INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection and methadone/buprenorphine monitoring conducted on August 27, 2024 through August 29, 2024 by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, Kirkbride Center 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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704.11(b)(2) & (3) LICENSURE Basis of Training Plan
704.11. Staff development program.
(b) Individual training plan.
(2) This plan shall be based upon an employee's previous education, experience, current job functions and job performance.
(3) Each individual employee shall complete the minimum training hours as listed in subsections (d)-(g). The subject areas in subsections (d)-(g), with the exception of subsection (g), are suggested training areas. They are not mandates. Subject selections shall be based upon needs delineated in the individual's training plan.
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Observations
Based on a review of personnel records, the facility failed to ensure that each annual written individual training plan was based upon an employee's previous education, experience, current job functions, and performance in twenty of twenty personnel records reviewed.
In every personnel record reviewed, the individual training plan was identical and was not individualized based upon each specific employee's previous education, experience, current job functions and job performance.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
The HR Director (or designee) is responsible for ongoing monitoring of training plans prior to filing in personnel records. The HR Director, along with the Program Director, is developing a new training plan format in order to capture individualized information based upon the staff member's previous education, experience, current job functions and performance; effective start date 11/1/24. Any variances identified will be brought to the attention of the relevant manager/director for remediation with their staff and any findings will be discussed monthly in rehab dashboard meeting. |
704.11(c)(1) LICENSURE Mandatory Communicable Disease Training
704.11. Staff development program.
(c) General training requirements.
(1) Staff persons and volunteers shall receive a minimum of 6 hours of HIV/AIDS and at least 4 hours of tuberculosis, sexually transmitted diseases and other health related topics training using a Department approved curriculum. Counselors and counselor assistants shall complete the training within the first year of employment. All other staff shall complete the training within the first 2 years of employment.
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Observations
Based on a review of personnel records, the facility failed to ensure all staff persons received a minimum of 6 hours of HIV/AIDS training and at least 4 hours of TB/STD and other health related topics training within the regulatory timeframe in eight of twelve applicable personnel records reviewed.
Employee # 8 was hired as a counselor on August 21, 2023 and was due to have the TB/STD training no later than August 21, 2024; however, the TB/STD training was not completed at the time of the inspection.
Employee # 19 was hired as a counselor on October 17, 2022 and was due to have the TB/STD training no later than October 17, 2023; however, the TB/STD training was not completed until February 12, 2024.
Employee # 21 was hired as a behavioral health technician on June 27, 2022 and was due to have the HIV/AIDS training no later than June 27, 2024; however, the HIV/AIDS training was not completed at the time of the inspection.
Employee # 22 was hired as a behavioral health technician on June 27, 2022 and was due to have the HIV/AIDS training no later than June 27, 2024; however, the HIV/AIDS training was not completed at the time of the inspection.
Employee # 23 was hired as a behavioral health technician on March 28, 2022 and was due to have the HIV/AIDS training no later than March 28, 2024; however, the HIV/AIDS training was not completed at the time of the inspection.
Employee # 24 was hired as a BHT supervisor on October 7, 2020 and was due to have the HIV/AIDS training no later than October 7, 2022; however, the HIV/AIDS training was not completed until August 26, 2023.
Employee # 25 was hired as an admissions coordinator on November 13, 2021 and was due to have the HIV/AIDS training no later than November 13, 2023; however, the HIV/AIDS training was not completed at the time of the inspection.
Employee # 26 was hired as a behavioral health technician on July 25, 2022 and was due to have the HIV/AIDS training and the TB/STD training no later than July 25, 2024; however, both the HIV/AIDS training and the TB/STD training were not completed at the time of the inspection.
This is a repeat citation from the September 7, 2023 through September 8, 2023 annual licensing renewal inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The HR Director (or designee) is responsible for monitoring and ensuring completion of the required communicable disease trainings within the regulatory timeframes. Moving forward as of 10/1/24, all new candidates for positions in the organization will be required to complete and provide HR with evidence of completion for the requisite trainings (HIV/AIDS and TB/STD) as part of their onboarding process. All identified staff cited have been notified and are required to complete these same trainings by 12/31/24 through the state's training website and/or through live BHTEN trainings as they become available. The HR Director and their staff will monitor ongoing compliance with mandatory training sessions and due dates for all employees and review findings with department managers. Any variances will be reported monthly to management team for review in rehab dashboard meeting. |
704.11(f)(2) LICENSURE Trng Hours Req-Coun
704.11. Staff development program.
(f) Training requirements for counselors.
