INITIAL COMMENTS
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This report is a result of an on-site licensure renewal, buprenorphine monitoring, and capacity increase inspection conducted on November 6, 2024 through November 8, 2024 by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, Millerton Acquisition Sub, LLC DBA Bradford Recovery Center 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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704.11(c)(1) LICENSURE Mandatory Communicable Disease Training
704.11. Staff development program.
(c) General training requirements.
(1) Staff persons and volunteers shall receive a minimum of 6 hours of HIV/AIDS and at least 4 hours of tuberculosis, sexually transmitted diseases and other health related topics training using a Department approved curriculum. Counselors and counselor assistants shall complete the training within the first year of employment. All other staff shall complete the training within the first 2 years of employment.
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Observations
Based on a review of personnel records, the facility failed to ensure that two of six employees received a minimum of 6 hours of HIV/AIDS and 4 hours of TB/STD training using a Department approved curriculum within the regulatory timeframe.
Employee # 3 has been in the position of counselor since May 23, 2023 and was due to have the communicable disease trainings no later than May 23, 2024. However, the HIV/AIDS and TB/STD trainings were not completed until September 28, 2024.
Employee # 6 has been a case manager since March 9, 2022 and was due to have the communicable disease trainings no later than March 9, 2024. However, the HIV/AIDS training was not completed until August 27, 2024, and the TB/STD training was not completed until September 20, 2024.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
HR Director along with Facility Manager will ensure that all staff has the required trainings completed in a timely manner in compliance with DDAP regulations. HR Director along with Facility Manager will monitor trainings monthly along with upcoming trainings that need completed by each staff member to ensure compliance. |
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
Based on a review of twenty-one client records, the facility failed to include documentation of all the required client rights, including that the project may not discriminate in the provision of services on the basis of creed, ethnicity, color, national origin, marital status and religion in fifteen applicable records reviewed.
Client # 1 was admitted to the Partial Hospitalization level of care on March 26, 2024 and was discharged on May 11, 2024.
Client # 2 was admitted to the Partial Hospitalization level of care on July 26, 2024 and was discharged on August 25, 2024.
Client # 3 was admitted to the Partial Hospitalization level of care on December 13, 2023 and was discharged on March 7, 2024.
Client # 4 was admitted to the Partial Hospitalization level of care on April 23, 2024 and was discharged on July 29, 2024.
Client # 5 was admitted to the Partial Hospitalization level of care on September 5, 2024 and was active at the time of the inspection.
Client # 6 was admitted to the Partial Hospitalization level of care on October 3, 2024 and was still active at the time of the inspection.
Client # 7 was admitted to the Partial Hospitalization level of care on July 11, 2024 and was active at the time of the inspection.
Client # 8 was admitted to the Detoxification level of care on January 30, 2024 and was transferred to a lower level of care on February 6, 2024.
Client # 9 was admitted to the Detoxification level of care on June 17, 2024 and was transferred to a lower level of care on June 23, 2024.
Client # 10 was admitted to the Detoxification level of care on June 3, 2024 and was transferred to a lower level of care on June 7, 2024.
Client # 11 was admitted to the Detoxification level of care on July 18, 2024 and was transferred to a lower level of care on July 23, 2024.
Client # 12 was admitted to the Detoxification level of care on November 2, 2024 and was active at the time of the inspection.
Client # 13 was admitted to the Detoxification level of care on November 4, 2024 and was active at the time of the inspection.
Client # 14 was admitted to the Detoxification level of care on September 19, 2024 and was transferred to a lower level of care on September 26, 2024.
Client # 21 was admitted to the Rehabilitation level of care on October 14, 2024 and was active at the time of the inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
An update to our client and patient's right intake form has been modified to include the update of PA code 709.30. The below written inclusion will be added to our client and patient rights intake forms.
An updated copy of the patient rights will be given to all present clients in-house. The Clinical Director will be holding a group to go over each right with present clients.
A copy of the updated rights will be posted throughout the facility visible for all clients.
(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.
(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.
(3) Clients have the right to inspect their own records. The project, facility or clinical director may temporarily remove portions of the records prior to the inspection by the client if the director determines that the information may be detrimental if presented to the client. Reasons for removing sections shall be documented in the record.
(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.
(6) Clients have the right to submit rebuttal data or memoranda to their own records.
