INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection and methadone monitoring inspection conducted on July 16 - 17, 2018 by staff from the Department of Drug and Alcohol Programs, Bureau of Quality Assurance for Prevention and Treatment, Division of Accountability and Program Improvement. Based on the findings of the on-site inspection, Charleroi Treatment Services LLC 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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705.28 (d) (1) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(1) Conduct unannounced fire drills at least once a month.
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Observations
The facility failed to document alternate exit routes were used during the monthly fire drills conducted from December 2017 through June 2018 based on a review of fire drill records on July 16, 2018.
The fire drill record indicated the side exit was the only exit used for all fire drills.
In addition, the facility failed to document whether or not the fire alarm/smoke detector was activated during fire drills for the following months: December 2017 and March through June 2018.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
As of July 2018, the facility will begin conducting fire safety drills utilizing all alternate exit routes. Appointed Fire and Safety officer will ensure compliance by setting off the smoke detector, again, alternating exit routs, as well as the completion of monthly fire safety forms. Effective 8/1/18 |
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
The facility did document an informed and voluntary consent from the client for the disclosure of information contained in the client record. However, the facility failed to adhere to the requirements in the federal confidentiality regulations by requiring the client to revoke the consent in writing in eight of nine client records reviewed on July 16 - 17, 2018.
The consent to release information form included the following statement: "If I revoke this authorization, I need to do so in writing and mail or hand deliver it to the HIPAA Privacy Officer of the Pinnacle Provider Entity named above, at the address set forth above."
Client # 1 was admitted on January 9, 2018. The consents were signed by the client on January 9, 2018.
Client # 2 was admitted on November 27, 2017 and discharged on March 21, 2018. The consents were signed by the client on November 27, 2017.
Client # 3 was admitted on April 26, 2018. The consents were signed by the client on June 15, 2018.
Client # 4 was admitted on December 11, 2017 and discharged on June 19, 2018. The consents were signed by the client on December 11, 2017, January 23, 2018 and January 30, 2018.
Client # 5 was admitted on January 30, 2018. The consents were signed by the client on January 30, 2018.
Client # 6 was admitted on December 18, 2017 and discharged on April 12, 2018. The consents were signed by the client on December 18, 2017.
Client # 7 was admitted on December 4, 2017 and discharged on April 14, 2018. The consents were signed by the client on December 4, 2017.
Client # 8 was admitted on January 9, 2018 and discharged on May 14, 2018. The consents were signed by the client on January 9, 2018.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Executive Director and Clinical Staff will renew and update all release of authorizations beginning July 2018. E.D will monitor the signed releases through weekly audits reports. These forms have been revised by removing the statement that requires written revocation. Effective Immediately. |
709.32 (b) LICENSURE Medication control
§ 709.32. Medication control.
(b) Verbal orders for medication can be given only by a physician or other medical professional authorized by State and Federal law to prescribe medication and verbal orders may be received only by another physician or medical professional authorized by State and Federal law to receive verbal orders. When a verbal or telephone order is given, it has to be authenticated in writing by a physician or other medical professional authorized by State and Federal law to prescribe medication. In detoxification levels of care, written authentication shall occur no later than 24 hours from the time the order was given. Otherwise, written authentication shall occur within 3 business days from the time the order was given.
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Observations
The facility failed to ensure that verbal orders for methadone were given only by a physician authorized by State and Federal law to prescribe medication in one of nine client records reviewed on July 16 - 17, 2018.
The Licensed Practical Nurse (LPN) gave and documented a verbal order for a 10 mg increase of methadone for client # 9 on June 9, 2018. An LPN is not authorized to give a verbal medication order. Client # 9 was admitted on May 22, 2018 and discharged on June 19, 2018.
The facility failed to ensure that verbal orders were received only by another physician or medical personnel authorized by State and Federal law to received verbal orders in two of nine client records.
A staff person that is not authorized medical personnel received and documented verbal orders from the physician in the following client records.
Client # 2 was admitted on November 27, 2017 and discharged on March 21, 2018. A verbal order for changing the patient's take home medication days to Wednesday, Saturday, and Sunday was documented on January 19, 2018.
Client # 8 was admitted on January 9, 2018 and discharged on May 14, 2018. A verbal order for a 10 mg increase of methadone was documented on March 12, 2018.
In addition, the physician failed to authenticate in writing a verbal order within three business days in client record # 2.
Client # 2 was admitted on November 27, 2017 and discharged on March 12, 2018. The physician issued a verbal order for take home medication on November 29, 2017. The physician did not authenticate this order in writing until December 12, 2017.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The LPN in question was given a final written warning, by E.D, addressing the procedure violation. Medical Director was also informed of her responsibilities, by E.D, and the correct procedure that needs taken place. Executive Director reviewed policies and procedures with both Medical Director and nursing staff as well as non-medical staff. This included management of verbal orders, as well as a visual training of appropriate process submission of requests through SMART. Medical director will review all verbal orders prior to request of electronic submission.
Effective Immediately.
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715.17(c)(1)(i-vi)) LICENSURE Medication control
(c) A narcotic treatment program shall develop and implement written policies and procedures regarding the medications used by patients which shall include, at a minimum:
(1) Administration of medication.
(i) A narcotic treatment physician shall determine the patient 's initial and subsequent dose and schedule. The physician shall communicate the initial and subsequent dose and schedule to the person responsible for the administration of medication. Each medication order and dosage change shall be written and signed by the narcotic treatment physician.
(ii) An agent shall be administered or dispensed only by a practitioner licensed under the appropriate Federal and State laws to dispense agents to patients.
(iii) Only authorized staff and patients who are receiving medication shall be permitted in the dispensing area.
(iv) There shall be only one patient permitted at a dispensing station at any given time.
(v) Each patient shall be observed when ingesting the agent.
(vi) Administering and dispensing shall be conducted in a manner that protects the patient from disruption or annoyance from other individuals.
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Observations
The facility failed to restrict the determination of the patient's dose to the physician in one of nine patient records reviewed on July 16 - 17, 2018.
The facility's LPN (licensed practical nurse) ordered a 10 mg increase of methadone for patient # 9 on June 9, 2018. State and Federal laws/regulations do not permit a LPN to order medication.
Patient # 9 was admitted May 22, 2018 and discharged on June 19, 2018.
The findings were reviewed with and confirmed by facility staff.
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Plan of Correction
Executive Director reviewed policies and procedures with both Medical Director and nursing staff. This included management of verbal orders, as well as a visual training of appropriate process submission of requests through SMART. Only the physician will be permitted to dose and to issue medication orders. Medical director will review all verbal orders prior to request of electronic submission. Executive Director issued a final warning to the LPN to address the dosing concern.
Effective Immediately.
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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
The facility failed to document the transfer of required patient file information to the receiving narcotic treatment program in two of three patient records reviewed on July 16 - 17, 2018.
Patient # 2 was admitted on November 27, 2017 and transferred to another narcotic treatment program on March 21, 2018.
Patient # 4 was admitted on December 11, 2017 and transferred to another narcotic treatment program on June 19, 2018.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Transfer Checklist was developed by Executive Director. Executive Director trained and reviewed the transfer checklist with all staff. E.D will monitor use of transfer checklist, via weekly chart audits, along with discharged patient's audits. Executive director will ensure all required transfer documents are sent to the receiving treatment program and documentation will be in the patient's record. Effective Immediately. |