INITIAL COMMENTS
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This report is a result of an on-site licensure renewal and Buprenorphine monitoring inspection conducted on February 8-10, 2021 by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection Caron Treatment Centers - Detox Unit 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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704.9(b) LICENSURE Performance evaluation
704.9. Supervision of counselor assistant.
(b) Performance evaluation. The counselor assistant shall be given a written semiannual performance evaluation based upon measurable performance standards. If the individual does not meet the standards at the time of evaluation, the counselor assistant shall remain in this status until the supervised period set forth in subsection (c) is completed and a satisfactory rating is received from the counselor assistant's supervisor.
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Observations
Based on one of twenty-four personnel records reviewed, the facility failed to provide documentation of a written semiannual performance evaluation based upon measurable performance standards for employee # 16.
Employee # 16 was hired as a counselor assistant on July 13, 2020 and was still in this position at the time of the inspection. A written semi-annual performance evaluation was due to be completed no later than January 13, 2021. There was no semi-annual performance evaluation completed.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Clinical Supervisors were reminded of the requirement to complete a semiannual performance evaluation for any counselor assistant.
The Human Resources Department will monitor the completion of the required evaluations on a monthly basis. |
705.2 (2) LICENSURE Building exterior and grounds.
705.2. Building exterior and grounds.
The residential facility shall:
(2) Keep the grounds of the facility clean, safe, sanitary and in good repair at all times for the safety and well-being of residents, employees and visitors. The exterior of the building and the building grounds or yard shall be free of hazards.
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Observations
Based on a physical plant inspection, there were emergency/fire exits that were blocked by snow or snow covered. Building 1000 had snow that blocked the exits on the first and second floor. Building 700 had an exit from the stairs that was snow covered.
These findings were reviewed with facility staff during the licensing process.
This is a repeat citation from inspection conducted on December 20, 2018.
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Plan of Correction
All snow that was blocking means of egress were cleared immediately during the inspection.
Snow removal procedures have been revised so that all means of egress for all buildings are now included in Caron's "primary route list" for snow removal. This change in procedures will ensure that all egress areas are considered priority cleaning. The Director of facilities (or designee), will perform walkthroughs during snowstorms to verify that all areas of egress are being cleaned. Any areas missed will be documented and cleaned immediately. |
705.2 (4) LICENSURE Building exterior and grounds.
705.2. Building exterior and grounds.
The residential facility shall:
(4) Store all trash, garbage and rubbish in noncombustible, covered containers that prevent the penetration of insects and rodents, and remove it, at least once every week.
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Observations
Based on a physical plant inspection, the facility failed to store all trash, garbage, and rubbish in noncombustible, covered containers that prevent the penetration of insects and rodents in outdoor trash sheds. The facility was storing trash bags in a wooden shed with a wire screen top.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
New trash receptacle units have been ordered and will be installed upon receipt. These units are located at a safe distance from the buildings and are completely enclosed. |
705.10 (d) (1) LICENSURE Fire safety.
705.10. Fire safety.
(d) Fire drills. The residential facility shall:
(1) Conduct unannounced fire drills at least once a month.
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Observations
Based on a review of the facility fire drill log, there was no documentation of a fire drill being conducted for the months of August 2019 and March 2020.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The requirements for the monthly completion of fire drills was reviewed with the Facilities Team. The fire drill schedule was revised to ensure monthly completion of drills. The Risk Management Department will monitor the completion of fire drills on a monthly basis and will report any concerns to the Director of Facilities and Corporate Director of Compliance, Quality & Risk. |
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
Based on a review of the facility fire drill log, the facility failed to maintain a written fire drill record to include 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 for the months of January 2019 through December 2019 and the months of January, February, August, September, October, November 2020.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Caron's Fire Drill Form was revised to include the following:
-number of persons in the facility at the time of the drill
-problems encountered
-whether the fire alarm or smoke detector was operative
Facilities staff were educated on the revised form.
The Risk Management Department will review the completed fire drill forms on a monthly basis and will report any concerns to the Director of Facilities and Corporate Director of Compliance, Quality & Risk. |
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
Based on a review of the facility fire drill log, the facility failed to provide documentation of conducting a fire drill during sleeping hours at least every 6 months.