(2) Each counselor shall complete at least 25 clock hours of training annually in areas such as:
(i) Client recordkeeping.
(ii) Confidentiality.
(iii) Pharmacology.
(iv) Treatment planning.
(v) Counseling techniques.
(vi) Drug and alcohol assessment.
(vii) Codependency.
(viii) Adult Children of Alcoholics (ACOA) issues.
(ix) Disease of addiction.
(x) Aftercare planning.
(xi) Principles of Alcoholics Anonymous and Narcotics Anonymous.
(xii) Ethics.
(xiii) Substance abuse trends.
(xiv) Interaction of addiction and mental illness.
(xv) Cultural awareness.
(xvi) Sexual harassment.
(xvii) Developmental psychology.
(xviii) Relapse prevention.
(3) If a counselor has been designated as lead counselor supervising other counselors, the training shall include courses appropriate to the functions of this position and a Department approved core curriculum or comparable training in supervision.
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Observations
Based on a review of personnel records, the facility failed to ensure each counselor completed at least 25 clock hours of training annually, during the facility's July 1, 2023 through June 30, 2024 training year, in two of four applicable personnel records reviewed.
Employee # 18 was hired as a counselor on July 19, 2005. The personnel record documented 19 hours of training received during the training year reviewed.
Employee # 20 was hired as a counselor on December 21, 2010. The personnel record documented 21 hours of training received during the training year reviewed.
This is a repeat citation from the September 7, 2023 through September 8, 2023 annual licensing renewal inspection.
These finding were reviewed with facility staff during the licensing process.
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Plan of Correction
The HR Director (or designee) is responsible for monitoring and ongoing compliance with mandatory training hours and due dates for relevant employees. While it was noted that employee #20 was on medical leave during the training year and just recently resigned and no longer with the organization, moving forward the organization understands that we may request an exception in any related cases should they occur. Moving forward, we have also moved our training year to coincide with the calendar (rather than fiscal) year and ongoing progress findings will be shared monthly with department managers for follow-up with their staff as the training calendar year progresses in order to ensure that managers stay aware of and involved in their staff's ongoing development and training. Any variances will be reported monthly to the management team for review in rehab dashboard meeting. |
704.12(a)(6) LICENSURE OutPatient Caseload
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.
(6) Outpatients. FTE counselor caseload for counseling in outpatient programs may not exceed 35 active clients.
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Observations
Based on a review of personnel records and the Staffing Requirements Facility Summary Report, the facility failed to ensure the FTE counselor caseload in outpatient programs did not exceed 35 active clients in one of one applicable personnel records reviewed.
The counselor Full Time Equivalent (FTE) is determined by dividing the total number of hours the counselor devotes to their clients by the facility's workweek. Then, in order to obtain the client/counselor ratio, the total number of clients on the counselor's outpatient caseload is divided by the FTE.
Employee # 18 was hired as a counselor on July 19, 2005 and was still in the position at the time of the inspection. The client/counselor ratio calculation was as follows: 20 / 40 = 0.5(FTE); 25 / 0.5 = 50, which equals to a FTE client/counselor ratio of 50:1.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
The Program Director (or designee) is responsible for ensuring compliance with appropriate client to counselor ratios. Moving forward, we have identified appropriate Nursing staff currently in-house who meet the qualifications/ training requirements to act as counselors under ACT 66 who will work in the Outpatient (OP) program and carry a caseload and provide counseling services to comply with and not exceed the regulatory ratios. The Program Manager (or designee) will monthly review staff/client ratios to ensure that the FTE counselor caseload does not exceed 35 active clients.
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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, the facility failed to 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.
On August 28, 2024, at approximately 11:40 AM, there was a broken windowpane in the window of Room 705/Group Room #1 within the outpatient area of the facility.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
The Property Manager is responsible for maintenance of the physical grounds and the broken window identified in Room 705 was repaired on 9/18/24. The Property Manager will ensure that ongoing routine weekly Environment of Care rounds include the Outpatient area, and any items identified in need of repair will be reported and addressed in a timely manner. |
709.24 (a) (3) LICENSURE Treatment/rehabilitation management.
