INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection and methadone monitoring inspection conducted on August 28-30, 2018 by staff from the Department of Drug and Alcohol Programs, Bureau of Quality Assurance for Prevention and Treatment, Division of Accountability and Program Improvement. Based on the findings of the on-site inspection, Dolminis 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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705.28 (d) (4) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential 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 which included whether the fire alarm or smoke detector was operative.
Fire drill logs for the time period of October 2017 to July 2018 were reviewed. The fire drill logs did not document whether the fire alarm or smoke detector were operative in all of the fire drill logs reviewed.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Effective 9/4/18, A column indicating that the fire/smoke alarm was operative at the time of the drill has been added to the fire drill log. A "Yes" or "No" will be documented in this column space at the time of the monthly fire drill.
All fire drill documentation will be completed and monitored monthly by the facility risk leaders
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715.23(c)(1-7) LICENSURE Patient records
(c) An annual evaluation of each patient 's status shall be completed by the patient 's counselor and shall be reviewed, dated and signed by the medical director. The annual evaluation period shall start on the date of the patient 's admission to a narcotic treatment program and shall address the following areas:
(1) Employment, education and training.
(2) Legal standing.
(3) Substance abuse.
(4) Financial management abilities.
(5) Physical and emotional health.
(6) Fulfillment of treatment objectives.
(7) Family and community supports.
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Observations
The facility failed to document that the annual evaluation of each patient 's status was dated and signed by the medical director in three of three patient records reviewed on August 28-30, 2018.
Patient records # 5, 6 and 8 had annual evaluations signed by a narcotic treatment physician who was not the medical director.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Effective 9/10/18, All staff have been instructed to begin routing all annual evaluations to the medical director only for signature. To ensure compliance the clinical supervisor will review the annual evaluation monthly during chart audits to ensure that counselors are submitting this form to the medical director for signature and not the NTP physician.
The monthly chart audit review results are submitted to the clinical compliance officers monthly for additional review.
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