INITIAL COMMENTS
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This report is a result of an on-site licensure renewal and buprenorphine monitoring inspection conducted on April 13, 2022, by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, Lehigh County Center for 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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705.6 (2) LICENSURE Bathrooms.
705.6. Bathrooms.
The residential facility shall:
(2) Provide a sink, a wall mirror, an operable soap dispenser, and either individual paper towels or a mechanical dryer in each bathroom.
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Observations
Based on a physical plant inspection on April 13, 2022, the facility failed to ensure each bathroom was provided with either individual paper towels or a mechanical dryer as the bathroom across from the Nurse ' s station did not have paper towels.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
On 4/15/2022 the facilities manager reviewed the procedure for filling towel racks in the bathrooms and have assigned the housekeeper to check every weekday (mon-fri) and fill as needed. Facility Manger spoke with the Supervisor on 4/26/22 and instructed her to add this to tech responsibilities on the weekend. The BH Tech. will check each morning (sat-sun) and fill as needed. Housekeeping and Facilities will complete daily inspection in order to ensure compliance. |
705.6 (5) LICENSURE Bathrooms.
705.6. Bathrooms.
The residential facility shall:
(5) Ventilate toilet and wash rooms by exhaust fan or window.
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Observations
Based on a physical plant inspection on April 13, 2022, the facility failed to ensure that the lobby bathroom was properly ventilated while in use by either an exhaust fan or a window.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
On 4/14/2022 the facilities manager called Johnson Controls to have vent system checked and serviced. An appointment was set for 4/18/2022 at 8:00am. Tech arrived at facility on 4/18/2022. Problems with all three vent fans where found and corrected that day. Facilities manager check all fan. They were all working properly. Facilities manager will inspect monthly and document on monthly inspection report. |
705.10 (d) (5) LICENSURE Fire safety.
705.10. Fire safety.
(d) Fire drills. The residential facility shall:
(5) Conduct a fire drill during sleeping hours at least every 6 months.
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Observations
Based on a review of fire drill logs from June 2021 through February 2022, the facility failed to conduct fire drills during sleeping hours at least every six months.
Based on the program schedule provided by facility staff, the unit sleeping hours are 10:15 P.M. through 06:00 A.M. The only fire drill during sleeping hours from the time period reviewed was on June 17, 2021. No additional fire drills were conducted during sleeping hours prior to the inspection.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Program Director spoke to Safety Officer about having two fir drills a year during the "sleeping hours" on April 19, 2022. Program Director will ensure two fire drills during the sleeping hours will be held during the calendar year. Program Director will review safety reports quarterly to ensure compliance. |
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
Based on a review of fourteen records, the facility failed to obtain an informed and voluntary consent from the client for the disclosure of information in three records reviewed. Additionally, the facility failed to keep disclosures of client identifying information with the limits established by Pa Code 255.5 (b) in two records reviewed.
Client #3 was admitted to the Detox activity on April 6, 2022 and was active in the Rehabilitation Activity at the time of the inspection. The record contained a consent to release information form to a government official signed by the client on April 7, 2022, which allowed for the release of psychiatric evaluation, history and physical, practitioner orders and progress notes, discharge, lab reports, med records, treatment plan, and discharge instructions.
Client #4 was admitted to the Detox activity on March 12, 2022 and was active in the Rehabilitation activity at the time of the inspection. The record contained a consent to release information form to a government official signed by the client on April 11, 2022, which allowed for the release of the treatment plan.
Client #6 was admitted to the Detox activity on April 30, 2021 and discharged from the Rehabilitation activity on June 8, 2021. The record contained documentation that personally identifying information was released to the Department of Human Services on April 30, 2021, with no consent to release information form signed by the client.
Client #7 was admitted to the Detox activity on March 4, 2021 and discharged on March 11, 2021. The record contained documentation that personally identifying information was released to the Department of Human Services on March 4, 2021, with no consent to release information form signed by the client.
Client #13 was admitted to the Rehabilitation activity on July 19, 2021 and discharged on July 26, 2021. The record contained documentation that personally identifying information was released to the Department of Human Services on July 19, 2021, with no consent to release information form signed by the client.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Clinical Director will have a 1 hour training on completing consents properly to ensure that the consents are within the guidelines for 255.5.
This training will occur on May, 11, 2022.
Clinical Director will also conduct weekly open audit chart reviews- reviewing the consents
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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 fourteen records, the facility failed to ensure that consent to release information forms included the name of the person, agency, or organization to whom disclosure is made in one record reviewed.
Client #13 was admitted on July 19, 2021 and was discharged July 26, 2021. The record contained two consent to release information forms signed by the client on July 22, 2021, that were missing a specific name, agency, or organization.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Clinical Director will have a 1 hour training on completing consents properly to ensure that the consents are within the guidelines for 255.5.
This training will occur on May, 11, 2022.
Clinical Director will also conduct weekly open audit chart reviews- reviewing the consents
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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 fourteen records, the facility failed to ensure that consent to release information forms included the specific information to be disclosed in one record reviewed.
Client #11 was admitted on November 24, 2021 and was discharged January 11, 2022. The record contained a consent to release information form to a family member signed by the client on December 3, 2021, that was missing the specific information to be disclosed.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Clinical Director will have a 1 hour training on completing consents properly to ensure that the consents are within the guidelines for 255.5.
This training will occur on May, 11, 2022.
Clinical Director will also conduct weekly open audit chart reviews- reviewing the consents
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709.28 (c) (3) 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:
(3) Purpose of disclosure.
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Observations
Based on a review of fourteen records, the facility failed to ensure that consent to release information forms included the purpose of disclosure in one record reviewed.
