INITIAL COMMENTS
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Based on the concerns arising from COVID-19, The Department of Drug and Alcohol Programs, Bureau of Quality Assurance for Prevention and Treatment, has implemented temporary procedures for conducting an annual renewal inspection.
The inspection will be divided into two parts.
1, an abbreviated off-site inspection, will be conducted off site, and will require the submission of administrative information via email to a Licensing Specialist.
2, an abbreviated on-site inspection, will be conducted on-site, at a later date and will include a review of client/patient records, and a physical plant inspection.
This report is a result of Part 1, an abbreviated off-site inspection, conducted on August 21, 2020 by staff from the Department of Drug and Alcohol Programs, Bureau of Quality Assurance for Prevention and Treatment. Not all regulations were reviewed, the remainder of the regulations, not reviewed during Part 1, will be reviewed at a later date.
Based on the findings of Part 1, an abbreviated off-site inspection, Snug Harbor Rehabilitation and Recovery 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 procedures for the staff development program.
The assessment procedure does not address existing staff or time frame for completion.
The overall plan does not address who is responsible, or when it will be completed.
The mechanism for feedback does not address who is responsible.
The annual evaluation of the overall training plan does not address who is responsible, or when it will be completed.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Staff Development policy updated.. Employees (both existing and new hires must complete and return their identified training needs document to Program Manager within 10 days after September 1st
This data is reviewed and compiled by Program Manager and Senior Management by September 30th for new training year beginning October 1st.
At the conclusion of each training session staff will be given a questionnaire evaluating the training. This will be collected at the end of the training by Program Manager. Program Manager and senior management will review data and make appropriate corrections to future training years,
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705.7 (b) (5) 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:
(5) Keep cold food at or below 40F, hot food at or above 140F, and frozen food at or below 0F.
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Observations
The facility failed to provide verification of temperatures for the refrigerator and the freezer located in the residential treatment building during the phyiscal plant inspection conducted on January 29, 2020.
705.7b6
The facility failed to store all food items off the floor in the residential treatment building during the physical plant inspection conducted on January 29, 2020.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
A log sheet placed in a binder. This log sheet displays
date and time
temperature
Refrigerator
Freezer
Initials of individuals monitoring temperature.
Cold food stored at 40F degrees and hot food at 140F degrees
Frozen items at 0F degrees
No bottles or containers of food will be stored on the floor. Staff have been educated on proper storage.
This is monitored daily and the initials of the individual performing the procedure listed each day.
Nursing staff will monitor detox facility and House Monitor will record residential units daily.
House Monitor is responsible for recording temperatures daily. |
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 written procedures which include (iii).
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
This policy has been expanded to include the need to have nursing staff assist potential incapacitated
clients in the detox setting for both fire drills and in the event there is an emergency evacuation needed. |
705.10 (a) (1) (i) LICENSURE Fire safety.
705.10. Fire safety.
(a) Exits.
(1) The residential facility shall:
(i) Ensure that stairways, hallways and exits from rooms and from the residential facility are unobstructed.
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Observations
The facility failed to ensure exits from the facility were unobstructed. During the physical plant inspection conducted on January 29, 2020, three of four exits in the detox building were key locked and not accessible.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Stairways, hallways and exits are un-obstructive and free for passing.
The doors changed out from electronic release and or key to push bar exits.
Program Manager and director will monitor this activity and random physical plant inspections will occur daily with use to ensure compliance. |
705.10 (b) (6) LICENSURE Fire safety.
705.10. Fire safety.
(b) Smoke detectors and fire alarms. The residential facility shall:
(6) Maintain all smoke detectors and fire alarms so that each person with a hearing impairment will be alerted in the event of a fire, if one or more residents or staff persons are not able to hear the smoke detector or fire alarm system.
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Observations
During the physical plant inspection conducted on January 29, 2020, the facility failed to ensure a person with a hearing impairment would be alerted in the event of a fire.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The parts have been ordered to repair the short in the strobe lights for hearing impaired individuals to protect them from danger in the event of fire. The repair is expected to be completed on or before 4/15/2020.
Regular inspections are performed by Fire Line on an annual basis.
The Maintenance Department will be responsible for the completion of this repair and ongoing monitoring during weekly checks of facility. |
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 maintain a written fire drill record that included whether the fire alarm or smoke detector was operative in the drills conducted in February, March, April, May(detox), June (detox) and July 2020.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Fire Line performs routine inspections of fire alarm system. Prior to fire drills the Safety Officer ensures alarms (smoke and fire) are operational.
