INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection, and a methadone monitoring inspection conducted on November 1-3, 2016, by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Parkside Recovery 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(f)(2) LICENSURE Trng Hours Req-Coun
704.11. Staff development program.
(f) Training requirements for counselors.
(2) Each counselor shall complete at least 25 clock hours of training annually in areas such as:
(i) Client recordkeeping.
(ii) Confidentiality.
(iii) Pharmacology.
(iv) Treatment planning.
(v) Counseling techniques.
(vi) Drug and alcohol assessment.
(vii) Codependency.
(viii) Adult Children of Alcoholics (ACOA) issues.
(ix) Disease of addiction.
(x) Aftercare planning.
(xi) Principles of Alcoholics Anonymous and Narcotics Anonymous.
(xii) Ethics.
(xiii) Substance abuse trends.
(xiv) Interaction of addiction and mental illness.
(xv) Cultural awareness.
(xvi) Sexual harassment.
(xvii) Developmental psychology.
(xviii) Relapse prevention.
(3) If a counselor has been designated as lead counselor supervising other counselors, the training shall include courses appropriate to the functions of this position and a Department approved core curriculum or comparable training in supervision.
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Observations
The facility failed to ensure that all of the counselors received at least 25 hours of annual training.
Staff Person #5 was hired as a counselor on 02/03/2014. The staff person only received 20 hours and 54 minutes of training in the training year beginning on 07/01/2015, and ending on 06/30/2016.
These findings were reviewed with facility staff as part of the inspection process.
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Plan of Correction
Supervisors will now be responsible to sign their counselors up for trainings as well as for collecting all their team members certificates regarding staff member's completion of trainings. Training Supervisor will be responsible in collecting all certificates from Supervisors and enter all names and training hours on a grid to ensure this deficiency does not re-occur. Training Supervisor will meet with the Program Director monthly to monitor the completion of the grid. |
709.28 (b) LICENSURE Confidentiality
§ 709.28. Confidentiality.
(b) The project shall secure hard copy client records within locked storage containers. Electronic records must be stored on secure, password protected data bases.
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Observations
The facility failed to properly secure patient records.
During the onsite inspection conducted on 11/03/2016, room 15b was filled with cardboard boxes containing patient records, but the door to room 15b was not locked, and was accessible to people other than the facility staff.
These findings were reviewed with facility staff as part of the inspection process.
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Plan of Correction
All records in room 15B will be moved by December 12th to a room with a double locked door. Additionally, the Medical Records Supervisor will make daily rounds are done to ensure that all doors are locked at all times which hold client records. Medical Records Supervisor will be responsible to also create a log sheet which will be marked off as daily rounds are conducted to ensure this deficiency does not re-occur. |
709.28 (c) 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.
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Observations
The facility failed to document an informed and voluntary consent in four patient records. During the annual licensing inspection and methadone monitoring inspection on November 1-3, 2016, twenty - one patient records were reviewed.
Patient #4 had a release of information with a dated signature of the client and a dated signature of the witness. The release of information was signed on 4-4-2016. The release of information was blank for the person/agency/organization to whom the disclosure is made, specific information disclosed, purpose of the disclosure, and the date/event/condition upon which the consent will expire.
Patient #17 - Information (regarding Buprenorphine prescription) was disclosed to the pharmacy on 8-29-2016, 9-2-2016, 9-9-2016, and 10-28-2016 but there was not a release of information signed by the patient.
Patient #18 - Information (regarding Buprenorphine prescription) was disclosed to the pharmacy on 10-13-2016, and 10-25-2016 but there was not a release of information signed by the patient.
Patient #19 - Information (regarding Buprenorphine prescription) was disclosed to the pharmacy on 9-1-2016, 9-26-2016, and 10-10-2016 but there was not a release of information signed by the patient.
The findings were reviewed with the facility staff during the licensing process.
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Plan of Correction
A training will be conducted by the Clinical Supervisors and the Intake Supervisor on December 9th regarding the proper procedure for filling out a release of information for client care to outside agency's. All releases of information regarding clients who Buprenorphine prescriptions have been signed by the clients noted on the Observation #0276. The Medical Records Supervisor and the Intake Supervisor will be responsible to make sure this deficiency does not re-occur. |
715.9(a)(1) 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:
(1) Verify that the individual has reached 18 years of age.
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Observations
The facility failed to properly screen clients prior to the administration of a narcotic agent.
Patient #12 was admitted for narcotic treatment on 8/11/16, and was discharged on 10/13/2016. The facility did not have documentation verifying the patient's identity and age.
These findings were reviewed with the facility staff as part of the inspection process.
