INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on September 12-13, 2018 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Interim House West 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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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
Fire drill documentation was reviewed on September 13, 2018, for the period of October 2017 - August 2018. For fire drills conducted on January 27, 2018 and April 29, 2018, the facility failed to ensure that the written fire drill record included the total number of people in the facility at the time of the drill.
This finding was reviewed with facility staff during the licensing inspection.
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Plan of Correction
The fire/drill log notations form was reviewed and revised 9/14/2018. Staff was informed of the fire/drill log notations form provision and was giving instruction on filling out the form correctly, i.e. date, time, giving the total number of people in the facility at the time of the drill, evacuation time, exit route, problems encountered and whether fire alarm or smoke detector was operative. The Facility Manager will be responsible for developing a routine schedule of fire drills and after the drill facility manager will review the fire drill notation log to ensure that all information is correct and documented.
Program Director will monitor staff's adherence to policy 705.10 (d) (4) fire safety protocols.
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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
Five client records were reviewed on September 12-13, 2018. The facility failed to document verification that the client was offered a copy of a consent to release information for client records # 1 and 2.
Client # 1 was admitted into treatment on June 11, 2018 and was still active in treatment. The client's record contained signed consent to release information forms for a personal contact, an insurance company, and a case management agency. Verification that the client was offered a copy of each consent form was not documented in the client's record.
Client # 2 was admitted into treatment on July 9, 2018 and was still active in treatment. The client's record contained a signed consent to release information form for an insurance company. Verification that the client was offered a copy of this consent form was not documented in the client's record.
These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
All participants that enter Interim House West will be made aware of all consent forms that release or receive information as it pertains to their treatment. Each participant will be offered a copy of the consent form and it will be documented if the participant accepts or refuses a copy of the consent form. All consent forms will be filed in each participant's chart and documented with a check mark that the participant received or refused a copy.
The Clinical Director will be responsible for conducting in-service training by 10/30/18 with all staff responsible for initiating and completing consent forms with participants during face-to-face with emphasis on ensuring the importance of verifying when participants are offered a consent form it is documented in participants charts. The Clinical Director will conduct bi-weekly chart audits to ensure that verifications are completed in order to adhere to policy 709.28(d).
Program Director will ensure that in-service training form is filed in training manual and that bi-weekly chart audits are done.
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709.32 (c) (4) (i) - (ii) LICENSURE Medication control
§ 709.32. Medication control.
(4) Methods for control and accountability of drugs, including, but not limited to:
(i) Who is authorized to remove drug.
(ii) The program ' s system for recording drugs, which includes the name of the drug, the dosage, the staff person, the time and the date.
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Observations
Five client records were reviewed on September 12-13, 2018. The facility failed to maintain a complete medication administration record for client records # 1, 2, 3, 4, and 5.
Client # 1 was admitted into treatment on June 11, 2018 and was still active in treatment. Medication administration record sheets indicated that prescription and PRN medications were administered to the client during the following months: June 2018, July 2018, August 2018, and September 2018. The facility failed to ensure that all medication dosing times were recorded on the record sheets.
Client # 2 was admitted into treatment on July 9, 2018 and was still active in treatment. Two medication administration record sheets for the month of September indicated that prescription and over-the-counter medications were administered to the client. The facility failed to ensure that all medication dosing times were recorded on the record sheets. In addition, the charting month was not documented on one of the two record sheets.
Client # 3 was admitted into treatment on April 2, 2018 and was discharged on July 9, 2018. Medication administration record sheets indicated that over-the-counter medications were administered to the client during the following months: April 2018, May 2018, and June 2018. The facility failed to ensure that all medication dosing times were recorded on the record sheets.
Client # 4 was admitted into treatment on June 5, 2017 and was discharged on March 20, 2018. Medication administration record sheets indicated that prescription and over-the-counter medications were administered to the client during the following months: October 2017, November 2017, December 2017, and March 2018. The facility failed to ensure that all medication dosing times were recorded on the record sheets.
Client # 5 was admitted into treatment on February 14, 2018 and was discharged on August 20, 2018. Medication administration record sheets indicated that prescription and over-the-counter medications were administered to the client during the following months: February 2018, March 2018, April 2018, May 2018, June 2018, July 2018, and August 2018. The facility failed to ensure that all medication dosing times were recorded on the record sheets.
These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
The IHW registered nurse is responsible for removal /disposal of drugs with a witness. All medications removed from the medication cart are logged. A medication record is maintained for each participant received monthly from the pharmacy. The nurse adds new medications orders (standing and PRN) to the medication record with the start date, dosage, and dosage times medication should be given.
Licensed and non-medical personnel administer medications that are outside of the standing dosing times (PRN). The Registered Nurse is responsible for the supervision and training of all personnel who are involved in the administration of medications. PRN medication are administered basic on the participants required to a alleviate discomfort. The medication is sign for on the MAR and the following information is recorded on the backside of the MAR, which includes the name of medication dosage, time, and reason why medication was given. Staff is required to check on the participant receiving PRN medication within one to two hours of administer to ascertain if the medication was effective and then record participant comment regarding relief.