Safety Officer monitors both fire and smoke alarms are operational during 3 to 11 rounds daily. |
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 include who is responsible and how it is documented in written procedures for outgoing referrals.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Policy has been updated to include Intake coordinator with input from Case Manager will be responsible for outgoing referrals and details of which are noted within the clients medical record to include last dose adminitration. |
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
The facility failed to obtain an informed and voluntary consent from the client prior to disclosure of information in four of five clients records reviewed on January 24, 2020.
Client records # 1, 2 and 3 did not document consents for the buprenorphine pharmacy, but information was disclosed.
Client Record #4 - did not document a consent for the insurance company, but a progress note dated on 11-27-2019 documents a phone call regarding authorization.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
A Release of information has been developed for the Pharmacy and for the Insurance(funding)agency specifying information to be released and start and end dates for the ROI.
Intake Counselor is responsible for completion of all consents.
Ultimate monitoring will be by the Program Manager upon chart review weekly.
Current clients will be asked to sign revised consent forms and these forms will be retained within the client medical record. |
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 include the specific information to be disclosed on release of information forms in three of five client records reviewed on January 24, 2020.
Client record #1 included a release of information form for a funding source signed on January 20, 2020. The release form did not identify the specific information to be disclosed; " other " any info needed by insurance company " . A fax form to the funder indicated medication/MAR and treatment plans were disclosed which exceed the parameters of 255.5.
Client record #3 - Release of information for Probation signed on December 30, 2019, does not indicate specific information to be disclosed.
Client record #5 - Release of information signed for another person on December 30, 2019, does not indicate specific information to be disclosed.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Release of Information forms have been revised to include the specific information being released. The "other" box has been eliminated.
Director is responsible for this corrective action form update.
Intake is responsible for the completion of ROI's upon admission.
The program manager will monitor this process during chart audits which will occur weekly.
Current clients will be asked to sign revised forms and this will be retained within the client medical record. |
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 include the purpose of disclosure on release of information forms in five of five client records reviewed on January 24, 2020.
Client record #1 - The purpose of disclosure was not identified on the funding release dated January 20, 2020.
Client record #2- The purpose of disclosure was not identified on three release forms dated on October 4, 2019 and October 7, 2019.
Client record #3 - The purpose of disclosure was not identified on the Probation office release dated December 30, 2019.
Client record #4 - The purpose of disclosure was not identified on a release dated November 15, 2019.
Client record #5- The purpose of disclosure was not identified on two release forms dated on December 30, 2019.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The consent for release of information forms have been revised to include the purpose of the information released. The staff has been educated.
Intake Staff will be responsible for the management of the Release of Information content, accuracy, and signatures as they receive the request.
Program Manager will audit this procedure during chart audits which occur weekly.
Current clients will be asked to sign revised consent forms and this will be retained within the client medical record. |
709.28 (c) (6) 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:
(6) Date, event or condition upon which the consent will expire.
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Observations
The facility failed to include the expiration on the release of information forms in three of five client records reviewed on January 24, 2020.
Client record #1 - The expiration was not identified on the funding release dated January 20, 2020.
Client record #3 - The expiration was not identified on the probation release dated December 30, 2019 for the pharmacy release dated January 2, 2020.
Client record #4 - The expiration was not identified on a release form dated on November 15, 2019.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The staff has been educated again on the process of completing the release of information. There must be a start and end date.
The end date will state clearly upon discharge or other. ROIs have been preprinted with "upon discharge" / or other for end date.
Program Manager will monitor this during regular chart audits which are performed weekly.
Current clients will be asked to sign revised consent forms. This signed form will be retained within the client medical record. |
709.28 (d) LICENSURE Confidentiality
§ 709.28. Confidentiality.
(d) A copy of a client consent shall be offered to the client and a copy maintained in the client record.
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Observations
The facility failed to document a copy of the consents were offered to the client in two of five client records reviewed on January 24, 2020. Client records #2 and #3 included releases that are blank for an offered copy.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The consent forms have been revised so that all include boxes at the bottom of the forms that state
I have received a copy
I have refused a copy
then the client signs.
This is performed in Intake and monitored by the Intake Counselor and Program Manger daily and with weekly chart audits for ongoing compliance.
Current clients will be asked to sign revised consent forms and the newly signed forms will be retained within the client medical record. |
709.30 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.
