INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on September 16-17, 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, Resources for Human Development 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
The facility failed to complete the 6 hours of HIV/AIDS and 4 hours TB/STD training within the first year of employment. Staff #4 did not have the trainings completed by the due date of 7-16-2019.
The findings were reviewed with the facility staff during the inspection.
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Plan of Correction
The Licensing Alerts for 1-97 and 6-97 have been obtained in order to identify the minimum expectations for HIV and TB/STD trainings. RHD will utilize our Licensed Practical Nurse to provide the 6 hour HIV training and the 4 hour TB/STD trainings on site. By 10/30/19 RHD's Fiscal Administrator, who is responsible for tracking training that is due and completed will notify RHD's HIV and TB/STD trainer as well as the Assistant Director of any staff that are overdue on completing these trainings within 1 year of employment. By 10/30/19 a training will be scheduled to ensure that any staff who have exceeded the one year deadline have been trained by 11/30/19. The Fiscal Administrator is also responsible for working with the Nursing trainer in order to ensure that future trainings are scheduled in such a way as to ensure that all current and future employees meet the one year deadline for completing HIV and TB/STD trainings either in house or outside of the program. |
705.10 (d) (4) LICENSURE Fire safety.
705.10. Fire safety.
(d) Fire drills. The residential facility shall:
(4) Maintain a written fire drill record including the date, time, the amount of time it took for evacuation, the exit route used, the number of persons in the facility at the time of the drill, problems encountered and whether the fire alarm or smoke detector was operative.
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Observations
The facility failed to include all required information on the fire drill record. Fire drills were reviewed from the last inspection, July 2017, to current, September 2019.
Fire drill documented for October 13, 2017 is missing the time of the drill.
Fire drill documented for April 14, 2018 is missing the evacuation time.
Fire drills documented for October 16, 2017, April 14, 2018 and March 23, 2019 are missing the exit used.
Fire drill documented for April 14, 2018 is missing the number of people in the facility at the time of the drill.
Thirty-two fire drill records reviewed, do not document problems encountered.
Fire drill documented for March 23, 2019 is missing if the smoke detector or fire alarm is operable.
The findings were reviewed with the facility staff during the inspection.
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Plan of Correction
RHD has instituted effective 9/24/19, a property inspection procedure that is completed each week by the Life Skills Supervisor and the Assistant Director. This inspection process will identify property issues or repairs that need to be completed as well as the status of Allegheny County Health Department guidelines and overall cleanliness of the program. This process will also check that the Fire Drill logs are completed and are accurate so that any deficiencies can be corrected quickly so that the deficiency will not be repeated. Our Fire Drill Reports reflect the required information however oversight of ensuring they are complete was not occurring consistently. An additional check will be that the Property Check sheets will be reviewed at the Assistant Director's supervision in order to ensure that oversight of the Fire Drill reports is being done consistently. |
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 obtain an informed and voluntary consent for a laboratory, and a pharmacy in two of two client records reviewed.
The findings were reviewed with the facility staff during the inspection.
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Plan of Correction
As a part of the forms routinely completed at the time of admission are a set of Release of Information forms to people, services and agencies that all clients in the program will need completed. As of 9/24/19, RHD has added to this packet of Release of information forms, ROI's for for the laboratories and pharmacies we utilize within the program. By 10/15/19 the Assistant Director will ensure that all current clients have release of information forms completed and signed for all laboratories we are currently using for services clients are receiving. The Assistant Director is responsible for verifying these releases are done when completing weekly quantitative file reviews. |
709.32 (c) (1) (i) - (ii) LICENSURE Medication control
§ 709.32. Medication control.
(c) The project shall have and implement a written policy and procedures regarding all medications used by clients which shall include, but not be limited to:
(1) Administration of medication, including the documentation of the administration of medication:
(i) By individuals permitted to administer by Pennsylvania law.
(ii) When self administered by the client.
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Observations
The facility failed to document a policy and procedure for the administration of Suboxone.
The findings were reviewed with the facility staff during the inspection.
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Plan of Correction
RHD has developed a written policy regarding all medications used by clients which includes, but not limited to administration of Buprenorphine including the documentation of the administration of medication by individuals permitted to administer by Pennsylvania law. RHD does not offer "take home" privileges at this site so self administration by the client is not addressed. This policy will be fully implemented by 10/15/19 and the Facility Director is responsible for ensuring the policy is followed. |
709.32 (c) (3) (i) - (v) LICENSURE Medication control
§ 709.32. Medication control.