Client #6 was admitted on April 30, 2021 and discharged on June 8, 2021. The record contained a consent to release information form to a medical facility signed by the witness on April 30, 2021, that was missing the purpose of the disclosure.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Clinical Director will have a 1 hour training on completing consents properly to ensure that the consents are within the guidelines for 255.5.
This training will occur on May, 11, 2022.
Clinical Director will also conduct weekly open audit chart reviews- reviewing the consents
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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
Based on a review of seven client records in the detoxification level of care, the facility failed ensure that verbal orders were authenticated in writing by a physician or other medical professional within 24 hours.
Client # 4 was admitted to the Detox activity on March 12, 2022. A verbal order was given on March 12, 2022 but was not authenticated in writing until March 15, 2022.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The medical director was informed of the deficiency noted during review on exit date 4/13/2022, in reference to 709.32(b) LICENSURE Medication control which requires verbal orders to be authenticated in writing within 24 hrs. Plan of action: Medical Director will provide training and education to staff on the requirements of 709.32(b) by 4/30/2022. The medical director will perform at minimum a weekly audit of the detox client's verbal orders to ensure compliancy. |
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
Based on a physical plant inspection on April 13, 2022, the facility failed to ensure that drugs for external use were stored separately from oral drugs as a tube of topical medication was stored with oral medications in the med cart.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
In reference to 709.32(c)(3)(i)-(v) LICENSURE Medication control: Corrective action includes an education training to all nursing staff which was completed on 4/29/2022. The nursing manager has also dedicated a new area for the storage of topical medications which is in a separate area from the oral medications. The nursing manager will perform weekly audits of the medication cart to ensure compliancy. |
715.9(a)(1) LICENSURE Intake
(a) Prior to administration of an agent, a narcotic treatment program shall screen each individual to determine eligibility for admission. The narcotic treatment program shall:
(1) Verify that the individual has reached 18 years of age.
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Observations
Based on a review of two applicable patient records, the facility failed to provide verification that the individual has reached 18 years of age in one record reviewed.
Patient #4 was admitted to the Detox activity on March 12, 2022 and transferred to the Rehabilitation activity on March 17, 2022.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
On May 2nd, Program Director will train all admissions staff to verify that a photo ID is provided for all clients admitting, if no photo ID is available that a Promise form and benefit verification form is completed for each admission. In addition a newly developed consent for DPW will be completed for each admission to verify age and identity. Program Director and/or Nurse Manager will review charts on a weekly basis to verify that these forms are in each chart |
715.9(a)(2) LICENSURE Intake
(a) Prior to administration of an agent, a narcotic treatment program shall screen each individual to determine eligibility for admission. The narcotic treatment program shall:
(2) Verify the individual 's identity, including name, address, date of birth, emergency contact and other identifying data.
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Observations
Based on a review of two applicable patient records, prior to administration of an agent, the facility failed to provide verification of the individuals identity, including name, address, and date of birth in one record reviewed.
Patient #4 was admitted to the Detox activity on March 12, 2022 and transferred to the Rehabilitation activity on March 17, 2022.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
On May 2nd, Program Director will train all admissions staff to verify that a photo ID is provided for all clients admitting, if no photo ID is available that a Promise form and benefit verification form is completed for each admission. In addition a newly developed consent for DPW will be completed for each admission to verify identity. Program Director and/or admissions staff review charts on a weekly basis to verify that these forms are in each chart. |
709.53(a)(8) LICENSURE Case Consultation Notes
709.53. Client records.
(a) There shall be a complete client record on an individual which includes information relative to the client's involvement with the project. This shall include, but not be limited to, the following:
(8) Case consultation notes.
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Observations
Based on a review of client records, the facility failed to ensure a complete client record on an individual which includes information relative to the client's involvement with the project including case consultation notes in two of four applicable records reviewed.
Client #11 was admitted on November 24, 2021 and discharged on January 11, 2022. The client record did not contain documentation of case consultation notes.
Client #12 was admitted on November 17, 2021 and discharged on December 6, 2021. The client record did not contain documentation of case consultation notes.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Clinical Director will ensure while conducting weekly closed/ Open charts audits that case consultations are completed in a timely and efficient manner in the client records. This will start 5/2/2022 and be on an ongoing basis |
709.53(a)(10) LICENSURE Discharge Summary
709.53. Client records.
(a) There shall be a complete client record on an individual which includes information relative to the client's involvement with the project. This shall include, but not be limited to, the following:
(10) Discharge summary.
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Observations
Based on a review of client records, the facility failed to ensure a complete client record on an individual which includes information relative to the client's involvement with the project including a discharge summary in two of four applicable records reviewed.
Client #6 was admitted on April 30, 2021 and discharged on June 8, 2021. The client record did not contain documentation of a discharge summary.
Client #13 was admitted on July 19, 2021 and discharged on July 26, 2021. The client record did not contain documentation of a discharge summary.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Clinical Director along with the primary counselor will ensure that within 5 days of discharge that a discharge summary is complete. This will be done by reviewing closed charts when auditing. Clinical Director will review with clinical staff on 5/4/2022. |
709.54(c) LICENSURE Follow-up policy
709.54. Project management services.
(c) The project shall develop a written client follow-up policy.
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Observations
Based on a review of seven client records, the facility failed to follow their written client follow-up policy, to include following up with clients who discharged without being referred to additional services.
Client #11 was admitted on November 24, 2021 and discharged on January 11, 2022.
Client #12 was admitted on November 17, 2021 and discharged on December 6, 2021.
Client #13 was admitted on July 19, 2021 and discharged on July 26, 2021.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Clinical Director will have weekly supervision with UR/ Detox staff member in discussing follow up calls with discharged clients. During this supervision the Clinical Director will review follow up calls with d/c clients. This will start beginning of May, 5, 2022. |