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Observations
The facility failed to document a client rights procedure for (3), (4), (5), and (6) at the time of the August 21, 2020 administrative review. The documentation of written acknowledgement was also missing all required areas during the client record review on January 22 - 24, 2020.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Client rights policy has been updated to reflect the client right to inspect their records with their counselor present, to appeal the decision limiting client access to certain information within 5 days of review, client right to appeal the decision to limit access also within 5 days of review, the client right to make corrections and to submit a rebuttal within 5 days after discharge or within 5 days after initial review. |
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
The facility failed to document the written acknowledgement included (2) creed, marital status, and sexual orientation. Client records were reviewed on January 24, 2020.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Client Rights in handbook as well as policy has been corrected to include creed, marital status and sexual orientation which were previously omitted.
Current clients will be given the corrected Client Right copy and signature will be requested acknowledging receipt. |
709.32 (b) LICENSURE Medication control
§ 709.32. Medication control.
(b) Verbal orders for medication can be given only by a physician or other medical professional authorized by State and Federal law to prescribe medication and verbal orders may be received only by another physician or medical professional authorized by State and Federal law to receive verbal orders. When a verbal or telephone order is given, it has to be authenticated in writing by a physician or other medical professional authorized by State and Federal law to prescribe medication. In detoxification levels of care, written authentication shall occur no later than 24 hours from the time the order was given. Otherwise, written authentication shall occur within 3 business days from the time the order was given.
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Observations
The facility failed to document a verbal order (VO) is authenticated in writing by the physician within the required time frame in three of five client records reviewed on January 24, 2020.
Client record #2 had VO dated October 4, 2019 that did not include a date on the physician's signature, therefore not able to determine if the VO was signed within 24 hours. This was a detoxification treatment client.
Client record #3 had VO dated December 30, 2019 that did not include a date on the physician's signature, therefore not able to determine if the VO was signed within 24 hours. This was a detoxification treatment client.
Client record #4 had VO dated November 15, 2019 and November 28, 2019 that did not include a date on the physician's signature, therefore not able to determine if the VO was signed within three business days. This was a residential treatment client.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Physicians and staff have been re-educated on this regulation and a tickler system has been implemented as a reminder tool to check dates times and signature of physician orders/ verbal orders.
The Nursing supervisor will review all verbal orders to ensure appropriate signatures within time frame. |
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
The facility failed to document an inspection of storage areas that includes (ii)(iii)(iv) for the detoxification storage area and the residential treatment storage area.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Medication Control Policy and form used for inspection have been updated to include:
1. refrigerated items stored in refrigerator
2. disinfectants stored away from medications
3. outdated medication identified and removed/destroyed
4. medications requiring special storage are appropriately stored.
5. Inspections are completed quarterly by two nurses.
Nurse Manager is responsible for ensuring compliance with this regulation. Storage is monitored daily and report documented by Nurse Manager quarterly at a minimum. |
709.34 (b) (4) LICENSURE Reporting of unusual incidents
§ 709.34. Reporting of unusual incidents.
(b) Policies and procedures must include the following:
(4) Ongoing monitoring of the corrective action plan.
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Observations
The facility failed to document an unusual incident policy and procedure that addresses who is responsible to monitor the corrective action plan.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The unusual event policy has been updated to include the monitoring of any corrections will be done by Program Manager and Senior Management Team. |
709.34 (b) (5) LICENSURE Reporting of unusual incidents
§ 709.34. Reporting of unusual incidents.
(b) Policies and procedures must include the following:
(5) Reporting mechanism to ensure that reporting of an unusual incident to an entity is in compliance with State and Federal confidentiality laws.
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Observations
The facility failed to document an unusual incident procedure that addresses who responsible or how it will be reported.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The policy has been updated to state Snug Harbor will utilize the Pa D and A electronic system. The Nurse Manager will be responsible with entering the data after receiving approval from management team and Nurse manager will retain a copy of report. |
709.63(a)(8) LICENSURE Follow-up Information
709.63. 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:
(8) Follow-up information.
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Observations
The facility failed to document a follow up in two of two applicable detoxification activity client records reviewed on January 24, 2020. Client records #2 and #3 did not include documentation of follow up.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Staff has been re-educated on the importance of clear and concise documentation of client follow-up procedures.
The discharge follow-up form has been discussed in detail with employees.
This process is monitored by Program Manager and supervisors quarterly. |
709.64(a)(1) LICENSURE Purchasing food/equipment
709.64. Project management services.
(a) The inpatient nonhospital project shall have written policies and procedures for its dietetic services which shall include, but not be limited to the following:
(1) Purchasing of food and equipment.
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Observations
The facility failed to document written procedures for dietetic services in the detoxification activity, (a)(1)-(4).