§ 709.24. Treatment/rehabilitation management.
(a) The governing body shall adopt a written plan for the coordination of client treatment and rehabilitation services which includes, but is not limited to:
(3) Written procedures for the management of treatment/rehabilitation services for clients.
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Observations
Based on review of client records and the policy and procedure manual, the facility failed to follow the project's written procedures for the management of treatment/rehabilitation services in one of one applicable client record reviewed.
The facility policy and procedure manual stated that the emergency contact will be notified within 12 hours of a patient's discharge against medical advice.
Client #3 was admitted to the detoxification level of care on March 18, 2024 and left against medical advice on March 29, 2024. The facility had until March 30, 2024 to notify the emergency contact of the AMA discharge; however, the emergency contact was not notified by the facility until April 11, 2024.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
The therapist who was responsible for the late documentation of attempted outreach to the Emergency Contact (EC) is no longer with the organization since April 2024 so is not available for any re-education/remediation. Nurse Managers are responsible for follow-up with EC notification within 12 hours of discharge and have been provided re-education to ensure compliance with such documentation in the event of a patient's discharge against medical advice. Also, in the event that the patient fails to identify or refuses to provide an EC and there is none listed this will be documented in the patient record at point of admission by the admission staff. Medical Records will conduct monthly chart audits to ensure EC documentation is in compliance with stated facility guidelines and report any variances for follow-up to appropriate managers if/when they occur.
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709.28 (b) LICENSURE Confidentiality
§ 709.28. Confidentiality.
(b) The project shall secure hard copy client records within locked storage containers. Electronic records must be stored on secure, password protected data bases.
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Observations
Based on a physical plant inspection, conducted on August 28, 2024, between 10:00 AM and 12:00 PM, the project failed to secure hard copy client records within locked storage containers. During the inspection, there were client records and other client-related documentation found unsecured in room #'s 321, 439, 523, and 701.
This is a repeat citation from the September 7, 2023 through September 8, 2023 annual licensing renewal inspection and the April 13, 2023 through April 14, 2023 provisional license follow-up inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
All staff members are responsible for maintaining confidentiality of client records in their offices. As of 8/28/24, the Program Director has instructed all Clinical Manager/Supervisors to monitor their assigned staff's offices to ensure that staff members whose offices were cited are provided re-education regarding confidentiality of client records and maintaining any PHI within locked storage containers. Also, those managers must check their assigned staffs' offices when any individual goes on an extended leave of absence or has left the organization to ensure any PHI is appropriately secured. Leadership is also exploring an electronic medical record system to be in place by 2025 which will help to alleviate such issues in the future. |
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 project failed to obtain a written informed and voluntary consent from the client for the disclosure of information contained in the client record in three of twenty-one client records.
Client #3 was admitted to the detoxification level of care on March 18, 2024 and was discharged on March 29, 2024. There was documentation of disclosures to an emergency contact on April 11, 2024; however, there was no release of information form signed by the client documented in the record prior to the disclosures.
Client # 17 was admitted to the outpatient maintenance level of care on June 9, 2022 and was still active at the time of the inspection. The release of information form to the funding source was signed by the client on December 2, 2023 and the form expired on May 30, 2024. An updated release of information form to the funding source was signed on July 4, 2024; however, there was evidence of disclosures to the funding source after the initial release form expired on May 30, 2024 and before the updated release form was signed on July 4, 2024.
Client # 21 was admitted to the outpatient maintenance level of care on January 12, 2023 and was discharged on January 24, 2024. The release of information form to the funding source was signed by the client on July 9, 2023 and the form expired on January 5, 2024. There was evidence of disclosures to the funding source after the release of information form expired; however, there was no updated consent to release information form signed by the client documented in the record prior to any of the disclosures made after January 5, 2024.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
All counselors are responsible for obtaining and maintaining appropriate releases of information in their patient records. The two counselors responsible in these cited cases in detox and outpatient were met with by their Clinical Manager on 9/13/24 and re-educated regarding their responsibility with obtaining and/or maintaining voluntary consents prior to any release of information to a third party. Compliance Analyst will conduct random monthly validation audits in both programs to monitor adherence with this regulation and any variances identified will be brought to the attention of the Program Director and Clinical Manager for remediation, and findings discussed monthly in rehab dashboard meeting. |
709.28 (c) (1) 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:
(1) Name of the person, agency or organization to whom disclosure is made.
