client management.
(b) The intake project shall have written policies and procedures to address special issues regarding treatment of clients. These policies and procedures shall include, but are not limited to:
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Observations
The facility failed to document written policies and procedures to address special issues regarding treatment of clients which included: individuals who lose consciousness; minors; individuals requiring transfer to a hospital or other treatment facility and individuals requiring detoxification.
These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
CPCDS Director will develop written policies and procedures by 10/1/19 to address special issues regarding treatment of clients including individuals who lose consciousness, minors, individuals requiring transfer to a hospital or other treatment facility and individuals requiring detoxification.
This will be housed in the Program Manual and the Director or designee will review with CPCDS staff by 10/15/19.
Director or designee will review program manual annually to ensure all required policies & procedures are in place. |
711.43(d)(3) LICENSURE Copies of consents
711.43. Client records.
(d) Confidentiality.
(3) A copy of a client consent shall be offered to the client and a copy maintained in the client records.
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Observations
The facility failed to document that a copy of consents were offered to the client in five of nine client records.
Nine client records were reviewed on August 27-28, 2019. Nine were reviewed for consents. In client records # 1, 2, 3, 4 and 7, there was no documentation that the consents were offered to the client.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
CPCDS clinicians will offer a copy of consents to all patients as evidenced by documentation.
All releases will be reviewed by Supervisors prior to sending to medical records to ensure compliance.
This was reviewed with staff on 9/3/19. |
711.92(d) LICENSURE Tx Plan Update
711.92. Treatment and rehabilitation services.
(d) Treatment and rehabilitation plans shall be reviewed and updated at least every 60 days.
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Observations
The facility failed to ensure that treatment and rehabilitation plans were reviewed and updated at least every 60 days in three of nine records reviewed.
Nine records were reviewed on August 27-28, 2019. All required treatment plan updates.
Client # 1 was missing an update due April 7, 2019.
Client # 3 was missing an update due May 22, 2019.
Client # 8 was missing an update due May 22, 2019.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Under the direction of the Director or designee:
All treatment plans will be reviewed and updated every 60 days.
Re-education of staff occurred on 9/3/19 re: requirements for tx plans
Clinical Supervisor or designee will continue monthly chart audits to ensure that treatment plan reviews are in compliance.
Clinical supervisor or designee will ensure that any treatment plan out of compliance will be completed within one week of audit. This is effective 9/3/19.
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