(3) Inspection of storage areas that ensures compliance with State and Federal laws and program policy. The policy must include, but not be limited to:
(i) What is to be verified through the inspection, who inspects, how often, but not less than quarterly, and in what manner it is to be recorded.
(ii) Disinfectants and drugs for external use are stored separately from oral and injectable drugs.
(iii) Drugs requiring special conditions for storage to insure stability are properly stored.
(iv) Outdated drugs are removed.
(v) Copies of drug-related regulations are available in appropriate areas.
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Observations
The facility failed to document quarterly inspections of storage areas since the last inspection in 2017.
The findings were reviewed with the facility staff during the inspection.
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Plan of Correction
RHD has instituted effective 9/24/19, a property inspection procedure that is completed each week by the Life Skills Supervisor and the Assistant Director. This inspection process will identify property issues or repairs that need to be completed as well as the status of Allegheny County Health Department guidelines and overall cleanliness of the program. This process will also check that Quarterly inspections of the medication storage area are completed by the medical staff. |
709.34 (c) (4) LICENSURE Reporting of unusual incidents
§ 709.34. Reporting of unusual incidents.
(c) To the extent permitted by State and Federal confidentiality laws, the project shall file a written unusual incident report with the Department within 3 business days following an unusual incident involving:
(4) Event at the facility requiring the presence of police, fire or ambulance personnel.
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Observations
The facility failed to notify the Department within three business days of an event requiring the presence of ambulance personnel.
A review of incident reports from July 2017 to September 2019 was conducted.
Nineteen unusual incident reports documented that an ambulance was called to the facility, but the incidents were not reported to the Department.
The findings were reviewed with the facility staff during the inspection.
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Plan of Correction
As of 9/24/19, the Director confirmed that the Assistant Director had the current DDAPL email address for where incident reports are to be sent. The Assistant Director is responsible for ensuring that incident reports are sent to this email address within 24 hours of the incident's occurrence. |
715.6(a) LICENSURE Physician staffing
(a) A narcotic treatment program shall designate a medical director to assume responsibility for administering all medical services performed by the narcotic treatment program
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Observations
The facility failed to designate a Medical director.
The findings were reviewed with the facility staff during the inspection.
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Plan of Correction
RHD has an existing contract with a Psychiatrist and have recently engaged him as our Medical Director. The Independent Contractor contract and Scope of Work description that covers the following functions will be implemented by 10/15/19:
Performing a medical history and physical exam.
Determining diagnosis and determining narcotic dependence.
Reviewing treatment plans.
Determining dosage/medications and all changes in dosages/medications.
RHD will NOT be ordering take home privileges.
Discuss cases with/within the treatment team.
Issue verbal orders pertaining to the care of persons in recovery.
Assess coexisting medical and psychiatric disorders.
Treat or support the appropriate referrals for treatment of these disorders.
Provide 24/7 support.
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715.6(c) LICENSURE Physician Staffing
(c) A narcotic treatment physician shall be otherwise available for consultation and verbal medication orders at all times when a narcotic treatment program is open and a narcotic treatment physician is not present.
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Observations
The facility failed to document the physician is available when the program is open, and the physician is not present at the facility.
The findings were reviewed with the facility staff during the inspection.
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Plan of Correction
RHD has an existing contract with a Psychiatrist and has recently engaged him as our Medical Director. The Independent Contractor contract and Scope of Work description includes 24/7 support and availability. This will be implemented by 10/15/19. |
715.9(d) LICENSURE Intake
(d) A narcotic treatment program shall explain to each patient treatment options; pharmacology of methadone, LAAM and other agents, including signs and symptoms of overdose and when to seek emergency assistance; detoxification rights; grievance procedures; and clinic charges, including the fee agreement signed by the patient.
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Observations
The facility failed to document each item was explained to each patient in two of two patient records. Documentation was missing for signs and symptoms of overdose, detox rights, grievance procedure, and clinic charges, including the fee agreement signed by the patient.
The findings were reviewed with the facility staff during the inspection.
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Plan of Correction
RHD has developed a procedure that includes a documentation package which includes explanations of the signs and symptoms of overdose and when to seek emergency services, detox rights, grievance procedure, release of information forms for specialty pharmacies used, informed consent to treatment with Buprenorphine and information concerning urinalysis. The packet would also include notification that as we are a residential program the costs for these services are included in our daily rate. This procedure will be implemented by 10/15/19 and the Assistant Director is responsible for ensuring it is followed through weekly quantitative file reviews. |
715.12(1-5) LICENSURE Informed patient consent
A narcotic treatment program shall obtain an informed, voluntary, written consent before an agent may be administered to the patient for either maintenance or detoxification treatment. The following shall appear on the patient consent form:
(1) That methadone and LAAM are narcotic drugs which can be harmful if taken without medical supervision.