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Observations
Based on a review of client records, the project failed to document the name of the person, agency, or organization to whom a disclosure was to be made to on a release of information form in one of twenty-one client records reviewed.
Client #7 was admitted to the detoxification level of care on August 27, 2024 and was active at the time of the inspection. A release of information form to a physician was signed and dated by the client on August 27, 2024; however, the name of the physician, agency or organization was not documented on the release form.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
The Admission Manager (or designee) is responsible for completion of all ROI consents obtained during the admission process. Client #7 is no longer active so the deficiency cannot be corrected. Starting 10/1/24 the Admission Manager will conduct random weekly audits of completed ROI consent forms for a period of 2 months to ensure that any release of information form documentation is adhered to per regulations and will conduct remediation with staff upon any findings. Medical Records will also conduct monthly validation audits, and any variances identified will be brought to the attention of the Admissions Manager immediately for remediation, and findings discussed monthly in rehab dashboard meeting."
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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 a review of client records, the project failed to document the specific information to be released on consent to release information forms in two of twenty-one client records reviewed.
Client #14 was admitted to the inpatient non-hospital level of care on June 20, 2024 and was active at the time of the inspection. A release of information form to probation and parole was signed by the client on August 23, 2024; however, the specific information to be disclosed was not documented on the release form. Additionally, a release of information form to a government agency was signed by the client on July 31, 2024; however, the specific information to be disclosed was not documented on the release form.
Client #15 was admitted to the outpatient maintenance level of care on June 17, 2023 and was still active at the time of the inspection. A release of information form to the emergency contact was signed by the client on December 13, 2023; however, the specific information to be disclosed was not documented on the release form.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
All counselors are responsible for fully and accurately completing release of information forms including the specific information to be disclosed. The two counselors responsible in these cited cases in inpatient and outpatient were met with by their Clinical Manager on 9/13/24 and were re-educated regarding this regulation and the deficiencies corrected in both cases (#14 and #15). The Compliance Analyst will conduct random monthly validation audits in both programs to monitor adherence with this regulation and any variances identified will be brought to the attention of the Program Director and Clinical Manager for remediation, and findings discussed monthly in rehab dashboard meeting.
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709.28 (c) (3) 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:
(3) Purpose of disclosure.
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Observations
Based on a review of client records, the project failed to document the purpose of the disclosure on consent to release information forms in two of twenty-one client records reviewed.
Client #14 was admitted to the inpatient non-hospital level of care on June 20, 2024 and was active at the time of the inspection. A release of information form to probation and parole was signed by the client on August 23, 2024; however, the purpose of the disclosure was not documented on the release form. Additionally, a release of information form to a government agency was signed by the client on July 31, 2024; however, the purpose of the disclosure was not documented on the release form.
Client #15 was admitted to the outpatient maintenance level of care on June 17, 2023 and was still active at the time of the inspection. A release of information form to the emergency contact was signed by the client on December 13, 2023; however, the purpose of the disclosure was not documented on the release form.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
All counselors are responsible for fully and accurately completing release of information forms including the purpose for the disclosure. The two counselors responsible in these cited cases in inpatient and outpatient were met with by their Clinical Manager on 9/13/24 and were re-educated regarding this regulation and the deficiencies corrected in both cases (#14 and #15). The Compliance Analyst will conduct random monthly validation audits in both programs to monitor adherence with this regulation and any variances identified will be brought to the attention of the Program Director and Clinical Manager for remediation, and findings discussed monthly in rehab dashboard meeting.
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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 patient records, the project failed to ensure a copy of a client consent to release information form was offered to the client in two of twenty-one client records reviewed.
Client #14 was admitted to the inpatient non-hospital level of care on June 20, 2024 and was active at the time of the inspection. A release of information form to probation and parole was signed by the client on August 23, 2024; however, there was no documentation indicating that a copy of the consent form was offered to the client. Additionally, a release of information form to a government agency was signed by the client on July 31, 2024; however, there was no documentation indicating that a copy of the consent form was offered to the client.
