INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on September 5 - 6, 2017 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Renewal Treatment 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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704.12(a)(1)(i) LICENSURE Client/couns ratios
704.12. Full-time equivalent (FTE) maximum client/staff and client/counselor ratios.
(a) General requirements. Projects shall be required to comply with the client/staff and client/counselor ratios in paragraphs (1)-(6) during primary care hours. These ratios refer to the total number of clients being treated including clients with diagnoses other than drug and alcohol addiction served in other facets of the project. Family units may be counted as one client.
(1) Inpatient nonhospital detoxification (residential detoxification).
(i) There shall be one FTE primary care staff person available for every seven clients during primary care hours.
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Observations
The facility failed to maintain a minimum of one FTE (full time equivalent) primary care staff person for every seven clients during primary care hours based on staff interviews and a review of the Staffing Requirements Facility Summary Report form (SRFSR) during the annual licensing inspection conducted on September 5 - 6, 2017.
Primary care hours for the detoxification activity are 24 hours per day, 7 days per week.
Per the SRFSR, the facility did not have any primary care staff coverage during the following dates and times:
8/3/17 - 12 AM - 8 AM and 8 PM - 12 AM
8/4/17 - 12 AM - 8 AM and 5 PM - 12 AM
8/5/17 - 12 AM - 8 AM and 8 PM - 12 AM
8/6/17 - 12 AM - 8 AM and 5 PM - 12 AM
8/11/17 - 12 AM - 8 AM, 5 PM - 10 PM and 11 PM - 12 AM
8/12/17 - 12 AM - 8 AM and 5 PM - 10 PM
8/13/17 - 12 AM - 8 AM and 11 PM - 12 AM
8/14/17 - 12 AM - 8 AM and 10 PM - 12 AM
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Renewal Treatment, Inc. shall maintain a minimum of one (1) FTE (full time equivalent) primary care staff person for every seven (7) clients during primary care hours. Primary care hours shall be defined twenty-four (24) hours per day, 7 days per week. Scheduled Primary Care staff shall include Clinical Supervisors, Counselors, Physicians, Physician Assistant, Registered Nurse and Licensed Practical Nurse. Primary Care staff levels shall be maintained at a level of one (1) primary care staff person on duty for the first seven (7) patients. For eight (8) through fourteen (14) patients, a second primary care staff person will be added. This ratio shall be maintained for all shifts, seven (7) days a week. The Project Director and Program Director shall be responsible for the implementation of this POC and shall ensure appropriate staffing levels are maintained when a detoxification patients is in our care. This POC is in place. |
709.32 (b) LICENSURE Medication control
§ 709.32. Medication control.
(b) Verbal orders for medication can be given only by a physician or other medical professional authorized by State and Federal law to prescribe medication and verbal orders may be received only by another physician or medical professional authorized by State and Federal law to receive verbal orders. When a verbal or telephone order is given, it has to be authenticated in writing by a physician or other medical professional authorized by State and Federal law to prescribe medication. In detoxification levels of care, written authentication shall occur no later than 24 hours from the time the order was given. Otherwise, written authentication shall occur within 3 business days from the time the order was given.
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Observations
The facility's physician failed to authenticate in writing verbal detoxification orders within 24 hours from the time the order was given in six detoxification client records reviewed during the annual licensing inspection conducted on September 5 - 6, 2017.
Client # 8 was admitted on August 3, 2017 and discharged on August 7, 2017. A verbal order was given by the physician on August 4, 2017 for the following medications: clonidine .1 mg, Vistaril 25 mg, trazodone 100 mg, Flexeril 10 mg and prednisone 40 mg.
Client # 9 was admitted on August 11, 2017 and discharged on August 15, 2017. A verbal order was given by the physician on August 11, 2017 for the following medications: glipizide 5 mg and simvastatin 20 mg.
Client # 10 was admitted on July 18, 2017 and discharged on July 19, 2017. A verbal order was given by the physician on July 19, 2017 for the following medication: trazodone 100 mg.
Client # 12 was admitted on March 24, 2017 and discharged on March 27, 2017. A verbal order was given by the physician on March 24, 2017 for the following medications: clonidine .1 mg, Vistaril 25 mg, Zofran 4 mg, ibuprofen 800 mg and Tylenol 500 mg.
Client # 13 was admitted on January 26, 2017 and discharged on January 27, 2017. A verbal order was given by the physician on January 26, 2017 for the following medications: clonidine .1 mg, Vistaril 25 mg, Zofran 4 mg, ibuprofen 800 mg and Tylenol 500 mg.
Client # 14 was admitted on January 20, 2017 and discharged on January 24, 2017. A verbal order was given by the physician on January 20, 2017 for the following medications: clonidine .1 mg, Vistaril 25 mg, Zofran 4 mg, ibuprofen 800 mg and Tylenol 500 mg.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Renewal Treatment, Inc.'s Physician shall authenticate in writing verbal detoxification orders within twenty-four (24) hours from the time the order was given. The Physician shall provide these signed written orders in person or via secure HIPPA compliant electronic means within the required time frame. Renewal Treatment, Inc.'s Nurse Supervisor, Nurse or Licensed Practical Nurse shall shall ensure that all verbal detoxification orders are followed up by written, signed orders within the required twenty-four (24) hour time period. All Primary Care staff that work with detoxification clients received training in regards to this requirement. The Project Director, Program Director and Clinical Supervisor shall ensure compliance with this POC. This POC is in place. |
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
The facility failed to document a psychosocial evaluation during the intake process in four detoxification client records reviewed during the annual licensing inspection conducted on September 5 - 6, 2017.
Client # 8 was admitted on August 3, 2017 and discharged on August 7, 2017.
Client # 9 was admitted on August 11, 2017 and discharged on August 15, 2017.
Client # 12 was admitted on March 24, 2017 and discharged on March 27, 2017.
Client # 14 was admitted on January 20, 2017 and discharged on January 24, 2017.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Renewal Treatment, Inc. shall ensure that intake procedures shall include documentation of Psychosocial evaluation. Renewal, Treatment Inc. shall add space to the Nurse assessment form for the purpose of a narrative Psychosocial evaluation. The detoxification patients primary counselor shall be responsible for completing the psychosocial evaluation during the intake process. All primary care staff that work with detoxification patients received training in regards to this requirement. The Program Director and Clinical Supervisor shall ensure compliance via supervision and chart review. This POC is in place. |
709.63(a) LICENSURE Client record
709.63. 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:
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Observations
The facility failed to document a complete client record including a record of services provided in six detoxification client records reviewed during the annual licensing inspection conducted on September 5 - 6, 2017.
The following clients received individual counseling that was not documented on the record of services provided:
Client # 8 was admitted on August 3, 2017 and discharged on August 7, 2017.
Client # 9 was admitted on August 11, 2017 and discharged on August 15, 2017.
Client # 11 was admitted on April 17, 2017 and discharged on April 18, 2017.
Client # 12 was admitted on March 24, 2017 and discharged on March 27, 2017.
Client # 13 was admitted on January 26, 2017 and discharged on January 27, 2017.
Client # 14 was admitted on January 20, 2017 and discharged on January 24, 2017.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Renewal Treatment, Inc. shall document a complete client record for all clients receiving detoxification services. The client record shall include a record of services. Renewal Treatment, Inc. shall utilize the record of services form that is used in the residential program for this purpose. This form will be added and utilized in all detoxification client records. All primary care staff that provide detoxification services received training in regards to this requirement. The Clinical Supervisor shall ensure compliance via supervision and chart review. The Program Director and Clinical Supervisor shall ensure compliance with this POC. |