INITIAL COMMENTS
|
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 2, an abbreviated on-site inspection, conducted on November 9, 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 were reviewed during Part 1.
Based on the findings of Part 2, an abbreviated on-site inspection, The Highland House, 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:
|
Plan of Correction
|
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(iv) Outdated drugs are removed.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.
|
Observations
Based on a review of the medication storage area and interview with the project/facility director on November 9, 2020, the facility failed to document a quarterly inspection of the medication storage area from July 2019 - October 2020.
The findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
The Clinical Director will perform a quarterly inspection of the medication closet and surrounding area to ensure compliance with the standards. The Clinical Director will complete an inspection report and submit it to the Executive Director and the staff that have authorization to access the medication closet so that they are aware of the findings. Any issues will be addressed and corrected immediately. Additional training will be provided if the situation warrants.
An inspection will be performed during the fourth quarter of 2020, and then quarterly thereafter. |
709.33 (a) LICENSURE Notification of termination.
§ 709.33. Notification of termination.
(a) Project staff shall notify the client, in writing, of a decision to involuntarily terminate the client ' s treatment at the project. The notice shall include the reason for termination.
|
Observations
Based on a review of client records, the project failed to document, in writing, that clients were notified of the decision to involuntarily terminate their treatment at the project in one of three client records reviewed on November 9, 2020.
Client # 4 was admitted April 23, 2020 and involuntarily terminated from treatment on May 11, 2020. No written involuntary termination notice was documented in the record of client # 4.
The findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
The Clinical Director will create a Discharge Checklist by 12/01/2020 that will be used as people are discharged from treatment. This checklist will include the Notification Letter provided to the resident explaining the reason for their discharge from treatment. The staff involved with the discharge will prepare this letter and provide a copy to the resident. A copy of the letter will be placed in the treatment chart. If the resident refuses, it will be noted on the agency copy. If there is no opportunity to provide the letter because of extenuating circumstances, a letter will be mailed to the forwarding address on file, and a notation will be made on the agency copy. |