INITIAL COMMENTS
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This report is a result of an on-site complaint investigation conducted on June 13-14, 2019 by staff from the Department of Drug and Alcohol Programs, Bureau of Quality Assurance for Prevention & Treatment. Based on the findings of the on-site inspection, Libertae Family House Libertae, Inc., was found to be not in compliance with the applicable chapters of 28 PA Code which pertain to the facility. The following deficiencies were identified during this investigation.
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Plan of Correction
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704.3(c) LICENSURE Clerical/Support Staff
704.3. General requirements for projects.
(c) Clerical and other support staff shall be employed in sufficient numbers to insure efficient and safe operation of all of the services provided by the project.
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Observations
The facility failed to ensure that staff was hired in sufficient numbers. Based on interviews with staff and residents the facility has been understaffed to the extent that some life-skills and other non-clinical groups do not have staff conducting them, as scheduled, which was reported by clients interviewed and confirmed by facility staff.
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Plan of Correction
The program has budgeted for and added staffing to each department that provides direct care. There are additional positions as follows:
Social Services Director - 3 Case Managers
Nurse - 2 Medical Assistants
Clinical Director - 2 Therapists
Operations Manager - 3 Treatment Techs
Libertae has engaged a consulting company to review and enhance hiring practices. Improvements have been made to reduce turnover. Clearance procedures have been upgraded to onboard new staff more quickly and effectively. All job descriptions have been reviewed and positions have been benchmarked for performance. The positions are advertised on two prominent sites. Applicants who indicate an interest online are taken to a screening that is aligned with each position for a fit to Libertae's staff. Orientation sessions for all new staff will be held monthly and any current staff that need a refresher will attend.
Each department leader is now interviewing appropriate candidates and offers of employment have been made to two case managers (both accepted), 2 medical assistants, and 1 therapist. Three treatment tech positions were filled. While it is anticipated that all positions will be filled sooner, the corrective action date is 10/15/2019. This will cover the contingency that other vacancies could open during the POC period.
The Client's Daily Schedule has been revised to provide more groups and ensure groups are always covered by staff. The Director of Clinical Services, in collaboration with the clinical team has increased the number of groups being provided and reviewed them to be sure that the correct number of evidence-based, psycho-educational therapy groups are offered daily and weekly with the proper coverage of each group assigned to clinical staff. Adjunct staff will continue to offer life-skills and other non-clinical groups and the Director of Social Services and Director of Operations are responsible to ensure coverage of these groups at all times.
Staffing call outs are the issue that led to this failure. Call outs by staff are made to each staff person's manager, who then reports them to the Office Manager for record keeping. In the case of call outs by those who are scheduled to facilitate groups, it is the respective Department Director's responsibility to ensure that arrangements for group coverage by the same level of staff, i.e. clinical for a group led by a clinical staff, is in place for that day.
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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
The facility failed to keep the grounds of the facility safe and in good repair.The sidewalk from the porch of the main building to the driveway between the Family House and Women's House was uneven and created a trip hazard.
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Plan of Correction
The sidewalk has been repaired. The wasp nest was removed. Maintenance of the facility is the responsibility of the Director of Operations. Direct oversight is provided by the Assistant Manager of Operations.
This corrective action plan will become part of facility's policy. The plan will consist of a seven-step process to ensure all maintenance issues are addressed in the following manner:
Step 1: Identify the problem
Step 2: Interim plan
Step 3: Identify the root cause
Step 4: Permanent action to be taken
Step 5: Verification
Step 6: Control
Step 7: Prevention
Example:
1. Identify the problem: Cracks in concrete
2. Interim plan: Caution tape the area off, post caution signs, notify all personnel of hazard in agency communication system, management notify all clients in a group session of hazard/s, and the need to avoid it until it is addressed.
3. Identify root cause: Cracks due to weatherization, that is the expansion and contraction of concrete due to seasonal changes of hot and cold weather.
4. Permanent Action: Walkways preventive maintenance shall be entered into Netfacilities Preventive Maintenance profile to notify the Assistant Operations Manager on a monthly basis to have maintenance personnel inspect all walkways on property to ensure their safety.
