INITIAL COMMENTS
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Based on the concerns arising from COVID-19, The Department of Drug and Alcohol Programs, Bureau of Program Licensure, has implemented temporary procedures for conducting an annual renewal inspection.
The inspection will be divided into two parts.
1, an abbreviated off-site inspection, will be conducted off site, and will require the submission of administrative information via email to a Licensing Specialist.
2, an abbreviated on-site inspection, will be conducted on-site at a later date and will include a review of client/patient records, and a physical plant inspection.
This report is a result of Part 2, an abbreviated on-site inspection, conducted on March 8, 2021 by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Not all regulations were reviewed, the remainder of the regulations were reviewed during Part 1.
Based on the findings of Part 2, an abbreviated on-site inspection, RHD Womanspace was found not to be in compliance with the applicable chapters of 28 PA Code which pertain to the facility. The following deficiencies were identified during this inspection:
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Plan of Correction
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705.7 (b) (5) LICENSURE Food service.
705.7. Food service.
(b) A residential facility may operate a central food preparation area to provide food services to multiple facilities or locations. A residential facility that operates an onsite food preparation area or a central food preparation area shall:
(5) Keep cold food at or below 40F, hot food at or above 140F, and frozen food at or below 0F.
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Observations
Based on a physical plant inspection, the facility failed to ensure that frozen food was kept at or below 0 degrees Fahrenheit. At approximately 5:05 PM on March 8, 2021, the freezer temperature was measured at 10 degrees Fahrenheit.
This finding was reviewed with facility staff during the licensing inspection.
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Plan of Correction
Program Director had all food moved to an alternate freezer on 3/8/21 until the freezer could be serviced by the repair company. Program Director and/or Site Supervisor will review temperature logs for refrigerators and freezers weekly to ensure that all temperatures are within the required range. The importance of completing temperature check logs and requirement for staff to communicate immediately around any refrigerator or freezer not working will be reviewed with all Community Care Specialists to ensure understanding and compliance. |
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 patient records, the facility failed to obtain an informed, voluntary, written consent before an agent may be administered to the patient for maintenance or detoxification treatment in nine of nine applicable patient records reviewed.
Patient # 1 was admitted on February 14, 2020 and was discharged on February 23, 2020. There was no documentation of an informed, voluntary, written consent before an agent was administered to the patient for detoxification in the patient record.
Patient # 2 was admitted on July 17, 2019 and was discharged on July 29, 2019. There was no documentation of an informed, voluntary, written consent before an agent was administered to the patient for detoxification in the patient record.
Patient # 3 was admitted on February 14, 2020 and was discharged on February 23, 2020. There was no documentation of an informed, voluntary, written consent before an agent was administered to the patient for detoxification in the patient record.
Patient # 4 was admitted on February 26, 2021 and was discharged on March 17, 2020. There was no documentation of an informed, voluntary, written consent before an agent was administered to the patient for detoxification in the patient record.
Patient # 5 was admitted on August 10, 2020 and was discharged on August 12, 2020. There was no documentation of an informed, voluntary, written consent before an agent was administered to the patient for detoxification in the patient record.
Patient # 7 was admitted on February 23, 2020 and was still active at the time of the inspection. There was no documentation of an informed, voluntary, written consent before an agent was administered to the patient for maintenance in the patient record.
Patient # 10 was admitted on July 29, 2019 and was discharged on March 2, 2020. There was no documentation of an informed, voluntary, written consent before an agent was administered to the patient for maintenance in the patient record.
Patient # 11 was admitted on February 23, 2021 and was discharged on May 12, 2020. There was no documentation of an informed, voluntary, written consent before an agent was administered to the patient for maintenance in the patient record.
Patient # 12 was admitted on March 17, 2020 and was discharged on May 12, 2020. There was no documentation of an informed, voluntary, written consent before an agent was administered to the patient for maintenance in the patient record.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
All patients reviewed are discharged at this time. Program director will review all current patient files (not included in this review) for maintenance medications and ensure that written medication specific consents are signed by 4/6/21. Medication specific consents will be utilized with every new client provided buprenorphine for detoxification and/or maintenance from the date of the review moving forward.
Program Director will review the existing drug-specific medication consents for buprenorphine and naltrexone with the medical director and program psychiatrist and reinforce use of the specific consents each time that the medications are used. Program Director and Nurse Manager will also discuss the need to utilize drug-specific consents with nursing staff to ensure program compliance. Program Director and/or Nurse Manager will review all documentation following the prescription of buprenorphine to ensure that proper consents are utilized. |