INITIAL COMMENTS
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This report is a result of an onsite licensure renewal and methadone monitoring inspection. The inspection was conducted on November 16-17, 2017 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the onsite inspection, Center for Behavioral Health-PA, 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 the inspection:
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Plan of Correction
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704.3 (b) LICENSURE Recruitment and Hiring
704.3. General requirements for projects.
(b) The project shall develop a policy that addresses the recruitment and hiring of staff persons who are appropriate to the population to be served. Every effort shall be made to hire staff persons representative of that population.
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Observations
The facility failed to document a policy that addresses the recruitment and hiring of staff persons who are appropriate to the population to be served and that every effort will be made to hire staff persons representative of that population.
These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
Recruitment and hiring policy will be revised by the Clinical Services Department to address the recruitment and hiring of staff persons who are appropriate to the population to be served. Every effort will be made to hire staff persons representative of the population served. Program staff will continue to work with Human Resources Business Partner in the recruitment and hiring of appropriate staff for the project. Clinic Director will oversee. |
705.24 (5) LICENSURE Bathrooms.
705.24. Bathrooms.
The nonresidential facility shall:
(5) Ventilate bathrooms by exhaust fan or window.
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Observations
The facility failed to have a bathroom that was ventilated by an operable exhaust fan or window during the physical plant inspection on November 17, 2017.
The client bathroom did not have an operable fan or window.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The condo association handy man has been contacted to replace the broken exhaust fan in the client bathroom. This repair will take place within the next week. Clinic Director will oversee. |
709.26 (a) (1) 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:
(1) Utilization of volunteers.
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Observations
The facility failed to have written project policies and procedures regarding the utilization of volunteers.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Personnel policy will be revised by the Clinical Services Department to include the utilization of volunteers in the project. Program will review policy revision with all staff in the January all staff meeting. Clinic Director will oversee. |
709.30 (1) 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.
(1) A client receiving care or treatment under section 7 of the act (71 P. S. § 1690.107) shall retain civil rights and liberties except as provided by statute. No client may be deprived of a civil right solely by reason of treatment.
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Observations
The facility failed to document written policies and procedures regarding all of the client rights.
The policy and procedure manual and the client handbook were reviewed. Neither the policy manual nor the client handbook documented 709.30 (4) Clients have the right to appeal a decision limiting access to their records to the director, (5) Clients have the right to request the correction of inaccurate, irrelevant, outdated or incomplete information in their records, or
(6) Clients have the right to submit rebuttal data or memoranda to their own record.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Client Rights policy and procedure will be revised by the Clinical Services Department to include the client's right to appeal a decision limiting access to records to the director; clients having the right to request the correction of inaccurate, irrelevant, outdated, or incomplete information in their records; and that clients have the right to submit rebuttal data or memoranda to their own record. Program management will review policy and procedure revisions with all staff at the January 2018 staff meeting. Clinic Director will oversee. |
709.34 (a) (1) LICENSURE Reporting of unusual incidents
§ 709.34. Reporting of unusual incidents.
(a) The project shall develop and implement policies and procedures to respond to the following unusual incidents:
(1) Physical assault or sexual assault by staff or a client.
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Observations
The facility failed to develop policies and procedures to respond to the following unusual incidents:
709.34 (a)
(4) Significant disruption of services due to disaster such as fire, storm, flood or other occurrence which closes the facility for more than 1 day.
(6) Event at the facility requiring the presence of police, fire or ambulance personnel.
(b) (5) Reporting mechanism to ensure that reporting of an unusual incident to an entity is in compliance with State confidentiality laws.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Unusual Incident policy and procedure will be revised by the Clinical Services Department to include how the project will report and respond to a significant disruption of services due to a disaster such as fire, storm, flood or other occurrence which closes the facility for more than one day including if the project requires the presence of police, fire, or ambulance personnel on site. Policy and procedure will be revised by Clinical Services Department to ensure that the revised policy and procedure of reporting an unusual incident to an entity is in full compliance with State confidentiality laws. Program management will review policy and procedure revisions with all staff at the January 2018 staff meeting. Clinic Director to oversee. |
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 the individual's emergency contact in seven of nine client records reviewed on November 16-17, 2017.