Client #16 was admitted to the outpatient maintenance level of care on March 10, 2024 and was still active at the time of the inspection. A release of information form to another treatment provider was signed by the client on March 10, 2024; however, there was no documentation indicating that a copy of the consent form was offered to the client.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
All counselors are responsible for fully and accurately completing release of information forms including documenting that a copy of the consent to release information was offered to the client. The two counselors responsible in these cited cases in inpatient and outpatient were met with by their Clinical Manager on 9/13/24 and were re-educated regarding this regulation and the deficiencies corrected in both cases (#14 and #16). The Compliance Analyst will conduct random monthly validation audits in both programs to monitor adherence with this regulation and any variances identified will be brought to the attention of the Program Director and Clinical Manager for remediation, and findings discussed monthly in rehab dashboard meeting.
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715.9(a)(2) LICENSURE Intake
(a) Prior to administration of an agent, a narcotic treatment program shall screen each individual to determine eligibility for admission. The narcotic treatment program shall:
(2) Verify the individual 's identity, including name, address, date of birth, emergency contact and other identifying data.
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Observations
Based on a review of patient records, the narcotic treatment program failed to verify the emergency contact, as part of the individual ' s identity to determine eligibility for admission and prior to the administration of an agent, in five of sixteen patient records reviewed.
Patient #2 was admitted to the detoxification level of care on December 4, 2023 and was discharged on December 9, 2023. There was no documentation verifying the patient's emergency contact in the record at the time of the inspection.
Patient #3 was admitted to the detoxification level of care on March 18, 2024 and was discharged on March 29, 2024. There was no documentation verifying the patient's emergency contact in the record at the time of the inspection.
Patient #6 was admitted to the detoxification level of care on August 25, 2024 and active at the time of the inspection. There was no documentation verifying the patient's emergency contact in the record at the time of the inspection.
Patient #8 was admitted to the inpatient non-hospital level of care on November 17, 2023 and was discharged on January 10, 2024. There was no documentation verifying the patient's emergency contact in the record at the time of the inspection.
Patient #12 was admitted to the inpatient non-hospital level of care on December 9, 2023 and was discharged on December 10, 2023. There was no documentation verifying the patient's emergency contact in the record at the time of the inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Admission Manager (or designee) is responsible for completion of all Release of Information (ROI) consents obtained during the admission process. Starting 9/23/24, in the event that an Emergency Contact (EC) has not been identified by the patient or they have refused or are unable to identify or designate anyone, Admission staff will maintain a blank EC ROI form in the record and utilize a "stamp" on the ROI indicating that the patient was either unwilling or unable to identify an EC. Medical Records will conduct routine chart audits for the presence of either a completed EC ROI or one that has been stamped if the patient refused or was unable to identify someone for that function. In the event of any variances, the Admissions Manager will be notified immediately for remediation with their staff, and findings discussed monthly in rehab dashboard meeting. |
715.9(b)(2) LICENSURE Intake
(b) Exceptions to the requirements in subsection (a) are:
(2) Upon readmitting a patient who has been out of a narcotic treatment program for 6 months or less after a voluntary termination, the narcotic treatment program shall update the information in and review the patient 's file to show current opiate narcotic dependency, but need not conduct a physical examination and applicable laboratory tests. Privileges earned during the previous treatment may be reinstated at the discretion of the narcotic treatment physician.
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Observations
Based on a review of patient records, the narcotic treatment program failed to review and update the information in the patient's file to show current opiate narcotic dependency upon readmitting a patient who has been out of a narcotic treatment program for 6 months or less in one of one applicable patient records reviewed.
Patient # 16 was discharged on December 2, 2023, then readmitted to the narcotic treatment program on March 10, 2024 and was still active at the time of the inspection. At the time of the inspection, there was no documentation indicating the patient ' s file was reviewed and updated to show current opiate narcotic dependency upon readmission.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
The Medical Director (or designee) is responsible for documentation of information in the patient record related to current opiate narcotic dependency. In review of this Patient #16's record, there was an unbroken chain of continued Methadone maintenance from our Outpatient clinic and while the patient was incarcerated for a period of 3 months up through their return to our clinic upon being released. The patient was readmitted after verification of their last dose and their MAT was continued by the Medical Director upon their return after meeting with the patient and review of the appropriate dosage information. As of 9/10/24, the Medical Director has been educated about this regulation in order to ensure that they will document in the record any such re-evaluation of an individual who has been readmitted after being away from the program for 6 months or less after a voluntary termination. Any such cases that arise in the future will also be monitored by the Dosing Nurse for ongoing compliance and any variances brought to the Medical Director's attention for remediation. |
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.