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Both 709.64 and 709.54
have been combined to reflect sameness of procedures for both areas.
In addition should a piece of equipment need repaired or replaced the Property Manager will be called to inspect and repair if he is able. If he is not he notifies Executive Director. An outside repair person will be called for repair of appliance or authorization will be given to replace the appliance and Ex Director will do so and have item delivered.
Food storage is in cabinet and rotated according to date by the house manager.
Foods are appropriately stored and temperatures recorded daily.
Property Manager monitors equipment regularly, at least quarterly. Food storage is monitored ongoing by House Monitor and routinely comepleted daily. |
715.9(a)(1) 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:
(1) Verify that the individual has reached 18 years of age.
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Observations
The facility failed to verify the individual reached 18 years of age in three of three patient records reviewed on January 24, 2020. Three patient records were reviewed for buprenorphine treatment. Client records #1, 2, and 3 did not include the age verification.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The age of 18 years + of the individual will be verified by drivers license or whatever means available including upon funding verification if drivers license is not available.
A photo copy of license will be maintained in the client chart (if available) if not whatever means of verification was used will be documented.
The nursing staff will self monitor this procedure and the Program Manager will monitor it completion quarterly. |
715.9(a)(2) 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:
(2) Verify the individual 's identity, including name, address, date of birth, emergency contact and other identifying data.
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Observations
The facility failed to verify the individual ' s identity in three of three patient records reviewed on January 24, 2020. Three patient records were reviewed for buprenorphine treatment. Client records #1, 2, and 3 did not include the individual ' s identity.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Prior to administration of an agent the client's photo is taken, proof of age (18 or older) is obtained from a form of identification such as a driver's license, the individual's emergency contact information is collected and all information is recorded and kept in the client record.
Nursing staff of detox and Intake Counselors will oversee this process and Program Manager will monitor quarterly. |
715.9(d) LICENSURE Intake
(d) A narcotic treatment program shall explain to each patient treatment options; pharmacology of methadone, LAAM and other agents, including signs and symptoms of overdose and when to seek emergency assistance; detoxification rights; grievance procedures; and clinic charges, including the fee agreement signed by the patient.
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Observations
The facility failed to document the items were explained to each patient in three of three patient records reviewed on January 24, 2020. Three patient records were reviewed for buprenorphine treatment. Client records #1, 2, and 3 did not include documentation.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
In order to provide a better understanding and compliance with this regulation a packet has been prepared for client education when Suboxone ( Buprenorphine) will be used in treatment. In addition a consent to treat using this medication will be explained, signed and witnessed. this document will be recorded in the client record.
The nursing staff will self monitor this procedure with oversight of the Program manager quarterly. |
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
The facility failed to document the informed patient consent for the use of buprenorphine in three of three patient records reviewed on January 24, 2020. Patient records # 1, 2, 3 did not document a patient consent for the use of buprenorphine.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
A Suboxone consent form has been developed for use with both male and female clients receiving this medication in detoxification. This form will be dated, signed and witnessed and placed in the client record. As with all consent s the client is offered a copy of the form.
1. Risks will be explained using the educational tool that has been prepared.
2. Adverse effect possibility explained
3. Alternative treatment discussed.
4. Possible risks and complications discussed with client
5. Risks to unborn children discussed,
This will be monitored by nursing staff in detox and overseen by the Program manager quarterly.
Clients are asked to sign consent forms when receiving buprenorphine. These forms are then retained within the client medical record. |
715.17(c)(1)(i-vi)) LICENSURE Medication control
(c) A narcotic treatment program shall develop and implement written policies and procedures regarding the medications used by patients which shall include, at a minimum:
(1) Administration of medication.
(i) A narcotic treatment physician shall determine the patient 's initial and subsequent dose and schedule. The physician shall communicate the initial and subsequent dose and schedule to the person responsible for the administration of medication. Each medication order and dosage change shall be written and signed by the narcotic treatment physician.
(ii) An agent shall be administered or dispensed only by a practitioner licensed under the appropriate Federal and State laws to dispense agents to patients.
(iii) Only authorized staff and patients who are receiving medication shall be permitted in the dispensing area.
(iv) There shall be only one patient permitted at a dispensing station at any given time.
(v) Each patient shall be observed when ingesting the agent.
(vi) Administering and dispensing shall be conducted in a manner that protects the patient from disruption or annoyance from other individuals.
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Observations
(i) The facility failed to document the medication order was written by the physician in one of three patient records reviewed on January 24. 2020.
