INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection and methadone monitoring inspection conducted on February 11-12, 2019 by staff from the Department of Drug and Alcohol Programs, Bureau of Quality Assurance for Prevention and Treatment. Based on the findings of the on-site inspection, RHJ Medical Center, Inc. / Vandergrift, LLC 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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704.6(a) LICENSURE Clinical Supervisor Qualifications
704.6. Qualifications for the position of clinical supervisor.
(a) A drug and alcohol treatment project shall have a full-time clinical supervisor for every eight full-time counselors or counselor assistants, or both.
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Observations
The drug and alcohol treatment project failed to have a full-time clinical supervisor for every eight full-time counselors and counselor assistants.
At the time of the inspection, February 11-12, 2019, the project had 16 total full-time counselors/counselor assistants and one full-time clinical supervisor.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Project Director will be responsible to ensure that the position of clinical supervisor will be filled. The current lead counselor is currently in training while reducing her current caseload and will be taking the required DDAP training in April of this year. Following the DDAP training and a reduction in caseload she will be promoted to Clinical Supervisor. In order to maintain future compliance we will have at least 1 full-time clinical supervisor for every 8 FTE counselors across the project. |
715.11 LICENSURE Confidentiality of patient records
A narcotic treatment program shall physically secure and maintain the confidentiality of all patient records in accordance with 42 CFR 2.22 (relating to notice to patients of Federal confidentiality requirements) and § 709.28 (relating to confidentiality).
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Observations
The facility failed to physically secure and maintain the confidentiality of all patient records in accordance with 42 CFR Part 2, Subpart B,
2.22 (relating to notice to patients of Federal confidentiality requirements) and 28 Pa. Code 709.28 (relating to confidentiality).
During the observation of methadone dispensing on February 12, 2019, it was observed that one patient put his three take home bottles in the general trash without blacking out his name. The nurse also did not black out his name. Upon removing three of the take home bottles from the trash can, it was observed that the patients name was clearly legible on the bottles. The patient's first and last names were visible. This practice did not ensure that the patient's confidentiality was physically secure and maintained.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Project/Facility Director are responsible to ensure that the confidentiality requirements are meet. In order to ensure compliance a training was provided to the nursing staff by the facility director, directing them to instruct the patients to black out their names on any take-home bottles that are being returned. If the patient fails to do so then the nurse receiving the take-homes will then black out the names prior to discarding them in the trash. To ensure future compliance the facility director will randomly, weekly monitor the nursing staff to observe the nurses making sure that the names are blacked out to protect confidentiality. After demonstrating competence, the facility director will then randomly, quarterly observe the nursing staff. |