5. Verification: Verify over a three-month period that the permanent action plan eliminates all possible hazards. If not, recommend and revise plan.
6. Control: To control future hazard/s within Libertae's walkways. The Assistant Operations Manager shall maintain, revise, and/or adjust all measure set forth in the maintenance corrective action plan to ensure all employees, clients, and guests while on Libertae's property are safe from any possible hazard/s.
7. Prevention: All new/employees shall be trained in Libertae's corrective action plan procedure, and in the use of our maintenance software NetFacilties. To ensure that all maintenance issues are addressed in a timely manner, the goal will be to address issues within 24 hours of discovery and/or notification of issue (depending on severity of issue).
In order to ensure that the deficiency does not occur again, the Assistant Manager of Operations will conduct a quarterly inspection of all buildings and grounds and note any hazards, need for maintenance and repairs and/or replacement of furnishings and equipment. Inspections will be done the third week of September, December, March and June, commencing September 18, 2019. A report of this inspection will be filed with the Director of Operations and copied to the CEO. In turn, a status report of buildings and grounds will be included in the quarterly Quality Assurance report made to the Board of Directors.
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705.29 (2) (iii) LICENSURE Child care.
705.29. Child care.
When a nonresidential facility admits children for services or for custodial care, the following requirements apply:
(2) Interior space. The nonresidential facility shall:
(iii) Maintain protective caps over each electrical outlet.
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Observations
The facility failed to maintain protective caps over each electrical outlet in the bathrooms located on the Family House floor.
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Plan of Correction
Protective caps that can only be removed with a screwdriver (sliding) have been placed on every electrical outlet in the bedrooms and bathrooms of the Family House. The deficiency was corrected by 7/19/2019.
In order to keep this deficiency and others like it from recurring, the following corrective action will be taken:
Maintenance of the facility is the responsibility of the Director of Operations. Direct oversight is provided by the Assistant Manager of Operations.
This corrective action plan will become part of facility's policy. The plan will consist of a seven-step process to ensure all maintenance issues are addressed in the following manner:
Step 1: Identify the problem
Step 2: Interim plan
Step 3: Identify the root cause
Step 4: Permanent action to be taken
Step 5: Verification
Step 6: Control
Step 7: Prevention
Example:
1. Identify the problem: protective caps are being removed and misplaced.
2. Interim plan: Notify all personnel of hazard in agency communication system, management notify all clients in a group session of hazard/s, and the need to avoid it until it is addressed.
3. Identify root cause: protective caps that can be removed readily are not appropriate for this setting. Screw-in caps need to be installed over each electrical outlet in the bathrooms located in the Family House floor.
4. Permanent Action: Electrical outlet hazard preventive maintenance shall be entered into Netfacilities Preventive Maintenance profile to notify the Assistant Operations Manager on a monthly basis to have maintenance personnel inspect all bathrooms in the Family House to ensure their safety.
5. Verification: Verify over a three-month period that the permanent action plan eliminates all possible hazards. If not, recommend and revise plan.
6. Control: To control future hazard/s within Libertae's Family House bathrooms. The Assistant Operations Manager shall maintain, revise, and/or adjust all measure set forth in the maintenance corrective action plan to ensure all employees, clients, and guests while on Libertae's property are safe from any possible hazard/s.
7. Prevention: All new/employees shall be trained in Libertae's corrective action plan procedure, and in the use of our maintenance software NetFacilties. To ensure that all maintenance issues are addressed in a timely manner, the goal will be to address issues within 24 hours of discovery and/or notification of issue (depending on severity of issue).
In order to ensure that the deficiency does not occur again, the Assistant Manager of Operations will conduct a quarterly inspection of all buildings and grounds and note any hazards, need for maintenance and repairs and/or replacement of furnishings and equipment. A report of this inspection will be filed with the Director of Operations and copied to the CEO. In turn, a status report of buildings and grounds will be included in the quarterly Quality Assurance report made to the Board of Directors.
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709.26 (a) (2) LICENSURE Personnel management.
§ 709.26. Personnel management.
