INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on October 19-20, 2015 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Parkside Recovery 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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709.26(d)(5)(i) LICENSURE Personnel Management
709.26. Personnel management.
(d) The personnel records shall include, but not be limited to:
(5) Work performance evaluation including the following:
(i) Individual staff performance shall be evaluated at least annually.
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Observations
Based on a review of personnel records, the facility failed to document an annual performance evaluation in two of four applicable personnel records.
The findings include:
Four personnel records requiring documentation of an annual performance evaluation were reviewed on October 19-20, 2015. The facility failed to document an annual performance evaluation in personnel records, #3 and 4.
Employee # 3 was hired as a counselor on September 2, 2008. The annual performance evaluation was due to be completed by September 2, 2015. There was no documentation of the completion of a performance evaluation in this employee's record at the time of the inspection.
Employee # 4 was hired as a counselor on May 18, 2009. The annual performance evaluation was due to be completed by May 18, 2015. There was no documentation of the completion of a performance evaluation in this employee's 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
Following a change in administration management staff is in the process of completing the outstanding performance evaluations. Performance Evaluations for Employee #3 and Employee #4 were completed 12/16/15. Program Director will develop and follow a calendar schedule to update all Performance Evaluations. All evaluation with again be completed in September 2016 to prevent a lag in completion 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. The consent shall be in writing and include, but not be limited to:
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Observations
Based on the review of client records, the facility failed to ensure that an informed and voluntary consent to release information form was obtained in one of twenty-one client records reviewed.
The findings included:
Twenty-one client records requiring complete informed and voluntary consent to release information forms were reviewed on October 19, 2015 through October 20, 2015. The facility failed to ensure that an informed and voluntary consent to release information form was obtained in client record # 2.
Client # 2 was admitted into treatment on July 31, 2014 and was still an active client at the time of the inspection. There were a total of 7 separate release of information forms in the client record - 4 consents were to four separate funding sources, 1 consent to a transportation company, 1 consent to the urinalysis lab, and 1 to the emergency contact - and they were all signed and dated on 7/31/2014. All 7 consent forms had an expiration date of 7/31/2015. There were no updated and current consent forms for all 7 entities documented in the client 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 releases were filed in the chart to complete the record February 17, 2016. The releases were completed on July 30, 2015 and were not filed in the chart at the time of audit. Internal staff training was conducted on Thursday December 3, 2015 by the Program Director to review how to properly complete Client Consent to Release Information. The training addressed and stressed the importance of maintaining up to date and current records for releasing client information at all times as well as informed and voluntary consent to release information forms are obtained. The Clinical Supervisor and Program Director will conduct weekly random chart audits and document on the Chart Monitoring Tool to ensure accuracy. The Clinical Supervisor will also discuss and document chart audit reviews on a monthly Supervision Form with Counselors on a monthly basis to ensure this deficiency does not reoccur. |
709.32(b) LICENSURE Medication Control
709.32. Medication control.
(b) Verbal medication orders may be accepted but shall be put in writing and signed within 24 hours thereafter by the prescribing physician.
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Observations
Based on a review of patient records, the facility failed to ensure that the narcotic treatment physician signed and dated a verbal order within the required regulatory 24 hour timeframe in one of twelve patient records reviewed.
The findings include:
Patient #13 was admitted into methadone maintenance treatment on May 26, 2015 and was still an active patient. A verbal order given by the NTP's medical director was received, signed, and dated by an LPN on June 18, 2015; however, it was not signed/dated by the prescribing narcotic treatment physician within the regulatory 24 hour timeframe.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Nursing Supervisor implemented a plan of action on 10/27/15 to ensure verbal orders are signed and dated within 24 hours from the ordering physician. If the respective physician remains off site within the allotted time frame, the verbal order is scanned and emailed. The physician confirms by signature on the order, and sends a hard copy to Parkside Germantown by interoffice mail for proper record keeping. When the physician is on site within 24 business hours, the order is confirmed by signature by the physician and filed. Parkside Germantown has recently acquired a consistent physician. Once this particular physician is acclimated to the NHS system, she will become responsible for giving and signing all verbal orders for program participants. |