INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on January 4, 2021 by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, Crisis Management Services, Inc. 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(b)(1) LICENSURE Individual training plan.
704.11. Staff development program.
(b) Individual training plan.
(1) A written individual training plan for each employee, appropriate to that employee's skill level, shall be developed annually with input from both the employee and the supervisor.
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Observations
The facility failed to ensure that a written individual training plan was developed annually for each employee, appropriate to that employee's skill level, with input from both the employee and the supervisor in one of five personnel records reviewed.Employee #1 was hired as the Project Director on July 1, 2014. The individual training plan was signed by the employee on January 7, 2020; however, there was no documented evidence that there was input from the supervisor. These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Chief Executive Officer of CMS will provide input, review, and sign the Project Director's training plan at the beginning of each training year. This has already been implemented and the Project Director's training plan was signed for this training year by the Chief Executive Officer on 1-20-21.
The Facility Director will ensure that the Project Director's training plan is completed. The Facility Director and Projector Director will develop training plans for all other staff members at the beginning of each training year or within 90 days of a new hire. The Project Director or Facility Director will sign each training plan as developed.
The Facility Director will ensure all training plans are completed monthly.
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705.10 (c) (3) LICENSURE Fire safety.
705.10. Fire safety.
(c) Fire extinguisher. The residential facility shall:
(3) Ensure fire extinguishers are inspected and approved annually by the local fire department or fire extinguisher company. The date of the inspection shall be indicated on the extinguisher or inspection tag. If a fire extinguisher is found to be inoperable, it shall be replaced or repaired within 48 hours of the time it was found to be inoperable.
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Observations
The facility failed to ensure that all fire extinguishers were inspected and approved annually by the local fire department or fire extinguisher company. Based on a physical plant inspection, there was a fire extinguisher located outside the group room that was last inspected in November 2019. These findings were reviewed with facility staff as part of the inspection process.
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Plan of Correction
One of the fire extinguishers was missed during an annual inspection and servicing of all extinguishers. The extinguisher that was not in compliance was in the hallway. That fire extinguisher was inspected and serviced by Schweizer Alarm Company on 1-6-21.
Going forward, all fire extinguishers will be inspected and serviced by Schweizer Alarm Company.
The inspection will occur every November and the Facility Director will review the tags by the end of November of each calendar year.
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705.10 (d) (5) LICENSURE Fire safety.
705.10. Fire safety.
(d) Fire drills. The residential facility shall:
(5) Conduct a fire drill during sleeping hours at least every 6 months.
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Observations
The facility failed to ensure that a fire drill was conducted during sleeping hours at least every six months. Based on review of the fire drill log, the facility comducted a fire drill during sleeping hours in January 2020; however, an additional overnight fire drill was not completed within the next six-months. These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Facilities/Maintenance Department will conduct fire drills during the overnight (sleeping hours) with one occurring in at the least January and June of each calendar year. All other monthly fire drills will vary in times. We completed one on 1-22-21 at 12:05 am.
The Facility Director will ensure that all fire drills are conducted according to the policy and documented into the fire drill log.
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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 a written informed and voluntary consent to release information form from the client for the disclosure of information contained in the client record in two of nine client records reviewed.Client # 7 was admitted on November 4, 2020 and was active at the time of the inspection. There was documentation of staff contact and a disclosure of client information to another treatment provider on December 30, 2020 and December 31, 2020; however, there was no consent to release information form signed by the client documented in the record prior to the disclosures.Client # 8 was admitted on October 7, 2020 and discharged on November 6, 2020. There was documentation of a disclosure of information to a pharmacy on October 8, 2020; however, there was no consent to release information form signed by the client documented in the record prior to the disclosures.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The active clients that were missing release of information forms were completed and signed on 1/6/2021.
The Project Director will conduct a training for clinical personnel regarding releases of information. The in-service will cover the legal and ethical obligations of obtaining consent to release information. This will be conducted by the Project Director and completed by 1-29-21.
In addition to the in-service conducted by the Project Director, all staff will complete the DDAP confidentiality training by 2-15-21. The Facility Director will ensure that all staff members completed the training and the training certificates will be placed in each staff members' training file.
The Facility and or Project Director will review the charts monthly to ensure that all staff is completing informed consents for all external contacts according to State, Federal, and program guidelines.
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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 obtain an informed, voluntary, written consent before an agent may be administered to the patient for either maintenance or detoxification treatment in three of three applicable client records reviewed.Client #7 was admitted on November 4, 2020 and was active at the time of the inspection.Client #8 was admitted on October 7, 2020 and was discharged on November 6, 2020.Client #9 was admitted on August 28, 2020 and was discharged on September 23, 2020. These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
A consent to treatment form was created on 1-15-21 specifically for the treatment of a narcotic agent. The Facility Director will meet with all medical personnel by 1-28-2021 to review the purpose and distribution of the consent to treatment form specifically dedicated to narcotic agents.
The consent to treatment form specifically dedicated to narcotic agents will be implemented on 1-29-21.
The Facility Director will review the clients records monthly to ensure that the distinctive consents are completed.
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709.53(a)(8) LICENSURE Case Consultation Notes
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:
(8) Case consultation notes.
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Observations
The facility failed to maintain a complete client record, which is to include case consultations, in three of nine client records reviewed.Client #1 was admitted on April 5, 2020 and discharged on June 8, 2020. There was no documentation of case consultation notes during the treatment episode. Client #2 was admitted on June 26, 2020 and discharged on August 24,2020. There was no documentation of case consultation notes during the treatment episode. Client #3 was admitted on July 6, 2020 and discharged on September 1, 2020. There was no documentation of case consultation notes during the treatment episode. These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Clinical Supervisor will create a form listing all clients that were admitted into the facility on a weekly basis. The form will be updated by the Clinical Supervisor on a weekly basis.
The list of clients requiring a written case consultation will be entered into the case consultation record and completed by the 10th day of treatment. If the case consultation cannot be completed by the 10th day of treatment, the primary addiction counselor will document the exception.
The Facility Director will review the case consultation book weekly. This procedure was implemented 1-12-21.
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