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Observations
Based on a review of patient records, the narcotic treatment program failed to document the completion of an initial drug-screening analysis for each prospective patient and a random urinalysis at least monthly thereafter in five of twenty-one patient records reviewed.
Patient #10 was admitted to the inpatient non-hospital level of care on December 24, 2023 and was discharged on March 11, 2024. There was no drug screen urinalysis documented during the month of February 2024.
Patient #11 was admitted to the inpatient non-hospital level of care on November 26, 2023 and was discharged on March 5, 2024. There was no drug screen urinalysis documented during the month of February 2024.
Patient #14 was admitted to the inpatient non-hospital level of care on June 20, 2024 and was active at the time of the inspection. There was no drug screen urinalysis documented during the month of July 2024.
Patient #16 was admitted to the outpatient maintenance level of care on March 10, 2024 and was active at the time of the inspection. The initial urine drug screen was completed on March 11, 2024; however, the patient received their initial dose of medication on March 10, 2024. Additionally, There was no drug screen urinalysis documented during the month of May 2024.
Patient #18 was admitted to the outpatient maintenance level of care on March 1, 2024 and was active at the time of the inspection. The initial urine drug screen was completed on March 22, 2024; however, the patient received their initial dose of medication on March 2, 2024.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Senior Nurse Managers are responsible for monitoring and ensuring ongoing completion for those clients requiring monthly random urinalysis as per stated regulation. They will cross-reference those individuals' completed urinalysis with the census sheet to ensure that all names listed for collection have been completed, results received and filed, and follow-up with unit staff as needed. Also, the Senior Nurse Managers are responsible for monitoring and ensuring ongoing completion of initial urinalysis by the outpatient Dosing Nurse for any patients admitted or readmitted to outpatient and has instructed the Dosing Nurse to obtain an initial urinalysis upon the admission or readmission of a client. Any variances identified will be reported to the Executive Nurse Manager (or designee) and followed up within 24 hours to ensure that a UDS is obtained. Any outstanding variances will be reported monthly during rehab dashboard meeting. |
715.20(1) 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.
(1) The transferring narcotic treatment program shall transfer patient files which include admission date, medical and psychosocial summaries, dosage level, urinalysis reports or summary, exception requests, and current status of the patient, and shall contain the written consent of the patient.
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Observations
Based on a review of patient records, the narcotic treatment program failed to transfer patient files, which is to include the admission date, medical and psychosocial summaries, dosage level, urinalysis reports or summary, exception requests, and the current status of the patient in five of five applicable patient records reviewed.
Patient #8 was admitted to the inpatient non-hospital level of care on November 17, 2023 and was transferred to another narcotic treatment program on January 10, 2024. There was no documentation, in the record, indicating the receiving narcotic treatment program was provided the medical and psychosocial summaries, urinalysis reports or summary, exception requests, and the current status of the patient.
Patient #9 was admitted to the inpatient non-hospital level of care on November 24, 2023 and was transferred to another narcotic treatment program on January 22, 2024. There was no documentation, in the record, indicating the receiving narcotic treatment program was provided the medical and psychosocial summaries, urinalysis reports or summary, exception requests, and the current status of the patient.
Patient #10 was admitted to the inpatient non-hospital level of care on December 24, 2023 and was transferred to another narcotic treatment program on March 11, 2024. There was no documentation, in the record, indicating the receiving narcotic treatment program was provided the medical and psychosocial summaries, urinalysis reports or summary, exception requests, and the current status of the patient.
Patient #11 was admitted to the inpatient non-hospital level of care on November 26, 2023 and was transferred to another narcotic treatment program on March 5, 2024. There was no documentation, in the record, indicating the receiving narcotic treatment program was provided the medical and psychosocial summaries, urinalysis reports or summary, exception requests, and the current status of the patient.
