INITIAL COMMENTS
|
This report is a result of an on-site licensure renewal inspection conducted on June 21-22, 2017 by staff from the Division of Drug and Alcohol Program Licensure and the Division of Accountability and Program Improvement. Based on the findings of the on-site licensure renewal inspection and complaint investigation, Gaudenzia Common Ground 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
|
704.12(a)(1)(i) LICENSURE Client/couns ratios
704.12. Full-time equivalent (FTE) maximum client/staff and client/counselor ratios.
(a) General requirements. Projects shall be required to comply with the client/staff and client/counselor ratios in paragraphs (1)-(6) during primary care hours. These ratios refer to the total number of clients being treated including clients with diagnoses other than drug and alcohol addiction served in other facets of the project. Family units may be counted as one client.
(1) Inpatient nonhospital detoxification (residential detoxification).
(i) There shall be one FTE primary care staff person available for every seven clients during primary care hours.
|
Observations
Based on a review of the Staffing Requirements Facility Summary Report that the facility submitted as part of the presubmission process, the facility exceeded the maximum Full-time equivalent client/staff ratios for the detoxification unit.
The client to staff ratio for inpatient nonhospital detoxification is 1 primary staff person for every 7 clients.
The daily census for the detoxification unit on 6/08/2017, was 9 clients, but there was only 1 primary care staff person scheduled at the following times: 12:00AM to 6:00AM, 7:00AM to 8:00AM, and 11:00PM to 12:00AM.
The daily census for the detoxification unit on 6/09/2017, was 10 clients, but there was only 1 primary care staff person scheduled at the following times: 12:00AM to 6:00AM, 7:00AM to 8:00AM, and 10:00PM to 12:00AM.
These findings were reviewed with facility staff as part of the inspection process.
|
Plan of Correction
The RN Supervisor will be responsible for completion of weekly schedules to ensure coverage for nursing is in compliance with a 1:7 ratio. The Program Director and RN supervisor are currently conducting interviews for the purpose of hiring 4 new LPN staff to maintain compliance with the detoxification program. The Program Director will be responsible for providing clinical staff, supervisors, or Agency nursing for the detox program in the event staff only one LPN is assigned to the shift. |
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.
|
Observations
Based on a review of facility records conducted during the onsite inspection, the facility failed properly document signed informed consent to release information in 2 of 13 records reviewed.
Patient #1 was admitted for detoxification treatment on 4/25/2017, and was discharged from detoxification on 5/1/2017. The signed consent to release information form for the patient ' s parents dated 4/25/2017, did not document the information to be disclosed.
Patient #12 was admitted for inpatient non-hospital treatment 5/18/2017, and was an active patient at the time of the onsite inspection. There was an informed consent to release information to a facility signed by the patient 06/20/2017, but was dated to expire on 5/25/2017.
These findings were reviewed with the facility staff as part of the inspection process.
|
Plan of Correction
The Program Director will be responsible for conducting a training with all clinical and nursing staff by 8/1/17. The training will focus on proper documentation of release of information, including signatures and dates, 255.5 regulations, documenting expiration dates, and handling revoked consents. The Program Supervisor and RN supervisor will be responsible to ensure that consents to disclose are completed properly and comply with state and federal regulations. The RN supervisor and Program Supervisor will conduct weekly chart audits to ensure releases are being properly completed. |
715.14(a) LICENSURE Urine testing
(a) A narcotic treatment program shall complete an initial drug-screening urinalysis for each prospective patient and a random urinalysis at least monthly thereafter.
|
Observations
Based on a review of patient records conducted during the onsite inspection, the facility failed to ensure that there was a documented urinalysis for all patients prior to the administration of a narcotic agent in 1 of 5 records reviewed.
Patient #3 was admitted for narcotic detoxification on 1/3/2017, and was discharged from narcotic detoxification on 1/9/2017. The patient was dosed with Suboxone on 1/4/2017, but at the time of the onsite inspection, there was no documentation of an initial drug screen for the patient.
These findings were reviewed with facility staff as part of the inspection process.
|
Plan of Correction
Nursing staff will be responsible for sending all new opiate detoxification admission to the laboratory for initial blood work or issue them a 10 panel drug urinalysis if admission is after laboratory hours. The RN supervisor will be responsible for ensuring that drug screening taken at time of admission are available and placed in the chart before the client is seen by the doctor and issued the suboxone taper. The Program Director will be responsible for meeting with all nursing staff and medical consultants to review the expected detoxification protocol. |