INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on September 12, 2018 by staff from the Department of Drug and Alcohol Programs, Bureau of Quality Assurance for Prevention and Treatment, Program Licensure Division. Based on the findings of the on-site inspection, PA Treatment and Healing was found to not 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 (3) LICENSURE Bathrooms.
705.6. Bathrooms.
The residential facility shall:
(3) Have hot and cold water under pressure. Hot water temperature may not exceed 120F.
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Observations
The facility failed to ensure that the hot water did not exceed 120 degrees fahrenheit in the bathroom.
During a site inspection on September 12, 2018, the water temperature measured 142 degrees fahrenheit in the bathroom.
These findings were reviewed with the facility staff during the licensing inspection.
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Plan of Correction
The facility failed to ensure that the hot water did not exceed 120 degrees in the bathroom with a measured reading of 142 degrees on September 12. The Program Director has contacted the landlord to adjust the water heater and will continue to do random measuring of the temperature of the water to maintain compliance. The agency will be in compliance with this standard as of 10/8/2018. |
709.30 (2) LICENSURE Client rights
§ 709.30. Client rights.
The project shall develop written policies and procedures on client rights and document written acknowledgement by clients that they have been notified of those rights.
(2) The project may not discriminate in the provision of services on the basis of age, race, creed, sex, ethnicity, color, national origin, marital status, sexual orientation, handicap or religion.
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Observations
The facility failed to document that they may not discriminate against color, marital status or handicap in their client rights policy.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The facility failed to document that they may not discriminate against color, marital status, or handicap in their client rights policy.
The Program Director will review client rights in the policy and procedure manual and document in client rights that we may not discriminate against color, marital status, or handicap.
The agency will be in compliance with this standard on 10/8/18
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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
The failed to verify that each individual had reached eighteen years of age prior to administration of an agent in a narcotic treatment program.
Client #5 was admitted on February 23, 2018 and was still active at the time of the inspection. The facility failed to get documentation ensuring that the client was at least eighteen years of age or older prior to administration of an agent in a narcotic treatment program.
These findings were reviewed with the facility.
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Plan of Correction
The agency failed to verify that each individual had reached eighteen years of age prior to administration of an agent in a narcotic treatment program.
The clinical staff person will obtain documentation that will verify the age of any client prior to administration of an agent in a narcotic treatment program at the time of admission. The agency will ensure compliance with this regulation through training clinical staff and review of client files by the facility director. This agency will be in compliance with this standard by 10/8/2018. |
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
The facility failed to verify an individual's identity, including name, address, and date of birth prior to administration of an agent in a narcotic treatment program.
Client #5 was admitted on February 23, 2018 and was still active at the time of the inspection. The facility failed to get documentation ensuring the client's identity, including name, address, and date of birth prior to administration of an agent in a narcotic treatment program.
These findings were reviewed with the facility staff.
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Plan of Correction
The facility failed to verify an individual's identity, including name, address, and date of birth prior to administration of an agent in a narcotic treatment program.
Counselor will be addressed regarding the requirement of obtaining documentation to verify an individual's identify including name, address, and date of birth prior to administration of an agent in narcotic treatment program and the facility director will ensure compliance with this regulation through ongoing supervision and quality reviews of client files. The agency will be in compliance with this standard as of 10/8/2018 |
715.13(a) LICENSURE Patient identification
(a) A narcotic treatment program shall use a system for patient identification for the purpose of verifying the correct identity of a patient prior to administration of an agent.
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Observations
The facility failed to use a system for patient identification for the purpose of verifying the correct identity of a patient prior to administration of an agent in a narcotic treatment program.
Client #5 was admitted on February 23, 2018 and was still active at the time of inspection. The facility failed to use a system for patient identification for the purpose of verifying the correct identity of a patient prior to administration of an agent in a narcotic treatment program.
These findings were reviewed with facility staff.
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Plan of Correction
The facility failed to use a system for patient identification for the purpose of verifying the correct identify of a patient prior to administration of an agent in a narcotic treatment program. The counselors will be instructed to obtain documentation that will verify the client's identity including name, address, date of birth and a picture in corresponding charts for the purpose of visible recognition. The Facility Director will ensure compliance with this standard through supervision and quality reviews of client charts. The agency will be in compliance with this standard by 10/8/2018. |
715.13(b) LICENSURE Patient identification
(b) A narcotic treatment program shall maintain onsite a photograph of each patient which includes the patient 's name and birth date. The narcotic treatment program shall update the photograph every 3 years.
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Observations
The facility failed to maintain an onsite photograph of each patient which includes the patient's name and date of birth.
Client #5 was admitted on February 23, 2018 and was still current at the time of inspection. The facility failed to have a photograph with the patient's name and date of birth in the client record.
These findings were reviewed with facility staff.
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Plan of Correction
The facility failed to maintain an onsite photograph of each patient which includes the patient's name and date of birth. The agency/Counselor will obtain a valid picture identification of each client upon admission which will include their name and date of birth. The Facility Director will ensure compliance with this standard through supervision and quality reviews of client charts. The agency will be in compliance with this standard as of 10/8/2018 |
709.92(b) LICENSURE Treatment and rehabilitation services
709.92. Treatment and rehabilitation services.
(b) Treatment and rehabilitation plans shall be reviewed and updated at least every 60 days.
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Observations
The facility failed to review and update treatment plans in three out of seven records.
Client #1 was admitted on February 8, 2017 and was still active at the time of the inspection. A treatment plan update was drafted on March 7, 2018, however the staff failed to have the client sign off on the treatment plan update. The next treatment plan update was drafted on May 2, 2018, however the staff failed to have the client sign off on the treatment plan update. The next treatment plan update was drafted on June 20, 2018, however the staff failed to have the client sign off on the treatment plan update until August 24, 2018. The following treatment plan update was drafted on August 15, 2018, however the staff failed to have the client sign off on the treatment plan update until August 24, 2018.
Client #5 was admitted on February 23, 2018 and was still active at the time of the inspection. A treatment plan update was completed on June 28, 2018, with the next being due no later than August 28, 2018. There was no treatment plan update dated August 28, 2018 or later in the record on the day of the inspection.
Client #8 was admitted on April 19, 2018 and was still active at the time of inspection. A comprehensive treatment plan was completed on June 25, 2018, with the next being due no later than August 25, 2018. The next treatment plan updated was not drafted until August 30, 2018 and the staff failed to have the client sign off on the treatment plan update.
These findings were reviewed with the facility staff during the licensing process.
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Plan of Correction
The facility failed to review and update treatment plans in three out of seven records.
The Facility Director will review the required documentation and required signatures during supervision with the clinical staff/counselors. The facility director will ensure compliance with this regulation through ongoing supervision and quality review of client files.
The agency will be in compliance with this standard as of 10/8/2018 |