INITIAL COMMENTS
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This report identifies the findings of an on-site complaint investigation conducted on April 3, 2007 by staff from the Division of Drug and Alcohol Program Licensure. The following deficiencies were identified during this inspection and a plan of correction is due on May 1, 2007.
709.14 Restriction on License (a)(5) Authorized capacity
The facility exceeded its authorized maximum capacity of 12. During the months of February 2007 and March 2007, the facility had a census of thirteen and fourteen for the free standing non-hospital inpatient activity.
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Plan of Correction
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705.4 (1) LICENSURE Counseling areas.
705.4. Counseling areas.
The residential facility shall:
(1) Maintain space for both individual and group counseling sessions.
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Observations
The facility failed to maintain counseling areas. The counseling offices in the residential wing are cluttered and being used for storage and present a safety issue for both clients and staff. Also, the kitchen and dining areas are not adequately cleaned and maintained, e.g., dirt and grease residue was present on counter and cupboard areas, the refrigerator was in need of cleaning, and the dining area floors were littered with food particles.
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Plan of Correction
Staff will create checklist defining all maintenance areas, effective 6/1/07. Checklist will be completed three (3) times a day.
Two (2) times a month a Counselor's Aide on duty will review in Life Skills Group the proper cleaning procedures with the group to assure all areas are being adequately cleaned and maintained, effective 6/1/07.
Counselors on the floor will check daily to ensure this procedure. Any issues will be followed up with verbal reports to the Director for further action.
The official areas have been redesigned, all clutter has been removed and all materials have been properly stored as of April 1, 2007. Counseling staff are responsible for continued cleanliness and organization.
Director to check monthly to ensure compliance. |
709.24(a) LICENSURE Treatment/Rehabilitation Management
709.24. Treatment/rehabilitation management.
(a) The governing body shall adopt a written plan for the coordination of client treatment and rehabilitation services which includes, but is not limited to:
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Observations
The facility failed to provide transportation for a client prescribed methadone. The project's policy under the Advance Treatment Services (ATS) Methadone Procedure indicates that for the first 90 days of treatment, staff will transport a client for methadone services.
It has been determined that the project's van is disabled and transportation services are not being provided. Also, it appears that referral sources are indicating that transportation needs are provided by Samara House. If there are no transportation services, then Samara House needs to correct the policies and procedures and formally notify all referral sources and payors of services.
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Plan of Correction
Existing staff will transport for the first 90 days, after 90 days tokens for public transportation will be given. Director to oversee to assure this procedure is taking place. To begin immediately.
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709.28(a)(2) LICENSURE Confidentiality
709.28. Confidentiality.
(a) A written procedure shall be developed by the project director which shall comply with 4 Pa. Code 255.5 (relating to projects and coordinating bodies: disclosure of client-oriented information). The procedure shall include, but not be limited to:
(2) Staff access to client records.
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Observations
The facility's policy failed to properly identify staff who have access to the records. The current policy does not clearly indicate by name or position what staff have access to the records.
42 CFR Part 2, Subpart B, Subsection 2.12(c)(3) indicates that "communications of information between or among personnel having a need for the information in connection with their duties that arise out .....". Therefore, to meet compliance with these regulations, the facility must specify in policy either by job title or name, who has access to the clinical records. Also, these positions that are permitted access need to have record access and the purpose of such defined in their job descriptions.
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Plan of Correction
Access to Files Policy has been updated to include Counselors' Aides and Program Assurance Liaison (PAL). All staff sign confidentiality clause when hired and this becomes regular part of the Personnel File. All job descriptions will be updated to include access to client files for the purpose of maintaining order of the charts, effective 6/1/07. |
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 shall be in writing and include, but not be limited to:
(2) Specific information disclosed.
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Observations
The facility exceeded the limitations imposed by 4 Pa. Code 255.5. Consent to release information forms to a probation officer and to an insurance company included specific information which exceeded this regulation in one of five records reviewed.
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Plan of Correction
All staff are trained on Confidentiality and Release of Information forms, as of 4/26/07.
