INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on October 14 - 15, 2020 by staff from the Department of Drug and Alcohol Programs, Bureau of Quality Assurance for Prevention and Treatment. Based on the findings of the on-site inspection, Polaris Detox LLC DBA Innovo Detox 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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704.5(c) LICENSURE Qualifications for Proj/Fac Dir
704.5. Qualifications for the positions of project director and facility director.
(c) The project director and the facility director shall meet the qualifications in at least one of the following paragraphs:
(1) A Master's Degree or above from an accredited college with a major in medicine, chemical dependency, psychology, social work, counseling, nursing (with a specialty in nursing/health administration, nursing/counseling education or a clinical specialty in the human services), public administration, business management or other related field and 2 years of experience in a human service agency, preferably in a drug and alcohol setting, which includes supervision of others, direct service and program planning.
(2) A Bachelor's Degree from an accredited college with a major in chemical dependency, psychology, social work, counseling, nursing (with a specialty in nursing/health administration, nursing/counseling education or a clinical specialty in the human services), public administration, business management or other related field and 3 years of experience in a human service agency, preferably in a drug and alcohol setting, which includes supervision of others, direct service and program planning.
(3) An Associate Degree from an accredited college with a major in chemical dependency, psychology, social work, counseling, nursing (with a specialty in nursing/health administration, nursing/counseling education or a clinical specialty in the human services), public administration, business management or other related field and 4 years of experience in a human service agency, preferably in a drug and alcohol setting, which includes supervision of others, direct service and program planning.
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Observations
Based on a review of personnel records, the facility failed to hire a project director that meets the qualifications. Employee #1 was hired August 1, 2019 and does not meet the educational qualifications for the position.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
A new Project and Facility Director, who meets the educational criteria, will be named and the request for change will be submitted to DDAP on 11/13/2020. The HR Specialist and Director of HR and Compliance will confirm all future staff meet the qualifications of their position. The HR team will add a line to the New Hire Checklist confirming qualifications were reviewed for each new hire.
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704.11(a) LICENSURE Staff Development Procedure
704.11. Staff development program.
(a) Components. The project director shall develop a comprehensive staff development program for agency personnel including policies and procedures for the program indicating who is responsible and the time frames for completion of the following components:
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Observations
Based on a review of policy and procedures, the facility failed to include time frames for completion and how each component of the staff development program will be documented.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Project Director & Director of HR and Compliance will include in the Staff Development Plan the timeframes for completion of 704.11(a)(1-4). The assessment of staff training needs will be completed within the first quarter of each year by the HR Department and Management. The overall plans for addressing these needs will be rolled out by the end of March each year by the HR Department. Feedback will be collected electronically by the HR Department annually in the first quarter of the calendar year. An annual evaluation of the overall training plan will occur (attendees include HR and Compliance Departments) after all feedback is recieved and before the overall plans are rolled out in March.
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705.10 (b) (6) LICENSURE Fire safety.
705.10. Fire safety.
(b) Smoke detectors and fire alarms. The residential facility shall:
(6) Maintain all smoke detectors and fire alarms so that each person with a hearing impairment will be alerted in the event of a fire, if one or more residents or staff persons are not able to hear the smoke detector or fire alarm system.
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Observations
Based on a physical plant inspection, the facility failed to maintain smoke detectors and fire alarm so a hearing-impaired person would be alerted in the event of a fire.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
A strobe fire alarm will be installed in one of the patient bedrooms by a contracting company. Installation date is confirmed for 11/19/2020.
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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 administrative information, the facility failed to conduct monthly fire drills. The facility was approved for services in January 2020, and began admitting patients in March 2020. As of the date of the inspection, zero fire drills have been conducted.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Safety Officer/Office Manager will facilitate unannounced monthly fire drills. Fire drills will be documented and logs will be maintained by the Safety Officer. The Compliance Specialist or Director of HR and Compliance will review the fire drills monthly to confirm the fire drills are being conducted and to ensure this deficiency does not recur. |
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 administrative information, the facility failed to conduct a fire drill during sleeping hours. The facility was approved for services in January 2020, and began admitting patients in March 2020. As of the date of the inspection, zero fire drills have been conducted during sleeping hours.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Safety Officer/Office Manager will facilitate fire drills during sleeping hours every 6 months. Fire drills will be documented and logs will be maintained by the Safety Officer. The Compliance Specialist or Director of HR and Compliance will review the fire drills monthly to confirm the fire drills are being conducted and to ensure this deficiency does not recur.
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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.
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Observations
Based on a review of client records, the facility failed to obtain an informed and voluntary consent from the client prior to disclosure of information in seven of seven client records.