The Registered Nurse will monitor all Medication Administration Records (MAR) for PRN medication, to ensure that all staff record the name of the drug administered, time given, the dosage, date of dosage and the initials of the staff person administering the drug, including participants initials.
The Registered Nurse will conduct in-service training by 11/16/18 for all staff involved in the administration of standing and PRN medications to ensure compliance with policies and procedures.
Total Quality Management will monitor adherence to the requirements of medication administration and control in conjunction with the Program Director.
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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
Two client records were reviewed for the use of Buprenorphine in the inpatient rehabilitation treatment activity on September 12-13, 2018. The facility failed to obtain an informed written patient consent prior to the administration of Buprenorphine for client record # 1.
Client # 1 was admitted into treatment on June 11, 2018 and was still active in treatment. The client received an initial dose of Buprenorphine on June 12, 2018. The informed written patient consent documented in the client's record was signed by the client on June 15, 2018.
This finding was reviewed with facility staff during the licensing inspection.
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Plan of Correction
The Medication Assisted Treatment (MAT) Consent Form was revised September 24, 2018 and includes the five elements to assure that participants are properly informed and have knowledge of MAT treatment benefits, risks, side effects, complications, and possible effects on their unborn child if pregnant. Key staff received training October 4, 2018 and understand the importance of obtaining written voluntary consent from participants eligible for MAT services.
Registered Nurse, Program Director and Total Quality Management will monitor staff's adherence to MAT protocols and obtain signed consent before initiating MAT Narcotics.
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715.13(b) LICENSURE Patient identification
(b) A narcotic treatment program shall maintain onsite a photograph of each patient which includes the patient 's name and birth date. The narcotic treatment program shall update the photograph every 3 years.
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Observations
Two client records were reviewed for the use of Buprenorphine in the inpatient rehabilitation treatment activity on September 12-13, 2018. For client record # 1, the facility failed to maintain an onsite photograph of the client that included the client's name and birth date.
Client # 1 was admitted into treatment on June 11, 2018 and was still active in treatment.
This finding was reviewed with facility staff during the licensing inspection.
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Plan of Correction
The nurse will direct appropriate staff to photograph all participants at admission. The participant's name and birthdate is added to the photograph, before printing. Photographs will be kept with the participant's medication record sheets. The process of adding participants name and birthdate to their photographs was implemented 10/1/2018.
Total Quality Management will monitor quarterly during onsite record reviews. The registered nurse will monitor completion of photographs weekly and notify the program director.
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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
Two client records were reviewed for the use of Buprenorphine in the inpatient rehabilitation treatment activity on September 12-13, 2018. The facility failed to maintain a complete medication administration record for client records # 1 and 2.
Client # 1 was admitted into treatment on June 11, 2018 and was still active in treatment. Eight medication administration record sheets indicated that Subutex and Suboxone were administered to the client during the following months: June 2018, July 2018, August 2018, and September 2018. The prescription dates for the Subutex and Suboxone were not documented on five of the eight record sheets. In addition, the facility failed to ensure that all dosing times for these medications were recorded on the record sheets.
Client # 2 was admitted into treatment on July 9, 2018 and was still active in treatment. A medication administration record sheet for the month of July 2018 recorded the administration of Suboxone to the client. The prescription date for the Suboxone was not documented on the record sheet. In addition, the facility failed to ensure that all dosing times for this medication were recorded on the record sheet.
These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
Policies discussing Medication Quality Control and Accountability, as well as Medication Disposal were reviewed, revised to reflect the MAT treatment requirements. The revisions were completed October 5, 2018.
The elements (4) (i-viii) are inclusive of the completed Medication Administration Record (MAR) that is received monthly from the contract Pharmacy. As new medication orders are received, it is the responsibility of the nurse to enter new orders per the participants MAR form and include all the elements identified (i-viii).
The contract Pharmacist visits the program quarterly and completes a report that is maintained at IHW. The report covers Medication Storage, Documentation, Refrigerated Medications, Controlled /Abusive Medications, and Expired, Disposal, Discontinued Medications.
Lastly, the registered nurse or other licensed staff is authorized to administer, and remove drugs from the medication cart. All medications administered are recorded per the participants' MAR sheet. MAT medications are stored under double lock/ the Medication Cart, only the nurse on duty has the key to the Medication Cart.
The Registered Nurse and the Licensed Practical Nurse will receive training/education regarding the documentation required for the administration of Buprenorphine on medication administration records. IHW is hiring a registered nurse and as part of her orientation will include the policies and regulation related to MAT treatment program. This will include medication administration and documentation of the process. The training will be conducted by the Nurse Coordinator orienting the Registered Nurse and the Licensed Practical Nurse on 11/9/2018.
The Program Director will monitor the nurse's adherence to all the 715 regulations. Total Quality Management will monitor compliance through chart audits.
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