(2) That methadone and LAAM are addictive medications and may, like other drugs used in medical practices, produce adverse results.
(3) That alternative methods of treatment exist.
(4) That the possible risks and complications of treatment have been explained to the patient.
(5) That methadone is transmitted to the unborn child and will cause physical dependence.
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Observations
The facility failed to obtain an informed patient consent in two of two patient records.
The findings were reviewed with the facility staff during the inspection.
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Plan of Correction
RHD has developed an Informed Consent form that will be utilized prior to prescribing Buprenorphine within the residential treatment program. The nursing staff is responsible for reviewing the form, ensuring that all signatures are obtained and providing the information reflected within the Informed Consent form. The Assistant Director is responsible for ensuring that the form is utilized consistently through weekly quantitative file reviews. The Informed Consent form will be implemented by 10/15/19. |
715.14(a) LICENSURE Urine testing
(a) A narcotic treatment program shall complete an initial drug-screening urinalysis for each prospective patient and a random urinalysis at least monthly thereafter.
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Observations
The facility failed to complete an initial drug screen in one of two patient records. An initial drug screen for July 2019 was not documented in patient record #2.
The findings were reviewed with the facility staff during the inspection.
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Plan of Correction
RHD has revised its' policies related to 715.14(a) ti include the procedures of completing urinalysis prior to Buprenorphine being prescribed and at least once per month while a client is being maintained on Buprenorphine. RHD has also developed a checklist that is signed off on by the medical staff that includes completion of urinalysis as a part of the checklist. The Assistant Director working along with the medical staff will ensure that this is done on ongoing basis by completing weekly quantitative file reviews. |
715.14(d) LICENSURE Urine testing
(d) A narcotic treatment program shall ensure that a laboratory that performs the testing required under this section shall be in compliance with applicable Federal requirements, specifically the Clinical Laboratory Improvement Amendments of 1998 (42 U.S.C.A. §§ 201 note, 263 and 263a notes), and State requirements, specifically the Pennsylvania Clinical Laboratory Act (35 P.S. §§ 2151-2165) and Chapter 5 (relating to clinical laboratories).
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Observations
The facility failed to obtain copies of the CLIA and Department of Health certificates for laboratories used by the facility.
The findings were reviewed with the facility staff during the inspection.
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Plan of Correction
As of 9/24/19, RHD has obtained the CLIA and Department of Health certificates for laboratories from Quest Diagnostic. The Program Director will ensure that updated certificates are obtained each year. |
715.15(f) LICENSURE Medication dosage
(f) The narcotic treatment program shall develop written policies and procedures relating to narcotic treatment medication dosage which includes the requirements of subsections (a)--(e).
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Observations
The facility failed to develop written policies and procedures relating to medication dosage for (a)(b).
The findings were reviewed with the facility staff during the inspection.
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Plan of Correction
RHD has developed policies and procedures related to 715.15(a) and 715.15(b). The Medical Director is responsible for ensuring that this policy is followed. This policy will be implemented by 10/15/19. |
715.28(a)(1-10) LICENSURE Unusual incidents
(a) A narcotic treatment program shall develop and implement policies and procedures to respond to the following unusual incidents:
(1) Physical assault by a patient.
(2) Inappropriate behavior by a patient causing disruption to the narcotic treatment program.
(3) Selling of drugs on the premises.
(4) Complaints of patient abuse (physical, verbal, sexual and emotional).
(5) Death or serious injury due to trauma, suicide, medication error or unusual circumstances.
(6) Significant disruption of services due to disaster such as fire, storm, flood or other occurrence.
(7) Incident with potential for negative community reaction or which the facility director believes may lead to community concern.
(8) Theft, burglary, break-in or similar incident at the facility.
(9) Drug related hospitalization of a patient.
(10) Other unusual incidents the narcotic treatment program believes should be documented.
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Observations
The facility failed to develop written policies and procedures for unusual incidents for (2), (4), (7), (9), and (10) .
The findings were reviewed with the facility staff during the inspection.
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Plan of Correction
RHD has existing policies (709.34)that cover reporting of unusual incidents. For those areas not covered by existing 709.34 policies, new ones have written and will be fully implemented by 10/15/19. The Facility Director is responsible for the implementation and for ensuring these policies are followed. |