Seven client records did not document consents for laboratories and six client records did not document consents for a funding source, but information was disclosed.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Compliance Specialist will create a Release of Information for the laboratory for patient's to sign upon intake. This ROI will automatically upload in the EMR when consents are generated by the Admissions Specialist. A QSOA was obtained from the company performing urine drug screens. Patient's utilizing insurance will sign a Release of Information, created by the Compliance Specialist, upon intake for their specific insurance company. The Compliance Specialist and/or the Director of HR and Compliance will be responsible for the implementation of the corrective action, and they will conduct monthly chart audits to monitor the completion of release of information forms. The audit will ensure this deficiency does not recur.
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709.28 (c) (5) 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:
(5) Dated signature of witness.
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Observations
Based on a review of client records, the facility failed to include a dated signature of witness on all release forms in seven of seven client records.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Compliance Specialist will update the Releases of Information requiring staff to sign as a witness after the patient signs the consent. This deficiency will not recur as the witness signature is required for the form to be completed in the EMR. The Compliance Specialist and Director of HR and Compliance will conduct monthly audits to ensure the forms are being signed correctly.
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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
Based on a review of client records, the facility failed to document a copy of the consents were offered to the client in seven of seven client records reviewed.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
All Releases of Information will be updated by the Compliance Specialist with an acknowledgement statement that patients are offered copies of the consents signed. This is a hard-coded section of the form, so this deficiency will not recur. The Compliance Specialist and Director of HR and Compliance will audit Releases of Information forms monthly to ensure completion.
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709.30 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.
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Observations
Based on a review of policies and procedures on client rights, the facility failed to include a procedure for all four components of the clients right to inspect their own record. Additionally, documentation of written acknowledgement by the clients that they were notified of all rights was missing.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Compliance Specialist will update the Patient's Rights to include all four components of the client's rights to inspect their own record. Additionally, verbiage will be added to acknowledge the patients were made aware of their rights. This new verbiage is hard-coded into the Patient Rights section, so this deficiency shall not recur. Additionally, the Compliance Specialist and Director of HR and Compliance will conduct monthly chart audits to ensure completion.
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709.30 (2) 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.
(2) The project may not discriminate in the provision of services on the basis of age, race, creed, sex, ethnicity, color, national origin, marital status, sexual orientation, handicap or religion.
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Observations
Based on a review of client records, the facility failed to document written acknowledgement by clients that they may not be discriminated on the basis of creed, sex, color, national origin and marital status in seven of seven client records.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Compliance Specialist will add verbiage to the Client's Rights acknowledging that clients may not be discriminated on the basis of creed, sex, color, national origin and marital status. Client's rights will be reviewed with patients during intake by the Admissions Specialist or Support Staff. This new verbiage is hard-coded into the Patient Rights section, so this deficiency shall not recur. Additionally, the Compliance Specialist and Director of HR and Compliance will conduct monthly chart audits to ensure completion.
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709.34 (c) (4) LICENSURE Reporting of unusual incidents
§ 709.34. Reporting of unusual incidents.
(c) To the extent permitted by State and Federal confidentiality laws, the project shall file a written unusual incident report with the Department within 3 business days following an unusual incident involving:
(4) Event at the facility requiring the presence of police, fire or ambulance personnel.
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Observations
Based on a review of administrative information, the facility failed to document that a written unusual incident report was submitted to the Department within 3 business days following an incident involving police personnel.
Police were called to the facility on September 27, 2020. There was no documentation that an unusual incident report was submitted to the Department as of the date of the inspection.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Compliance Specialist or the Director of HR & Compliance will report all required unusual incidents to DDAP within 3 business days. The Compliance Specialist and Director of HR and Compliance are responsible for ensuring the corrective action is implemented. The Compliance Team will review all Incident Reports to ensure required submission occurs. Staff was educated on 10/26/2020 to alert the Compliance Team when a reportable incident occurs.
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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 a review of client records, the facility failed to document follow-up per the facility policy and procedure in one of two applicable client records. Client record # 2 failed to document a follow-up.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Compliance Specialist in conjunction with the Admissions Team is responsible for ensuring the corrective action is implemented. The team extended the patient follow-up period to 45 days post discharge to allow ample time for the follow-ups to be completed. The Admissions team will document the attempted outreach if unable to reach the patient or document the follow-up call if the patient is available. The Compliance Team will conduct monthly audits of the follow-up calls to ensure the deficiency does not recur.
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715.6(b)(1-9) LICENSURE Physician Staffing
(b) A narcotic treatment program may employ narcotic treatment physicians to assist the medical director. A narcotic treatment physician 's responsibilities include:
(1) Performing a medical history and physical exam.
(2) Determining diagnosis and determining narcotic dependence.
(3) Reviewing treatment plans.
(4) Determining dosage and all changes in doses.
(5) Ordering take-home privileges.