Client records # 1, 2, 3, 5, 9, 10 and 11 did not document an emergency contact.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Program Specialist will conduct training to ensure all staff are offering patients the ability to place a consent to release on file for an emergency contact. All patients will be provided with opportunity to add an emergency contact consent to release in his.her chart. If patients refuse to allow an emergency contact on file this will be documented in the patient chart. Program Specialist will implement and Clinical Director will complete audits to oversee. |
715.10(f) LICENSURE Pregnant patients
(f) The narcotic treatment program shall ensure that each female patient is fully informed of the possible risk to her or her unborn child from continued use of illicit drugs and from use of, or withdrawal from a narcotic drug administered or dispensed by the program in comprehensive maintenance or detoxification treatment.
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Observations
The facility failed to fully inform each female patient of the possible risk, to her and her unborn child, of continued use of illicit drugs and from the use of, or withdrawal from a narcotic drug administered or dispensed by the program for comprehensive maintenance or detoxification treatment in three of four patient records reviewed on November 16-17, 2017.
Client # 2 was admitted on February 7, 2017. Documentation that the client was fully informed of the possible risk to her and her unborn child occurred on September 1, 2017 when the client was confirmed pregnant.
There was no documentation in client records # 10 and 11 that they were fully informed of the possible risk.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The medical staff have been trained to utilize the "Pregnant Patient Acknowledgement of Risks" form with each female patient. This document informs the female patient of the possible risk, to her and her unborn child, of continued use of illicit drugs and from the use of, or withdrawal from a narcotic drug administered or dispensed by the program for comprehensive maintenance or detoxification treatment. The Medical Director and CRNP will implement this form and the Clinic Director will oversee and perform chart audits to ensure form is being used and female patients are informed of the risks. |
715.20 LICENSURE Patient transfers
A narcotic treatment program shall develop written transfer policies and procedures which shall require that the narcotic treatment program transfer a patient to another narcotic treatment program for continued maintenance, detoxification or another treatment activity within 7 days of the request of the patient.
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Observations
The facility failed to develop complete written transfer policies and procedures.
The policy and procedure manual was reviewed. The policies and procedures did not include that the facility would transfer the patient within 7 days of the request of the patient, and 715.20(4).
709.20(4) states that the receiving narcotic treatment program shall document in writing that it notified the transferring narcotic treatment program of the admission of the patient and the date of the initial dose given to the patient by the receiving narcotic treatment program.
These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
Transfer policy and procedure will be revised by the Clinical Services Department to include the project will transfer a patient within 7 days of the patients request to be transferred. Program management will review policy and procedure revisions with all staff at the January 2018 staff meeting. Clinic Director will oversee.
Transfer policy and procedure will be revised by the Clinical Services Department to include the project shall document in writing that it notified the transferring narcotic treatment program of the admission of the patient and the date of the initial dose given to the patient by the receiving narcotic program. Program management will review policy and procedure revisions with all staff at the January 2018 staff meeting. Program Specialist will oversee. |
715.21(1)(i-iv) LICENSURE Patient termination
A narcotic treatment program shall develop and implement policies and procedures regarding involuntary terminations. Involuntary terminations shall be initiated only when all other efforts to retain the patient in the program have failed.
(1) A narcotic treatment program may involuntarily terminate a patient from the narcotic treatment program if it deems that the termination would be in the best interests of the health or safety of the patient and others, or the program finds any of the following conditions to exist:
(i) The patient has committed or threatened to commit acts of physical violence in or around the narcotic treatment program premises.
(ii) The patient possessed a controlled substance without a prescription or sold or distributed a controlled substance, in or around the narcotic treatment program premises.
(iii) The patient has been absent from the narcotic treatment program for 3 consecutive days or longer without cause.
(iv) The patient has failed to follow treatment plan objectives.
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Observations
The facility failed to develop policies which included 715.21 (1) (iv).
The policy and procedure manual was reviewed. The policy did not include that a patient may be involuntarily discharged if the patient has failed to follow treatment plan objectives.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Termination policy and procedure will be revised by the Clinical Services Department to include a patient may be involuntarily discharged from the project if the patient has failed to follow treatment plan objectives. Program management will review policy and procedure revisions with all staff at the January 2018 staff meeting. Clinic Director will oversee. |