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 February 4, 2021 through February 5, 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, The Consortium 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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705.22 (2) LICENSURE Building exterior and grounds.
705.22. Building exterior and grounds.
The nonresidential 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 clients, 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 clients, employees, and visitors. On February 4, 2021 at approximately 10:50 AM, there was an exterior glass windowpane in room 162 that was broken.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
By 2/22/21 the window in questions will be replaced. Facilities staff will continue to monitor for building damage for immediate resolution |
705.24 (3) LICENSURE Bathrooms.
705.24. Bathrooms.
The nonresidential facility shall:
(3) Have hot and cold water under pressure. Hot water temperature may not exceed 120F.
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Observations
Based on a physical plant inspection, the facility failed to have hot water under pressure in all facility bathrooms. On February 4, 2021 at approximately 10:30 AM, there was no running hot water in the bathroom located within room 154.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
Plan of Correction: By 2/19/21, hot water will be repaired in the sink in the staff break room. Facilities staff will continue to monitor all building sinks to ensure they remain in proper working order. |
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, the facility failed to secure hard copy client records within locked storage containers. On February 4, 2021 at approximately 10:15 AM, there were unsecured paper client records in the facility daycare room, the billing office, room 228 and room 236.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
Plan of Correction: By 2/22/21 Division Director will review confidentiality and safe record keeping practices with all staff. All files will be stored in accordance with confidentiality standards. |
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 facility failed to document the name of the person, agency, or organization to whom the disclosure was to be made on consent to release information forms in two of six client records reviewed.
Client # 1 was admitted on October 20, 2020 and was still active at the time of the inspection. The release of information form for the emergency contact was signed and dated by the client on October 20, 2020, but the form did not list the name of the person, agency, or organization to whom the disclosure was to be made.
Client # 4 was admitted on March 11, 2019 and was discharged on April 14, 2020. The release of information forms for the emergency contact and for the coordination of care were signed and dated by the client on March 11, 2020, but the form did not list the name of the person, agency, or organization to whom the disclosure was to be made.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
By 3/1/21 business office director will facilitate a training with business office staff responsible for having members complete consents. One area of focus of this training will be ensuring that emergency contacts are specifiedand filled out completely.
By 3/1/21 the consent forms identified will be corrected in the active client chart listed. By this date, Quality Assurance Specialist will perform weekly monitoring to ensure these forms are filled out correctly for all members. |
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 facility failed to document the specific information to be disclosed on a consent to release information form in one of six client records reviewed.
Client # 4 was admitted on March 11, 2019 and was discharged on April 14, 2020. The release of information form to a government agency was signed and dated by the client on March 11, 2020, but the form did not document the specific information to be disclosed.
This findings were reviewed with facility staff during the licensing process.
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Plan of Correction
By 3/1/21 business office director will facilitate a training with business office staff responsible for having members complete consents. One area of focus of this training will be ensuring that the specific information to be disclosed is specified.
By 3/1/21, Quality Assurance Specialist will conduct weekly reviews to ensure all releases have been completed in accordance with directives and best practices. |
715.10(f) LICENSURE Pregnant patients
(f) The narcotic treatment program shall ensure that each female patient is fully informed of the possible risk to her or her unborn child from continued use of illicit drugs and from use of, or withdrawal from a narcotic drug administered or dispensed by the program in comprehensive maintenance or detoxification treatment.
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Observations
Based on a review of patient records, the facility failed to ensure that each female patient is fully informed of the possible risk to her or her unborn child from continued use of illicit drugs and from use of, or withdrawal from a narcotic drug administered or dispensed by the program in comprehensive maintenance or detoxification treatment in one of one applicable patient records reviewed.