(6) Discussing cases with the treatment team.
(7) Issuing verbal orders pertaining to patient care.
(8) Assessing coexisting medical and psychiatric disorders.
(9) Treating or making appropriate referrals for treatment of these disorders.
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Observations
Based on a review of the administrative information, the facility failed to include the following in the physician responsibilities:
(1) Performing a medical history and physical exam,
(2) Determining diagnosis and determining narcotic dependence,
(3) Reviewing treatment plans,
(4) Determining dosage and all changes in doses,
(5)Ordering take-home privileges.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Director of HR and Compliance is responsible for ensuring the corrective action is implemented. The Director of HR and Compliance will update the Medical Director Privileges to include all physician responsibilities from 715.6(b)(1-9). The Medical Director will sign off on the updated privilege's. The HR Specialist and Director of HR and Compliance will ensure all job descriptions and privileges are updated and monitored accordingly.
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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 a review of client records, the facility failed to document the informed patient consent for the use of buprenorphine in three of four patient records reviewed. Patient records # 2, 3, and 5 did not document a patient consent for the use of buprenorphine.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Nursing staff will be responsible for obtaining patient signatures on Buprenorphine Consents. Director of Nursing will ensure the corrective action is implemented by providing instruction to all nurses that this is the Nursing Team's responsibility. The Compliance Specialist and Director of Compliance will conduct monthly audits of patient records to ensure the buprenorphine consent is signed. The audit will be documented and monitored by the Compliance Team to ensure this deficiency does not recur.
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715.20 LICENSURE Patient transfers
A narcotic treatment program shall develop written transfer policies and procedures which shall require that the narcotic treatment program transfer a patient to another narcotic treatment program for continued maintenance, detoxification or another treatment activity within 7 days of the request of the patient.
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Observations
Based on a review of the transfer policies and procedures, the facility failed to document a written transfer procedure that includes who is responsible, when it is completed and how it will be documented.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Compliance Specialist is responsible for typing the Transfer Policy and incorporating it into the Policies and Procedures. In the event that Polaris Detox, LLC. transfers a patient to another NTP, the Continuing Care Coordinator will be responsible for transferring medical records confidentially and documenting what records were sent to the receiving facility in the EMR. If a patient is received from another NTP to Polaris Detox, LLC. the Admissions Team will be responsible for documenting communication with the transferring NTP and advising the transferring NTP of the initial dose given to the patient. The Compliance Specialist and the Director of HR and Compliance will conduct monthly chart audits to ensure the Transfer Policy is being followed.
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715.22(b) LICENSURE Patient grievance procedures
(b) The procedure shall permit aggrieved patients a full and fair opportunity to be heard, to question and confront persons and evidence used against them and to have a fair review of their grievances by the narcotic treatment program director. If the grievance is filed against the narcotic treatment program director, the review of the case shall be conducted by either a multi-representative group of the narcotic treatment program or a subcommittee of the governing body instituted for the express purposes of grievance adjudication.
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Observations
Based on a review of the patient grievance procedure, the facility failed to include a procedure for grievances filed against the narcotic treatment program director.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Compliance Specialist will update the patient grievance procedure so that patients know to contact the Director of HR and Compliance with any grievances with the Executive Director. Compliance Specialist updated the Patient Grievance Procedure in the Policies and Procedures, as well as, in the EMR system.
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715.23(b)(14) LICENSURE Patient records
(b) Each patient file shall include the following information:
(14) Case consultation notes regarding the patient.
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Observations
Based on a review of client records, the facility failed to document a case consultation per the facility policy and procedure in four of four patient records. Patient records #2, 3, 4 and 5 failed to document a case consultation.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Executive Director or designee will document when a patient's case is discussed in daily rounds. The documentation will be uploaded into a patient's chart under 'Progress Notes' and will be titled 'Case Consultation'. The Compliance Specialist and Director of HR and Compliance will conduct monthly audits of patient records to ensure the case consultation notes are being documented. The Compliance Specialist is responsible for ensuring the corrective action is implemented. The audits will ensure this deficiency does not recur.
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709.53(a)(8) LICENSURE Case Consultation Notes
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:
(8) Case consultation notes.
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Observations
Based on a review of client records, the facility failed to document a case consultation per the facility policy and procedure in two of two applicable client records. Client records #6 and #7 failed to document a case consultation.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Executive Director or designee will document when a patient's case is discussed in daily rounds. The documentation will be uploaded into a patient's chart under 'Progress Notes' and will be titled 'Case Consultation'. The Compliance Specialist and Director of HR and Compliance will conduct monthly audits of patient records to ensure the case consultation notes are being documented. The Compliance Specialist is responsible for ensuring the corrective action is implemented. The audits will ensure this deficiency does not recur.
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