(a) The governing body shall adopt and have implemented written project personnel policies and procedures in compliance with State and Federal employment laws. In addition, the written policies and procedures must specifically include, but are not limited to:
(2) Rules of conduct.
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Observations
The facility failed to adhere to procedures for personnel management. Facility ' Staff-Client Interaction Policy ' states that a professional status be maintained with clients and prohibits any favoritism or preferential treatment be provided by staff members to any client.A relative of a staff member was admitted for treatment in the Family House program. According to information accumulated during the investigation and onsite visit this staff member engaged the client in an unprofessional manner, and manipulated other facility staff in a manner which allowed facility child care and medication procedures to be circumvented in her case.
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Plan of Correction
Whenever it comes to light that a staff person has violated the personnel policies and procedures the disciplinary process is invoked.
This staff person's supervisor was informed of the unprofessional nature of the interactions and a disciplinary warning was issued.
Ongoing supervision is being conducted to monitor the adherence to policies and procedures by this staff. Person responsible is Director of Finance, who supervises this employee. Due to the nature of this infraction, the staff member cited will be mandated to attend Ethics training scheduled for November 26, 2019 in Allentown, PA. BCDAC has been contacted and Libertae's Office Manager, who is responsible for ensuring that all staff trainings are completed, will be notified if it becomes available sooner and/or closer.
The Policies and Procedures for personnel management have been revised by the CEO of Libertae and submitted to the Board of Directors for approval at the next meeting on September 26, 2019. This issue will be presented to the QA committee of the Board to ensure that the policy as written regarding Staff-Client Interaction is sufficient to cover all contingencies. Additional policies have been drafted to include staff conduct regarding contact with clients, for instance, via social media, texting. These too, will be submitted for Board approval.
Once the Personnel Policies and Procedures Manual has been reviewed and approved by the Board of Directors on September 26, 2019, it will be disseminated to all staff. A staff meeting will be held on October 21, 2019 devoted to reviewing the Manual and answering questions. Coverage of the Personnel Policies and Procedures will be a standard part of a monthly all-day orientation of all new staff who were on-boarded the previous month.
Coverage of personnel policies and procedures will be an agenda item at every team meeting and staff meeting, and whenever a failure to adhere to same is brought to management's attention this will be addressed both specifically with any staff in question through supervision and the disciplinary process when applicable, and generally at staff meetings and departmental meetings.
Libertae will implement an anonymous reporting mechanism that will be available for staff that may observe any policy violations of this type. Implementation date will coincide with the October 21, 2019 staff meeting. |
709.32 (a) LICENSURE Medication control
§ 709.32. Medication control.
(a) Projects furnishing pharmaceutical services shall present a license from the Department of Health ' s Board of Examiners or the Department of State ' s State Board of Pharmacy and a DEA registration to Department employees. Other notices of review or inspection, or both, shall be made available upon request.
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Observations
The facility failed to adhere to procedures for medication management in this level of care.*Facility policy states that when verbal change orders for medication are given " The doctor will fax/scan/email the signed order to Libertae within 24 hours of making the verbal order. When the doctor is next on-site the original signature will be attached to the scanned/faxed/emailed signed order that was already received by the facility " .Medical records reviewed indicated that a female client, chart # 9769, was admitted to on 5/6/2019. A verbal order for chart #9769 was received from the contracted physician on 5/7/2019, and signed by the receiving staff at the facility, however there was no documentation that the signed order was ever delivered to the facility and the order was never signed by the physician. Facility staff acknowledged that the procedure was not followed in this case.
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Plan of Correction
In this case, failure to adhere to the policy was due to lack of follow-up. Also the physician had an unexpected absence, which compounded the oversight.
The facility's full time RN will maintain a log of all verbal change orders for medications given by the physician by date and with a check off for the physician's signature by date. This log will be available for review on a monthly basis in Quality Assurance meetings with CEO and Director of Clinical Services.
The correction in place is that future verbal orders will be signed off by the physician indirectly and immediately in the electronic health record which can be accessed from any off-site location. While the physician and the RN are communicating via telephone when a verbal change order for medication is being issued, the RN will enter a Subjective-Objective-Assessment & Plan (SOAP) note simultaneously for the physician's signature at that same time.