An overnight fire drill was not conducted between Janaury 2020-November 2020.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The requirements for completion of a fire drill during sleeping hours was reviewed with the Facilities Team. The fire drill schedule was revised to ensure a fire drill is conducted during sleeping hours every six months. The Risk Management Department will monitor the completion of fire drills on a monthly basis and will report any concerns to the Director of Facilities and Corporate Director of Compliance, Quality & Risk. |
709.28 (c) (2) 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. The consent must be in writing and include, but not be limited to:
(2) Specific information disclosed.
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Observations
Based on two of twenty-two client records reviewed, the facility failed to obtain an informed and voluntary consent from the client for the disclosure of information keeping information to be disclosed within the limits of 255.5 (a) (6) to an employer.
Client # 16 was admitted on January 11, 2021 and was still active at the time of the inspection. An informed and voluntary consent form to an employer signed and dated on February 5, 2021, allowed for the release of progress update, written/verbal verification to include admission/discharge dates, reason for admission, and type of discharge.
Client # 18 was admitted on January 14, 2021 and was still active at the time of the inspection. An informed and voluntary consent form to an employer signed and dated on January 25, 2021, allowed for the release of progress update, written/verbal verification to include admission/discharge dates, reason for admission, and type of discharge.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Caron's informed consent form for the disclosure of information for employers will be revised to ensure the information is within the limits of 255.5. Once the form is revised, staff will be reeducated on the limits of 255.5.
The Health Records Management department will monitor the completion of the disclosure of information for employers form to ensure the disclosure does not exceed 255.5 |
709.28 (c) (4) 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. The consent must be in writing and include, but not be limited to:
(4) Dated signature of client or guardian as provided for under 42 CFR 2.14(a) and (b) and 2.15 (relating to minor patients; and incompetent and deceased patients).
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Observations
Based on two of twenty-two client records reviewed, the facility failed to obtain an informed and voluntary consent from the client for the disclosure of information to include a signature of the client.
Client # 1 was admitted on February 3, 2021 and was still active at the time of the inspection. An informed and voluntary consent from the client to a funding source did not have the client ' s signature.
Client # 22 was admitted on April 22, 2020 and was discharged on May 23, 2020. An informed and voluntary consent from the client to a funding source did not have the client ' s signature.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Admission staff will be reeducated on the procedures for completion of informed and voluntary consents, including the required patient signature.
The Health Records Management Department will monitor the completion of consents for patients on a weekly basis and will provide a report to the Admissions Department Supervisor.
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709.30 (3) LICENSURE Client rights
709.30. Client rights.
The project shall develop written policies and procedures on client rights and document written acknowledgement by clients that they have been notified of those rights.
(3) Clients have the right to inspect their own records. The project, facility or clinical director may temporarily remove portions of the records prior to the inspection by the client if the director determines that the information may be detrimental if presented to the client. Reasons for removing sections shall be documented in the record.
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Observations
Based on twenty-two of twenty-two client records reviewed, the facility failed to document written acknowledgement by clients that they have been notified of those rights to include reasons for removing sections shall be documented in the record.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Caron's Patient Rights will be revised to include:
reasons for removing sections shall be documented in the record.
The revised Patient Rights will be reviewed provided to all patients being admitted to Caron. Patient's will continue to sign an acknowledgement of receipt of their rights. |
709.63(a)(8) LICENSURE Follow-up Information
709.63. 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) Follow-up information.
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Observations
Based on five of six applicable client records reviewed, the facility failed to provide a complete client record to include follow-up information in accordance with the facility policy and procedure manual. The facility policy and procedure manual indicate follow-up information to occur within seven days of discharge.
Client # 2 was admitted on May 29, 2020 and was discharged on May 31, 2020. There was no follow-up information documented in the client record.
Client # 3 was admitted on August 8, 2020 and was discharged on August 10, 2020. There was no follow-up information documented in the client record.
Client # 6 was admitted on May 6, 2020 and was discharged on May 8, 2020. There was no follow-up information documented in the client record.
Client # 7 was admitted on May 15, 2020 and was discharged on May 16, 2020. There was no follow-up information documented in the client record.
Client # 8 was admitted on December 25, 2020 and was discharged on December 26, 2020. There was no follow-up information documented in the client record.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Caron's policy and procedure on the completion of patient follow up was revised and staff will be educated on the revised procedures.
The Quality Improvement Department will monitor the completion of patient follow up calls through completion of chart reviews on a monthly basis. The results of the chart reviews will be reviewed with the Clinical Supervisor.
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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
Based on one of seven applicable patient records reviewed, 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 patient record # 15.