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Plan of Correction
The Intake Specialists will make sure that all individuals seeking treatment will have a valid I.D before being assessed for treatment. The Intake Supervisor will be responsible for auditing each chart received by the Intake Specialists. Each chart will have an audit sheet which will be used by the Intake Supervisor to check off that an I.D. with the individuals identity and age is present to ensure that this deficiency does not re-occur. |
715.15(b) LICENSURE Medication dosage
(b) The narcotic treatment physician shall determine the proper dosage level for a patient, except as otherwise provided in this section. If the narcotic treatment physician determining the initial dose is not the narcotic treatment physician who conducted the patient examination, the narcotic treatment physician shall consult with the narcotic treatment physician who performed the examination before determining the patient 's initial dose and schedule.
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Observations
The facility's physician failed to adhere to the dosing protocol listed on the medication by prescribing that single dose Suboxone film be cut in two of three patient records reviewed during the annual licensing inspection conducted on November 1 - 3, 2016.
Per the manufacturer's dosing and administration instructions "Suboxone sublingual film must be administered whole". Prescriptions need to be for the manufactured quantities of 12 mg/3 mg, 8 mg/2 mg, 4 mg/1 mg or 2 mg/.5 mg doses.
Patient # 18 was admitted into Suboxone treatment on October 13, 2016. The physician prescribed films of Suboxone on October 13, 2016 and October 25, 2016.
Patient # 19 was admitted into Suboxone treatment on September 1, 2016. It is documented in the patient record that on 9-1-2016 the physician " gave 1 1/2 film to patient to take later ".
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
All Physicians have been instructed by the Chief Medical Officer of Parkside Recovery to follow the dosing protocol listed on the medication Suboxone in regards to its dosing and administration. Physicians will only prescribe whole films and not prescribe "half" films. The Chief Medical Officer will be responsible to make sure this deficiency does not re-occur during supervision with the Physicians. |
715.20(1) 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.
(1) The transferring narcotic treatment program shall transfer patient files which include admission date, medical and psychosocial summaries, dosage level, urinalysis reports or summary, exception requests, and current status of the patient, and shall contain the written consent of the patient.
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Observations
The facility failed to document that transfer out materials were sent in three of four patient records. During the annual licensing inspection and methadone monitoring inspection on November 1-3, 2016, twenty - one patient records were reviewed. Four patient records were applicable to document transfer out information. Patient records #1, #3, & #9 were missing documentation.
These findings were reviewed with the facility staff during the licensing process.
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Plan of Correction
The Clinical Supervisors will monitor the client transfer process with their counselors in supervision and audit the transfer packet before it is sent to the receiving facility. All Clinical Supervisors will now be responsible for putting the completed transfer packets in the clients chart as opposed to Medical Records and check it off as completed on their teams caseload list. The Clinical Supervisors will be responsible ensure this deficiency does not re-occur. |
715.23(b)(5) LICENSURE Patient records
(b) Each patient file shall include the following information:
(5) The results of all annual physical examinations given by the narcotic treatment program which includes an annual reevaluation by the narcotic treatment physician.
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Observations
The facility failed to document an annual physical examination in one patient record. During the annual licensing inspection and methadone monitoring inspection on November 1-3, 2016, twenty - one patient records were reviewed. Two patient records were applicable to document an annual physical exam. Patient record #6 was missing documentation.
These findings were reviewed with the facility staff during the licensing process.
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Plan of Correction
The nurses in the Medical Department will run a report in Avatar each month for all clients whose Anniversary date falls in that month. The nurse will then notify each client through the Avatar system their physical and blood work date. A second nurse wills double check the list to make sure that no client was missed for that month. After the Physical is completed, the nurse will receive the chart and audit all Physical paperwork before sending the chart up to Medical Records. The Nurse Supervisor will be responsible to ensure this deficiency does not re-occur though supervision with the nurses in the Medical Department |
715.23(c)(1-7) LICENSURE Patient records
(c) An annual evaluation of each patient 's status shall be completed by the patient 's counselor and shall be reviewed, dated and signed by the medical director. The annual evaluation period shall start on the date of the patient 's admission to a narcotic treatment program and shall address the following areas:
(1) Employment, education and training.
(2) Legal standing.
(3) Substance abuse.
(4) Financial management abilities.
(5) Physical and emotional health.
(6) Fulfillment of treatment objectives.
(7) Family and community supports.
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Observations
The facility failed to document an annual evaluation in two of three patient records. During the annual licensing inspection and methadone monitoring inspection on November 1-3, 2016, twenty - one patient records were reviewed. Three patient records were applicable to document an annual evaluation. Patient records #2 & #6 were missing documentation.
These findings were reviewed with the facility staff during the licensing process.
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Plan of Correction
All client annual form due dates will be added to the counselors caseload sheet. The Clinical Supervisors will be responsible now as opposed to the counselors previously for receiving the annuals as they are completed by the counselor and client. The Clinical Supervisors will take the annual to the Physicians for sign off. All completed annuals will be checked off on the counselors caseload sheet by the Clinical Supervisors. The Clinical Supervisors will be responsible to ensure this deficiency does not re-occur. |