Patient record #1 included a medication order for buprenorphine. The order did not include the date and time, and was not written by the physician.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
We have revised the physician order form to clearly state date and time, medication and dosage, route and frequency, start and end date as well as purpose.
Medication control for narcotic treatment policy shall be revised to make clear orders must be written by physician, timed and dated and signed by physician.
This procedure is monitored by the nursing staff and overseen by the program manager and Medical director quarterly. |
715.17(c)(4)(i-viii) LICENSURE Medication control
(c) A narcotic treatment program shall develop and implement written policies and procedures regarding the medications used by patients which shall include, at a minimum:
(4) Method for control and accountability of drugs. A narcotic treatment program shall develop and implement written policies and procedures regarding who is authorized to remove drugs from the storage area and the method for accounting for all stored drugs. An agent or other drug prescribed or administered shall be documented on an individual medication record or sheet in a manner sufficient to maintain an accurate accounting of medication at all times and shall include:
(i) The name of the medication.
(ii) The date prescribed.
(iii) The dosage.
(iv) The frequency.
(v) The route of administration.
(vi) The date and time administered.
(vii) The name of the person administering the medication.
(viii) The take-home schedule, if applicable.
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Observations
(vi) The facility failed to document the time administered on the Buprenorphine Medication Administration Record in patient record #3 reviewed on January 24, 2020. Patient #3 was given buprenorphine on January 1, 2020, but no time was indicated on the MAR.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Nursing staff and physicians have been re-educated on dating and timing of medication administration.
This is monitored by nursing staff, medical director quarterly. |
715.20 LICENSURE Patient transfers
A narcotic treatment program shall develop written transfer policies and procedures which shall require that the narcotic treatment program transfer a patient to another narcotic treatment program for continued maintenance, detoxification or another treatment activity within 7 days of the request of the patient.
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Observations
The facility failed to document a written transfer procedure that includes who is responsible and how it will be documented.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The policy has been updated to include the responsibility belongs to the Intake Coordinator with input from Case Manager and Counseling for outgoing referrals.
This information is documented in the clients chart by Intake, Counseling, CASE Manager. Included in this information is documented last dose of medication, dosage, frequency prior to transfer/outgoing referral when appropriate.
On going monitoring will be responsibility of Program Manager and Senior Management Team. |
715.26(b) LICENSURE Security
(b) Each narcotic treatment program shall provide the Department with a specific plan describing the efforts it will make to avoid disruption of the community by its patients and the actions it will take to assure responsiveness to the community. This plan shall designate a staff member to act as community liaison.
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Observations
The facility failed to designate a staff member to act as community liaison.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
This policy has been updated to state more clearly the Community Liaison is our Marketing Person. |
709.51(b)(6) LICENSURE Psychosocial evaluation
709.51. Intake and admission.
(b) Intake procedures shall include documentation of:
(6) Psychosocial evaluation.
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Observations
The facility failed to document a psychosocial evaluation in two of two client records reviewed on January 24, 2020. Two client records were reviewed for the residential treatment activity. Client records #4 and #5 did not include a psychosocial evaluation.
Client record #4 was admitted on November 14, 2019 and discharged on November 29, 2019.
Client record #5 was admitted on December 30, 2019 and discharged on January 21, 2020.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Intake personnel has been re-educated on the psychosocial completion. Counselors should complete this process on day 2 of intake into detoxification and on day 3 of residential if detox was not performed on campus.
Intake counselors will perform this process and Project Manager will oversee this will be monitored quarterly. |
709.53(a) LICENSURE Complete Client Record
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:
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Observations
The facility failed to document a complete client record in two client records reviewed for the residential treatment activity on January 24, 2020.
(a)(3) - A record of service was not documented in two of two client records, records #4 and #5.
(a)(10) - A discharge summary was not documented in one of two client records. Client record #4 did not include a discharge summary.
(a)(11) - Follow-up information was not documented in two of two client records, records #4 and #5.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The staff has been re-educated on the content to be included in the client record.
Emphasis is placed on services provided to the client, discharge summary and follow-up after discharge which will be part of the client record.
Project manager will oversee and monitor this procedure by weekly charts audits. |
709.54(a)(1) LICENSURE Purchasing food/equipment
709.54. Project management services.
(a) An inpatient nonhospital project shall have written policies and procedures for its dietetic services which include, but are not limited to:
(1) Purchasing of food and equipment.
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Observations
The facility failed to document written procedures for dietetic services in the residential treatment activity, (a)(1)-(4).
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
This policy has been combined with 709.64 as services are a duplicated for detox and residential:
food preparation
equipment breakdown
food storage
stock rotation |