INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on June 5 - 6, 2019 by staff from the Department of Drug and Alcohol Programs, Bureau of Quality Assurance for Prevention and Treatment. Based on the findings of the on-site inspection, CenClear Child Services Inc. 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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709.28 (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 failed to document a written, informed and voluntary consent from the client prior to the disclosure of information contained in the client record in three of seven client records reviewed on June 5 - 6, 2019.
Client # 1 was admitted March 20, 2019 and discharged June 4, 2019. The client's name, diagnosis, medication and physical evaluation documentation were faxed to a medical provider on April 8, 2019.
A prescription for Suboxone was called into a pharmacy on April 23, 2019.
Client # 2 was admitted March 23, 2018 and discharged May 1, 2019. A prescription for Suboxone was called into a pharmacy on December 4, 2018.
Client # 4 was admitted January 23, 2019. A prescription for Suboxone was called into a pharmacy on February 13, 2019.
The client's name, diagnosis and physical evaluation documentation were faxed to an insurance company on February 21, 2019.
The client's name, diagnosis and drug test results were faxed to an insurance company on April 8, 2019.
A prescription for Suboxone was called into a pharmacy on June 3, 2019.
In addition, the facility exceeded the limitations imposed at 4 Pa. Code 255.5 when releasing information to an insurance company in client record # 4. The facility released the client's physical evaluation by fax on February 21, 2019. The facility released drug test results by fax on April 8, 2019.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
After review of this particular finding with DDAP staff, it was recognized that this was due to lack of proper training. All nurses will complete necessary Confidentiality Training provided by DDAP as training dates and times become available. If training dates are available, this will occur within 2 months of hire. MAT Coordinator will complete monthly patient record reviews to ensure this deficiency does not occur. Facility Director will ensure this training occurs to avoid any further deficiencies within this area. (**It should be noted that both Clearfield and Punxsutawney MAT Program Sites have ended on June 30, 2019. CCBH is supporting the Center of Excellence at this time for MAT Services- all consumers have been transferred in accordance with Pa. Code 715.20). |
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 document quarterly inspections of the medication storage area from July 2018 through June 2019 based on an inspection of the storage area conducted on June 5, 2019 at approximately 3:30 PM.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
After review of this particular finding with DDAP staff, a Quarterly Storage Inspection binder was created and includes a checklist with specific questions:
**Are disinfectants and drugs for external use stored separately from oral and injective drugs?
**Are drugs requiring special conditions for storage properly stored?
**Are outdated and contaminated drugs removed and destroyed according to Federal and State regulations?
**Is administration of controlled substances documented?
**Are controlled substances and other abusable drugs stored in accordance with Federal and State regulations?
The MAT Coordinator will complete the quarterly inspections and Facility Director will review this to ensure that this is occurring to avoid any further deficiencies within this area. (**It should be noted that both Clearfield and Punxsutawney MAT Program Sites have ended on June 30, 2019. CCBH is supporting the Center of Excellence at this time for MAT Services- all consumers have been transferred in accordance with Pa. Code 715.20).
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