Patient # 1 was admitted on October 20, 2020 and was still active at the time of the inspection. There was no documentation that the patient was informed of the possible risk to their unborn child from continued use of illicit drugs and from use of, or withdrawal from a narcotic drug administered or dispensed by the program in comprehensive maintenance or detoxification treatment in the patient record at the time of the inspection.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
Plan of Correction: By 3/1/21 Quality Assurance Manager will review process of notification of pregnant patients on the possible risk to unborn child with the intake team. Quality Assurance Manager will also audit these forms from 3/1/21 forward for completeness. |
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 in one of six patient records reviewed.
Patient # 1 was admitted on October 20, 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.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
Plan of Correction: By 3/1/21 Quality Assurance Manager will review process of collecting informed and voluntary consent to treatment with the intake team. Quality Assurance Manager will also audit these forms from 3/1/21 forward for completeness. |
715..23(b)(1) LICENSURE Patient records
(b) Each patient file shall include the following information:
(1) A complete personal history.
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Observations
Based on a review of patient records, the facility failed to document a complete personal history in one of six patient records reviewed.
Patient # 4 was admitted on March 11, 2019 and was discharged on April 14, 2020. There was no completed personal history documented in the patient record at the time of the inspection.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
Plan of Correction: By 3/1/21 Quality Assurance Manager will review process of completing personal histories with the intake team. Quality Assurance Manager will also audit these forms from 3/1/21 forward for completeness. |
715.23(b)(2) LICENSURE Patient records
(b) Each patient file shall include the following information
(2) A complete drug and alcohol history.
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Observations
Based on a review of patient records, the facility failed to document a complete drug and alcohol history in one of six patient records reviewed.
Patient # 4 was admitted on March 11, 2019 and was discharged on April 14, 2020. There was no completed drug and alcohol history documented in the patient record at the time of the inspection.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
Plan of Correction: By 3/1/21 Quality Assurance Manager will review process of completing drug and alcohol histories with the intake team. Quality Assurance Manager will also audit these forms from 3/1/21 forward for completeness. |
715.23(b)(15) LICENSURE Patient records
(b) Each patient file shall include the following information:
(15) Psychosocial evaluations of the patient.
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Observations
Based on a review of patient records, the facility failed to document a psychosocial evaluation in one of six patient records reviewed.
Patient # 4 was admitted on March 11, 2019 and was discharged on April 14, 2020. There was no completed psychosocial evaluation documented in the patient record at the time of the inspection.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
By 3/1/21 Quality Assurance Manager will review process of completing psychosocial histories with the intake team. Quality Assurance Manager will also audit these forms from 3/1/21 forward for completeness. |
715.23(b)(24) LICENSURE Patient records
(b) Each patient file shall include the following information:
(24) Follow-up information regarding the patient.
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Observations
Based on a review of patient records, the facility failed to document follow up information in the patient record in two of three applicable client records reviewed.
Patient # 4 was admitted on March 11, 2019 and was discharged on April 14, 2020. The patient record failed to document follow up information regarding the patient as of the date of the inspection.
Patient # 5 was admitted on February 11, 2019 and was discharged on September 30, 2019. The patient record failed to document follow up information regarding the patient as of the date of the inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
By 3/1/21 Division Director will provide training to clinical team regarding best practices for provision of follow up for patients after discharge. Quality Assurance Manager will audit this follow up to ensure it is happening in accordance with guidelines. |
715.23(c)(1-7) LICENSURE Patient records
(c) An annual evaluation of each patient 's status shall be completed by the patient 's counselor and shall be reviewed, dated and signed by the medical director. The annual evaluation period shall start on the date of the patient 's admission to a narcotic treatment program and shall address the following areas:
(1) Employment, education and training.
(2) Legal standing.
(3) Substance abuse.
(4) Financial management abilities.
(5) Physical and emotional health.
(6) Fulfillment of treatment objectives.
(7) Family and community supports.
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Observations
Based on a review of patient records, the facility failed to ensure that the counselor completed annual evaluation of each patient's status was reviewed, dated and signed by the medical director in one of one applicable patient records reviewed.