Responsibility for receiving verbal order and documenting - RN
Responsibility for signing the verbal order in electronic health record within 24 hours - Physician
Responsibility for reviewing procedures and ensure correction does not re-occur - CEO |
709.32 (c) (2) LICENSURE Medication control
§ 709.32. Medication control.
(c) The project shall have and implement a written policy and procedures regarding all medications used by clients which shall include, but not be limited to:
(2) Drug storage areas including, but not limited to, the secure storage of controlled substances and other abusable drugs in accordance with State and Federal regulations and program requirements.
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Observations
The facility failed to ensure that controlled substances were properly stored. Facility policy states that "All narcotic medications are double locked. They are stored in a separately locked drawer area within the locked medication cart. "*Several discontinued medications were discovered in the medical office; among these medications were narcotic medications that were not double locked.
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Plan of Correction
It is now the responsibility of the RN which is a position that Libertae recently created and filled on January 1, 2019 to oversee all medication storage and discontinuation.
All policies and procedures regarding the above have been thoroughly reviewed and modified and implemented. Double locked boxes are in every area of the facility where medications are stored, including the medical office. All narcotic medications are now stored in double locked boxes until time of destruction/disposal.
Responsibility for this rests with RN and overseen by CEO. |
709.32 (c) (3) (i) - (v) LICENSURE Medication control
§ 709.32. Medication control.
(3) Inspection of storage areas that ensures compliance with State and Federal laws and program policy. The policy must include, but not be limited to:
(i) What is to be verified through the inspection, who inspects, how often, but not less than quarterly, and in what manner it is to be recorded.
(ii) Disinfectants and drugs for external use are stored separately from oral and injectable drugs.
(iii) Drugs requiring special conditions for storage to insure stability are properly stored.
(iv) Outdated drugs are removed.
(v) Copies of drug-related regulations are available in appropriate areas.
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Observations
The facility failed to ensure that medication storage areas were inspected at least quarterly. There were no inspection reports provided by the facility to determine when the last inspection took place. Staff also acknowleged that the inspections were not being conducted. Additionally, the facility failed to ensure that outdated and/or discontinued medication was disposed of in accordance with facility policy and procedure. Facility policy and procedure for medication control, dated February 1, 2017, states that when medication will be disposed of by facility staff, a witness will be present and a medication disposal form will be completed and signed by both staff. The medication disposal forms were not being completed when medication was being diposed of, which was acknowledged by the director and nursing staff.
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Plan of Correction
Medication storage areas will be inspected quarterly by the RN with the assistance of staff Medical Assistants on the 4th Wednesdays of September, December, March and June. Inspection reports will be filed with the Director of Operations and the CEO will be copied.
Twice per week the RN with the aid of the Medical Assistants will inspect each medication cart to identify any medications that have been discontinued or are outdated. Any outdated and/or discontinued medication will be disposed of in an appropriate container stationed in the medication storage area. The RN will dispose of the medications while witnessed by a second staff person, either Medical Assistant or Treatment Tech on duty. The RN will make a notation in the medication disposal binder in each medication storage area of the disposal of the discontinued and/or outdated medication. The RN with the Medical Assistant will enter a medication reconciliation form for each discontinued and/or outdated medication for individual clients. This documentation will be filed into the electronic health record of each client by the RN. The RN will review the Medication Disposal Binders on a weekly basis.
In order to keep the deficiency from recurring, the RN will participate in monthly Quality Assurance meetings where she will review all medication policies and procedures , furnish reports to the CEO and make recommendations for any process improvements. In turn the Quality Assurance Committee of the Board of Directors will review facility compliance with the policy and procedure.
The facility will maintain medication storage area inspection reports in the office of the Director of Operations and furnish them at the time of inspections. |
709.32 (c) (5) LICENSURE Medication control
§ 709.32. Medication control.
(5) Security of drugs, including, but not limited to, the loss, theft or misuse of drugs.