The intake coordinator will audit all incoming clients' charts to ensure the proper documentation is being signed by all clients.
Daily and weekly chart audits will continue throughout the year to ensure compliance.
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709.33 (a) LICENSURE Notification of termination.
§ 709.33. Notification of termination.
(a) Project staff shall notify the client, in writing, of a decision to involuntarily terminate the client ' s treatment at the project. The notice shall include the reason for termination.
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Observations
Based on a review of twenty-one client records, the facility failed to document that the client was notified, in writing, of the facility's decision to involuntarily terminate the client's treatment at the project in one of two applicable records reviewed.
Client # 15 was transferred to the Rehabilitation level of care on February 6, 2024 and was involuntarily discharged on February 20, 2024. The record contained no documentation that the client was notified, in writing, of the facility's decision to involuntarily terminate.
This is a repeat citation from the November 8, 2023 annual licensing renewal inspection.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
A group supervision will be conducted for all staff with client contact to ensure proper documentation is entered into the EMR to include written notice of involuntary termination (Administrative Discharge) of treatment with an explanation for termination.
All clinical staff will be responsible for entering the proper documentation is entered into the EMR prior to the client being discharged from the facility.
The Clinical Director will audit ten charts for 4 months to ensure compliance. This will begin on 12/12/2024 and end on 3/12/2025.
The Clinical Director will continue to follow up with staff during FLASH to ensure proper administrative discharge notification if entered into the EMR. Daily and weekly audits will continue throughout the year.
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709.82(d)(1) LICENSURE Treatment and rehabilitation services
709.82. Treatment and rehabilitation services.
(d) Counseling shall be provided to a client on a regular and scheduled basis. The following services shall be included and documented:
(1) Individual counseling, at least twice weekly.
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Observations
Based on a review of client records, the facility failed to ensure counseling was provided to a client on a regular and scheduled basis to include and document individual counseling, at least twice weekly in six out of seven records reviewed.
Client #2 was admitted on July 26, 2024 and was discharged on August 25, 2024. The individual treatment and rehabilitation plan completed on July 29, 2024, indicated that the client was to receive two individual sessions per week; however, the record contained only documentation for one individual session for the weeks of July 28, 2024 thru August 3, 2024 and August 18, 2024 thru August 24, 2024.
Client #3 was admitted on December 13, 2023 and discharged on March 7, 2024. The individual treatment and rehabilitation plan completed on February 12, 2024, indicated that the client was to receive two individual sessions per week; however the record contained only documentation for one individual session for the weeks of December 17, 2023 thru December 23, 2023, January 21, 2024 thru January 27, 2024, February 4, 2024 thru February 10, 2024 and February 18, 2024 thru February 24, 2024. In addition, the record contained no documentation of individual sessions for the weeks of December 24, 2023 thru December 30,2023, December 31, 2023 thru January 6, 2024, January 28, 2024 thru February 3, 2024 and February 11, 2024 thru February 17, 2024.
Client #4 was admitted on April 23, 2024 and discharged on July 29, 2024. The individual treatment and rehabilitation plan completed on June 25, 2024, indicated that the client was to receive two individual sessions per week; however, the record contained only one individual session for the week of May 26, 2024 thru June 1, 2024 and the record contained no documentation of individual sessions for the week of May 12, 2024 thru May 18, 2024.
Client #5 was admitted on September 5, 2024 and active at time of inspection. The individual treatment and rehabilitation plan completed on October 2, 2024 indicated that the client was to receive two individual sessions per week; however, the record contained no documentation of an individual session between September 6, 2024 and time of inspection.
Client #6 was admitted on October 3, 2024 and was active at the time of the inspection. The individual treatment and rehabilitation plan completed on October 3, 2024, indicated that the client was to receive two individual sessions per week; however, the record contained only one individual session for the weeks of October 13, 2024 thru October 19, 2024, and October 27, 2024 thru November 2, 2024, and the record contained no documentation of an individual session for the weeks of October 6, 2024 thru October 12, 2024, October 20, 2024 thru October 26, 2024.