Counselors and Director will check files weekly to ensure accuracy.
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709.32(c)(2) LICENSURE Medication Control
709.32. Medication control.
(c) The project shall have a written policy regarding medications used by clients which shall include, but not be limited to:
(2) Drug storage areas.
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Observations
The facility failed to properly store medications. The project stores the majority of the client's medications and vitamins in a locked refrigerator. Medications need to be stored according to the manufacturers storage requirements. Also, the facility failed to follow their policy on drug storage. The current practice is not consistent with the policy.
The facility failed to identify staff having access by name or job title in their storage areas policy under Medication Control.
Also, the methadone procedures for storage and loss/stolen doses needs to be incorporated into the project's medication control policies and procedures.
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Plan of Correction
-Meds stored per policy and procedure. As of 4/26/07, Policy and Procedures revised by Nurse and Director. Revisions include all staff, Counselors, Counselor's Aides, Program Assurance Liaison (PAL), Nurse and Director have access to medication cabinet and medication refrigerator. All medication as of 4/26/07 is stored in the medical office. Meds are stored according to content. Meds cabinet and refrigerator check performed monthly by Nurse and overseen by Director. All staff trained on 4/26/07 on storage of medication per Policy and Procedures by Nurse and overseen by Director.
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709.32(c)(4) LICENSURE Medication Control
709.32. Medication control.
(c) The project shall have a written policy regarding medications used by clients which shall include, but not be limited to:
(4) Methods for control and accountability of drugs.
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Observations
The facility failed to consistently document medication administration. The project forms used for monitoring medication administration, specifically the "Medication Administration Sheet" and the "Controlled Substance Record", are not being used properly. Missed medications are not consistently documented, medications administered are not consistently initialed by staff, and the inventory on the controlled substance record is not being properly recorded.
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Plan of Correction
Policy and Procedures revision made as of 4/26/07 by Nurse and Director. Revisions made all staff (Counselors, Counselor's Aides, Program Assurance Liaison (PAL), Nurse and Director) are responsible for MAR/Narcotic Sheet completion, Nurse and Director to oversee, medication to be dispensed only in medical office, designated times set. Nurse LPN/RN to ensure daily completion and compliance to be overseen by Nurse and checked monthly by Director. Methadone procedures and stored meds to be checked in and out, locked in client lockbox and medicine cabinet. Loss and theft incident reports to be completed by staff involved, Nurse and Director to oversee. All staff (Counselors, Counselor's Aides, Program Assurance Liaison (PAL) and Nurse) will have access to dispense Methadone. As of 4/26/07, all staff (Counselors, Counselor's Aides, Program Assurance Liaison (PAL) and Director) have been trained by the Nurse LPN/RN, on how to complete incident/loss/theft form, MAR/Narcotic Sheet completion and medication dispensing. Nurse to ensure daily completion, to be overseen by Director. |
709.51(a)(2) LICENSURE Treatment Methodology
709.51. Intake and admission.
(a) The project director shall develop a written plan providing for intake and admission which includes, but is not limited to:
(2) Treatment methodology.
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Observations
The facility failed to document services required by agency policy. The project policy includes a written plan for child prevention services that indicates "Therapeutic services will include weekly individual sessions with child and will address:.....". However, there is no documentation in the client's record to support that this service is being offered.
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Plan of Correction
Children's Prevention Services files will be incorporated into the back of the client files, effective June 1, 2007, instead of being maintained separately.
Child Prevention Specialist responsible for accuracy.
Director to oversee monthly. |
709.53(a)(3) LICENSURE Records of Service
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:
(3) Record of services provided.
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Observations
The facility fraudulently documented information on the record of service. Records of services were pre-dated for the month of April and the nutrition and spirituality seminars were pre-initialed as services rendered.
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Plan of Correction
Staff responsible for this non-compliance has been terminated from this position.
All staff have been instructed to follow this regulation as of 4/27/07.
Director to oversee monthly to ensure compliance. |