Patient #2 was admitted on December 23, 2019 and was still active at the time of the inspection. The annual evaluation was completed by the counselor on December 19, 2020, but there was no documentation that it was reviewed, dated, and signed by the medical director.
This findings were reviewed with facility staff during the licensing process.
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Plan of Correction
By 3/1/21, Division Director will provide oversight to Medical Director to ensure process of signing off on annual evaluations is done properly. Quality Assurance Manager will audit these forms for completeness moving forward.
By 3/1/21 the deficiency in the chart noted will be corrected by Quality Assurance Specialist. |
715.23(d)(2) LICENSURE Patient records
(d) A narcotic treatment program shall prepare a treatment plan that outlines realistic short and long-term treatment goals which are mutually acceptable to the patient and the narcotic treatment program.
(2) The narcotic treatment physician or the patient 's counselor shall review, reevaluate, modify and update each patient 's treatment plan as required by Chapters 157, 709 and 711 (relating to drug and alcohol services general provisions; standards for licensure of freestanding treatment activities; and standards for certification of treatment activities which are a part of a health care facility).
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Observations
Based on a review of patient records, the facility failed to review, reevaluate, modify, and update each patient's treatment plan every 60 days in four of six patient records reviewed.
Patient #2 was admitted on December 23, 2019 and was still active at the time of the inspection. The comprehensive treatment plan was completed on January 23, 2020 and the next update was due no later than March 23, 2020; however, the update was not completed until May 9, 2020. Additionally, a treatment plan update was completed on July 9, 2020 and the next update was due no later than September 9, 2020; however, the update was not completed until December 5, 2020.
Patient # 4 was admitted on March 11, 2019 and was discharged on April 14, 2020. A treatment plan update was completed on December 11, 2019 and the next update was due no later than February 11, 2020; however, the update was not completed until March 4, 2020.
Patient # 5 was admitted on February 11, 2019 and was discharged on September 30, 2019. A treatment plan update was completed on July 3, 2019 and the next update was due no later than September 3, 2019; however, the update was not completed prior to discharge.
Patient # 6 was admitted on July 23, 2019 and was discharged on January 13, 2020. A treatment plan update was completed on October 1, 2019 and the next update was due no later than December 1, 2019; however, the update was not completed until December 19, 2019.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
By 3/1/21, Division Director will provide training to all clinical staff around the guidelines for timely completion of treatment plans. This training will focus on the timelines for which treatment plans are to be completed.
By 3/1/21, Quality Assurance Specialist and Clinical Supervisor team will conduct weekly reviews of treatment plans to ensure that they are being submitted in a timely fashion and of a quality that meets standards. |
715.28(c)(1-5) LICENSURE Unusual incidents
(c) A narcotic treatment program shall file a written Unusual Incident Report with the Department within 48 hours following an unusual incident including the following:
(1) Complaints of patient abuse (physical, verbal, sexual and emotional).
(2) Death or serious injury due to trauma, suicide, medication error or unusual circumstances.
(3) Significant disruption of services due to a disaster such as a fire, storm, flood or other occurrence.
(4) Incidents with potential for negative community reaction or which the facility director believes may lead to community concern.
(5) Drug related hospitalization of a patient.
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Observations
Based on a review of administrative documents, the facility failed to notify the Department within 48 hours of the offsite death of an active patient in three incidents during the review period.
The facility was notified of the three separate incidents on the following dates:
February 25, 2020
July 23, 2020
November 27, 2020
These findings were reviewed with project and facility staff during the licensing process.
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Plan of Correction
By 3/1/21, Division Director will provide training to Assistant Division Director to ensure that that the 48 hour notification rule is strictly adhered to.
By 3/1/21, Assistant Division Director will take over the oversight of this reporting. Any client death will be reviewed by both Division Director and Assistant Division Director and will be communicated with DDAP within the 48 hour standard. This will be a centralized responsibility incumbent upon program leadership. |