Client #7 was admitted on July 11, 2024 and active at time of inspection. The individual treatment and rehabilitation plans completed on July 11, 2024, August 9, 2024, and November 6, 2024 indicated that the client was to receive two individual sessions per week; however, the record contained only one individual session for the weeks of July 11, 2024 thru July 20, 2024, August 4, 2024 thru August 10, 2024, August 25, 2024 thru August 31, 2024, September 8, 2024 thru September 14, 2024, September 15, 2024 thru September 21, 2024, October 6, 2024 thru October 12, 2024, October 13, 2024 thru October 19, 2024, and October 20, 2024 thru October 26, 2024 and the record contained no documentation of an individual session for the week of August 11, 2024 thru August 17, 2024.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
A group supervision will be completed with all PHP clinical staff to educate them on the necessity of ensuring two individual sessions will be completed and documented properly during clients stay in the 2.5 level of care.
The Clinical Director will audit 10 charts weekly for the next 90 days to ensure compliance. We will continue to follow up with staff during FLASH to ensure proper and timely documentation is being placed in the EMR. This will begin on 12/12/2024 and end on 3/12/2025.
Daily and weekly audits will continue throughout the year.
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709.62(c)(vi) LICENSURE Psychosocial Eval
709.62. Intake and admission.
(c) Intake procedures shall include documentation of the following:
(6) Psychosocial evaluation.
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Observations
Based on a review of client records, the facility failed to document a psychosocial evaluation in five of five applicable records reviewed.
Client # 8 was admitted on January 30, 2024 and was transferred to a lower level of care on February 6, 2024. The record did not contain a psychosocial evaluation.
Client # 9 was admitted on June 17, 2024 and was transferred to a lower level of care on June 23, 2024. The record did not contain a psychosocial evaluation.
Client # 10 was admitted on June 3, 2024 and was transferred to a lower level of care on June 7, 2024. The record did not contain a psychosocial evaluation.
Client # 11 was admitted on July 18, 2024 and was transferred to a lower level of care on July 23, 2024. The record did not contain a psychosocial evaluation.
Client # 14 was admitted on September 19, 2024 and was transferred to a lower level of care on September 26, 2024. The record did not contain a psychosocial evaluation.
These finding were discussed with facility staff during the licensing process.
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Plan of Correction
A policy change will be completed by 12/12/2024 that will include the psychosocial is to be completed for all clients before they step down from 3.7 to a 3.5 level of care. The Nursing Director will conduct a group supervision with the medical team to reflect the changes in the policy. This change will reflect in the completion of the psychosocial completed in BestNotes. Nurse Manager will continue auditing 10 new charts monthly for new admissions entered into 3.7 level of care. This will ensure the psychosocial is being completed before clients step down to a lower level of care.
The Nurse Manager will audit ten charts monthly for 3 months to ensure compliance. This will begin on 12/12/2024 and end on 3/12/2025. |
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 patient records, the facility failed to ensure that verification of the individual's identity was obtained during the intake process in one of three applicable records reviewed.
Patient # 12 was admitted to the Detoxification level of care on November 2, 2024 and was active at the time of the inspection. The record did not contain documentation that the individual's identity was verified during intake.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
A new document will be created for all new intake into treatment that contain the client's race, age, date of birth, and last 4 of the client's social security number.
A group supervision will be completed with all intake staff to review the changes in the documentation. The intake supervisor will audit 10 charts monthly for 90 days to ensure proper verification is being made to admit clients into the Narcotic Treatment Program. This will begin on 12/12/2024 and end on 3/12/2025.
Daily and weekly audits will continue throughout the year.
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715.17(c)(1)(i-vi)) LICENSURE Medication control
(c) A narcotic treatment program shall develop and implement written policies and procedures regarding the medications used by patients which shall include, at a minimum:
(1) Administration of medication.
(i) A narcotic treatment physician shall determine the patient 's initial and subsequent dose and schedule. The physician shall communicate the initial and subsequent dose and schedule to the person responsible for the administration of medication. Each medication order and dosage change shall be written and signed by the narcotic treatment physician.
(ii) An agent shall be administered or dispensed only by a practitioner licensed under the appropriate Federal and State laws to dispense agents to patients.
(iii) Only authorized staff and patients who are receiving medication shall be permitted in the dispensing area.
(iv) There shall be only one patient permitted at a dispensing station at any given time.
(v) Each patient shall be observed when ingesting the agent.
(vi) Administering and dispensing shall be conducted in a manner that protects the patient from disruption or annoyance from other individuals.
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Observations
Based on a review of patient records, the facility failed to ensure that each medication order was written and signed by the narcotic treatment physician in one of three records reviewed.