Patient #13 was admitted to the inpatient non-hospital level of care on January 30, 2024 and was transferred to another narcotic treatment program on March 11, 2024. There was no documentation, in the record, indicating the receiving narcotic treatment program was provided the medical and psychosocial summaries, urinalysis reports or summary, exception requests, and the current status of the patient.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Clinic Coordinator is responsible for transferring patient files which include admission date, medical and psychosocial summaries, dosage level, urinalysis reports or summary, exception requests, and current status of the patient, along with the written consent of the patient. Previously upon discharge and transfer to another narcotic treatment program (NTP), the full packet of aforementioned information was sent in all cases in which our facility initiated MAT and transferred them to another narcotic treatment program, and only written consent, last dosage, admission and discharge dates with summary in cases where the client was already an open case at an existing narcotic treatment program. As of 9/12/24, the Coordinator has been educated that they are required to send all the required elements to all narcotic treatment programs upon discharge/transfer and file evidentiary documentation in the patient record. The Compliance Analyst will conduct random monthly validation audits to monitor adherence with this regulation and any variances identified will be brought to the attention of the Program Director and Clinical Manager for remediation, and findings discussed monthly in rehab dashboard meeting. |
715.21(2) LICENSURE Patient termination
A narcotic treatment program shall develop and implement policies and procedures regarding involuntary terminations. Involuntary terminations shall be initiated only when all other efforts to retain the patient in the program have failed.
(2) A patient terminated involuntarily, except a patient who commits or threatens to commit acts of physical violence, shall be afforded the opportunity to receive detoxification of at least 7 days. The detoxification may take place at the facility or the patient may be referred to another narcotic treatment program or hospital licensed and approved by the Department for detoxification.
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Observations
Based on a review of patient records, the narcotic treatment program failed to provide an involuntarily terminated patient with an opportunity to receive detoxification of at least 7 days in one of one applicable patient records reviewed.
Patient #4 was admitted to the detoxification level of care on July 31, 2024 and was administratively discharged on August 5, 2024. There was documentation stating the patient was involuntarily terminated from the program; however, there was no documentation showing that the patient was given an opportunity to receive detoxification of at least 7 days.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
Clinical Managers are responsible for reviewing Administrative Discharges. Upon review of the patient #4 file, client was on open case at an existing narcotic treatment program and was to have returned there to continue their dose rather than receive detoxification, but this was not clearly documented. To resolve this issue we have updated the involuntary discharge document as of 9/23/24 to include verbiage evidencing that clients are informed of the opportunity to receive detoxification of at least 7 days at the facility or may be referred to another narcotic treatment program, excepting cases in which a patient commits or threatens to commit acts of physical violence. Staff have also been notified of this information and updated document. Moving forward, Compliance Analyst will conduct an audit for 60 days to confirm compliance with use of the updated and completed document in all Administrative Discharge cases that arise and report any variances to clinical managers for remediation with staff.
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709.17(a)(3) LICENSURE Subchapter B.Licensing Procedures.Refusal/rev
709.17. Refusal or revocation of license.
(a) The Department may revoke or refuse to issue a license for any of the following reasons:
(3) Failure to comply with a plan of correction approved by the Department, unless the Department approves an extension or modification of the plan of correction.
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Observations
Based on a physical plant inspection and an administrative review, the facility failed to comply with plans of correction that were approved by the Department.
Plans of correction for not securing hard copy client records within locked storage containers were submitted an approved by the Department for the September 7, 2023 through September 8, 2023 annual licensing renewal inspection and the April 13, 2023 through April 14, 2023 provisional license follow-up inspection. Not securing hard copy client records within locked storage containers was again found to be a deficiency in the August 27, 2024 through August 29, 2024 annual licensing inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
To address deficiency in following prior approved POC and ensure follow-through of the POC moving forward, starting 10/14/24 the ED is responsible for and will conduct ongoing random observations of staff offices for the safe security/storage of PHI and monitor ongoing compliance. Any findings will be immediately reviewed in the daily leadership meeting for follow-up disciplinary action by managers with their respective staff responsible for such deficiencies. For PI purposes, POC data will be analyzed and findings reported monthly to leadership in Rehab Dashboard meetings for ongoing awareness and remediation (when necessary) in efforts to ensure deficiencies do not recur.
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