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Observations
The facility failed to adhere to procedures for preventing the misuse of medication.*Facility policy states that " initial doses of buprenorphine or LAAM and other approved medications should be based on the package insert. " It was discovered during the onsite investigation that some clients were provided medication that had been prescribed to other clients who was no longer at the facility and/or medication which had been discontinued for use by the original client.Facility staff acknowledged that this procedure was not followed in these cases.
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Plan of Correction
In order to prevent the diversion, abuse, and/or misuse of prescription medications at its facility, Libertae will follow the following procedures:
1. At pre-admission, the Manager of Admissions will ascertain what medications are currently being prescribed to an impending client and with what amounts of these medications will the client be arriving. The prescription insurance status of each incoming client will also be verified by the Manager of Admissions.
2. At intake - the Intake Coordinator will receive from the admitting client all medications that she has in possession.
3. The Intake Coordinator will hand off the admitting client's medications to the Medical Case Manager who will open a medication log in the client's chart. The actual medications will be secured in the residents' medication carts by the Treatment Tech on shift.
4. The Medical Case Manager, within 24 hours of admission, will meet with the client to review all medical needs, including the need for medication refills, and/or changes.
5. The Medical Case Manager will schedule any and all medical appointments for a client, including with the facility's consulting psychiatrist. The Case Manager will receive any outside medical reports, including prescriptions given. Libertae's consulting physician will review the Prescription Drug Monitoring Program for each client seen for a medication monitoring appointment, to ensure against prescription misuse.
6. The RN with the staff Medical Assistants will enter all new and changed and/or discontinued medication orders into the client's chart. All discontinued and/or outdated medications will be immediately disposed of.
7. In the case of a client who discharges from the facility and does not take medications with her at the time of discharge, it is the responsibility of the RN with the staff Medical Assistant or Treatment Tech on duty to dispose of the remaining medications immediately according to the medication control policy and procedures.
8. Whenever a client of Libertae loses prescription drug coverage during treatment, Libertae will purchase an adequate supply of her medications to bridge until coverage is reinstated. The RN will notify the Director of Finance of need for prescription drug coverage. The Medical Case Manager will work to reinstate prescription drug coverage for the client.
9. Whenever a client of Libertae who has an opioid use disorder should report symptoms of withdrawal that are not being adequately addressed by her current medication regiment, the RN will consult with the physician to determine if a medication change order is necessary, and/or an immediate evaluation for admission to a detoxification unit is needed.
In order to prevent the deficiency from recurring and to improve service delivery, the RN will participate in all monthly Quality Assurance Committee meetings where she will report to the CEO any and all medication incidents and make process improvements recommendations as needed. |
709.51(b)(5) LICENSURE Physical Examination
709.51. Intake and admission.
(b) Intake procedures shall include documentation of:
(5) Physical examination.
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Observations
The facility failed to document a physical examination at intake. Client # 9769, was admitted to on 5/6/2019, however no physical examination was documented for this client.
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Plan of Correction
It is the responsibility of the Manager of Admissions to obtain all medical documentation either prior to or upon admission to determine whether or not a physical exam has been completed within the last 30 days. If documentation of an exam is received by the Manager of Admissions before or upon admission, then the Manager of Admissions will file the documented physical examination in the client's record at intake. If the exam has not been completed, documentation of same will be recorded in the chart. In this case, the Manager of Admissions will report to the Case Manager who is responsible for scheduling all medical appointments that the client will need an appointment at a local primary care provider for a physical exam within seven days of admission. Receipt of the documentation of this physical examination is the responsibility of the Case Manager who then is to file same in the client's record. Alternatively, the Case Manager will determine if the client can be seen by the consulting physician to Libertae on a timelier basis for a medication management appointment at the facility, whereby a physical exam will be conducted at this time and recorded in the client's record by the consulting physician.
The Director of Clinical Services, Registered Nurse and Manager of Admissions will participate in monthly Quality Assurance meetings where a report of chart reviews conducted by each member of the committee will be on the agenda, to include completeness of all documentation of physical examinations for clients admitted within the past 30 days. This will ensure that the deficiency will not recur.
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