Patient # 12 was admitted to the Detoxification level of care on November 2, 2024 and was active at the time of the inspection. Medication was administered to the individual on November 3, 2024; however, the record did not contain a medication order that was written and signed by the narcotic treatment physician.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Bradford Recovery Center will review the policy through a group supervision with all medical staff by 12/12/2024 that will include proper documentation being implemented into the EMR specific to administration of medication that is signed off in the EMR by the narcotic treatment physician.
The Nurse Manager will audit 10 charts weekly for the next 90 days to ensure compliance. We will continue to follow up with medical staff during FLASH to ensure proper documentation is being placed in the EMR.
Daily and weekly audits will continue throughout the year.
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715.17(c)(4)(i-viii) LICENSURE Medication control
(c) A narcotic treatment program shall develop and implement written policies and procedures regarding the medications used by patients which shall include, at a minimum:
(4) Method for control and accountability of drugs. A narcotic treatment program shall develop and implement written policies and procedures regarding who is authorized to remove drugs from the storage area and the method for accounting for all stored drugs. An agent or other drug prescribed or administered shall be documented on an individual medication record or sheet in a manner sufficient to maintain an accurate accounting of medication at all times and shall include:
(i) The name of the medication.
(ii) The date prescribed.
(iii) The dosage.
(iv) The frequency.
(v) The route of administration.
(vi) The date and time administered.
(vii) The name of the person administering the medication.
(viii) The take-home schedule, if applicable.
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Observations
Based on a review of patient records, the facility failed to ensure that agents prescribed or administered were documented on an individual medication record or sheet that included the date and time administered and the name of the person administering the medication, in two of three applicable records reviewed.
Patient # 9 was admitted to the Detoxification level of care on June 17, 2024 and was transferred to a lower level of care on June 23, 2024. The record contained documentation of a medication order written on June 18, 2024; however, the record did not contain documentation of dates and times the medication was administered, whether the medication was refused by the patient, or discontinued by the physician.
Patient # 10 was admitted to the Detoxification level of care on June 3, 2024 and was transferred to a lower level of care on June 7, 2024. The record contained documentation of a medication order written on June 5, 2024, to begin on June 6, 2024; however, the record did not contain documentation of dates and times the medication was administered, whether the medication was refused by the patient, or discontinued by the physician.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
A group supervision will be provided to all nursing staff to ensure that medications prescribed are entered into the MAR and that proper documentation is being completed inside the MAR to reflect if a medication has been refused or discontinued.
Nurse Manager will do weekly chart audits of clients in the detox level of care for 3 months to ensure compliance. This will begin on 12/12/2024 and end on 3/12/2025.
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709.52(c) LICENSURE Provision of Counseling Services
709.52. Treatment and rehabilitation services.
(c) The project shall assure that counseling services are provided according to the individual treatment and rehabilitation plan.
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Observations
Based on a review of client records, the facility failed to ensure that counseling services were provided according to the individual treatment and rehabilitation plans in three of six applicable records reviewed.
Client # 15 was transferred to the Rehabilitation level of care on February 6, 2024 and was discharged on February 20, 2024. The treatment plan completed on February 7, 2024, indicated that the client was to receive one individual session per week; however, the record did not document individual sessions offered between February 7, 2024 through February 14, 2024, when the next treatment plan update was completed.
Client # 16 was transferred to the Rehabilitation level of care on June 23, 2024 and was discharged on July 29, 2024. The treatment plan completed on June 26, 2024, indicated that the client was to receive one individual session per week; however, the record contained no documentation of an individual session between June 26, 2024 and July 18, 2024.
Client # 17 was transferred to the Rehabilitation level of care on June 7, 2024 and was discharged on June 28, 2024. The treatment plans completed on June 9, 2024 and June 16, 2024, indicated that the client was to receive one individual session per week; however, the record only contained documentation that one individual was offered prior to discharge.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
A group supervision will be completed with all clinical staff by 12/12/2024 to educate them on the necessity of ensuring treatment and rehab service reflect individual treatment and rehabilitation plan.
The Clinical Director will audit 10 charts weekly for the next 90 days to ensure compliance. Administrative Staff and the Clinical Director will continue to follow up with staff during FLASH (morning meeting with clinical) to ensure proper documentation is being placed in the EMR.
Daily and weekly chart audits will continue throughout the year.
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