Patient # 15 was admitted on October 9, 2020 and was discharged on November 8, 2020. There was no documentation of an informed consent in the patient record.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Nursing staff will be reeducated on the requirement for completion of the informed consent for buprenorphine prior to administration of buprenorphine.
The Quality Improvement Department will monitor the completion of the consent for buprenorphine through monthly chart reviews and will provide a report to the Director of Nursing. |
715.23(d) LICENSURE Patient records
(d) A narcotic treatment program shall prepare a treatment plan that outlines realistic short and long-term treatment goals which are mutually acceptable to the patient and the narcotic treatment program.
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Observations
Based on three of seven applicable client records reviewed, the facility failed to document the acknowledgement of an individual treatment and rehabilitation plan being developed with the client in client records # 9, 11, 12, 14 and 15.
Client # 9 was admitted on December 29, 2020 and was still active at the time of the inspection. An individual treatment and rehabilitation plan date January 2, 2021 was not signed by the client.
Client # 11 was admitted on January 20, 2021 and was still active at the time of the inspection. An individual treatment and rehabilitation plan date January 25, 2021 was not signed by the client.
Client # 12 was admitted on January 19, 2021 and was still active at the time of the inspection. . An individual treatment and rehabilitation plan date January 26, 2021 was not signed by the client.
Client # 14 was admitted on September 26, 2020 and was discharged on October 25, 2020. An individual treatment and rehabilitation plan date October 1, 2020 was not signed by the client.
Client # 15 was admitted on October 9, 2020 and was discharged on November 8, 2020. An individual treatment and rehabilitation plan date October 20, 2020 was not signed by the client.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Staff were reeducated on the requirement for patient signatures on all treatment plans and treatment plan updates.
The Quality Improvement Department will monitor compliance with patient signatures on treatment plans through completion of chart reviews on a monthly basis. The results of the chart reviews will be reviewed with the Clinical Supervisor.
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709.52(a) LICENSURE Individual TX and REHAB Plan
709.52. Treatment and rehabilitation services.
(a) An individual treatment and rehabilitation plan shall be developed with a client. This plan shall include, but not be limited to, written documentation of:
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Observations
Based on three of seven applicable client records reviewed, the facility failed to document the acknowledgement of an individual treatment and rehabilitation plan being developed with the client in client records # 17, 19, and 22.
Client # 17 was admitted on January 24, 2021 and was still active at the time of the inspection. An individual treatment and rehabilitation plan date February 1, 2021 was not signed by the client.
Client # 19 was admitted on January 19, 2021 and was still active at the time of the inspection. An individual treatment and rehabilitation plan date January 25, 2021 was not signed by the client.
Client # 22 was admitted on April 22, 2020 and was discharged on May 23, 2020. An individual treatment and rehabilitation plan date April 30, 2020 was not signed by the client.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Staff were reeducated on the requirement for patient signatures on all treatment plans and treatment plan updates.
The Quality Improvement Department will monitor compliance with patient signatures on treatment plans through completion of chart reviews on a monthly basis. The results of the chart reviews will be reviewed with the Clinical Supervisor. |
709.53(a)(11) LICENSURE Follow-up information
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:
(11) Follow-up information.
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Observations
Based on six of six applicable client records reviewed, the facility failed to provide a complete client record to include follow-up information in accordance with the facility policy and procedure manual. The facility policy and procedure manual indicate follow-up information to occur at within seven days of discharge.
Client # 13 was admitted on August 25, 2020 and was discharged on September 5, 2020. There was no follow-up information documented in the client record.
Client # 14 was admitted on September 26, 2020 and was discharged on October 25, 2020. There was no follow-up information documented in the client record.
Client # 15 was admitted on October 9, 2020 and was discharged on November 8, 2020. There was no follow-up information documented in the client record.
Client # 20 was admitted on December 9, 2020 and was discharged on January 6, 2021. There was no follow-up information documented in the client record.
Client # 21 was admitted on August 1, 2020 and was discharged on September 1, 2020. There was no follow-up information documented in the client record.
Client # 22 was admitted on April 22, 2020 and was discharged on May 23, 2020. There was no follow-up information documented in the client record.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Caron's policy and procedure on the completion of patient follow up was revised and staff were educated on the revised procedures.
The Quality Improvement Department will monitor the completion of patient follow up calls through completion of chart reviews on a monthly basis. The results of the chart reviews will be reviewed with the Clinical Supervisor. |