INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on March 15, 2018 by staff from the Department of Drug and Alcohol Programs, Division of Accountability and Program Improvement. Based on the findings of the on-site inspection, Familylinks, 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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705.10 (d) (1) LICENSURE Fire safety.
705.10. Fire safety.
(d) Fire drills. The residential facility shall:
(1) Conduct unannounced fire drills at least once a month.
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Observations
The facility failed to conduct unannounced fire drills at least once per month and prepare alternate exit routes to be used during fire drills.
The fire drill logs for the time period of August 2017 to February 2018 were reviewed on March 15, 2018. There was no fire drill documented for the month of January 2018 and all of the drills documented utilized the same exit (front door).
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Shady Facility will conduct consecutive monthly fire drills for the facility. Each scheduled monthly Fire Drill will be documented and documentation to be filled in the Fire Drill Log Binder that is accessible on site. The log of monthly fire drills will be reviewed as part of the Safety Checklist and the compliance will be reviewed at the monthly agency wide Safety Meetings. The Shady Facility will conduct these Monthly Fire Drills with plans to exit through alternate routes within the facility. Staff and Program participants will be participating in these drills monthly. The Safety Committee Staff within Shady facility will implement theses noted changes beginning the Month of May 2018. |
709.34 (c) (1) 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:
(1) Physical or sexual assault by staff or a client.
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Observations
The facilty failed to notify the Department of an unusual incident involving a client death within 3 business days.
Client #7 was admitted to treatment on November 15, 2017 and discharged due to death on January 31, 2018. There was no unusual incident report documented for this incident.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Unusual Incident Policy and procedure to be reviewed by all Shady Recovery Support Center Staff on May 1, 2018. Staff informed and updated to use updated email and fax number to submit all unusual incidents with 3 business days. The email will be used as a confirmation of receipt of submission and the Fax receipt will be kept and attached to the report as record of submission. Facility Director and/or Clinical Supervisor will monitor procedure for submission/confirmation. |
715.10(f) LICENSURE Pregnant patients
(f) The narcotic treatment program shall ensure that each female patient is fully informed of the possible risk to her or her unborn child from continued use of illicit drugs and from use of, or withdrawal from a narcotic drug administered or dispensed by the program in comprehensive maintenance or detoxification treatment.
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Observations
The facility failed to ensure that each female patient was fully informed of the possible risk to her or her unborn child from continued use of illicit drugs and from use of, or withdrawal from a narcotic drug administered or dispensed by the program in comprehensive maintenance or detoxification treatment.
Buprenorphine patient records were reviewed on March 15, 2018. Patients # 5 and 7 were identified as female patients. No notification regarding the risks (as noted above) were provided to these patients.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
All identified female patients within childbearing age will be provided information during Induction to Buprenorphine services the possible risk to her and her unborn child from continued use of, or withdrawal from a narcotic drug administered or dispensed in detoxification treatment or comprehensive maintenance. This information will be provided during Initial Assessment and female patient will sign on a document that she was counseled on this information. This process will be monitored by Facility Director and or Clinical Supervisor through chart audits. |
715.19(1) LICENSURE Psychotherapy services
A narcotic treatment program shall provide individualized psychotherapy services and shall meet the following requirements:
(1) A narcotic treatment program shall provide each patient an average of 2.5 hours of psychotherapy per month during the patient 's first 2 years, 1 hour of which shall be individual psychotherapy. Additional psychotherapy shall be provided as dictated by ongoing assessment of the patient.
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Observations
The facilty failed to provide each patient an average of 2.5 hours of psychotherapy per month during the patient's first 2 years.
Three buprenorphine patient records were reviewed on March 15, 2018. All three patients were required to complete at least 2.5 hours of psychotherapy. Patient record #7 did not include documentation of at least 2.5 hours of psychotherapy per month for the first two years.
Patient #7 was admitted on November 15, 2017 and discharged on January 31, 2018. Patient #7 did not have any psychotherapy documented for the months of November, December and January.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
All buprenorphine patients will receive 2.5 hours of psychotherapy each month. Treatment will be documented into electronic records and each client will sign an encounter form for each treatment session. The therapist will maintain treatment notes in the medical electronic records which will be monitored by facility director and/or Clinical Supervisor daily. The Therapist will submit weekly attendance reports to the Prescribing Medical staff regarding patient is compliant or non compliant with treatment. Attendance will be monitored weekly by the Facility Director and/or Clinical Supervisor. Clinical staff and prescribing medical staff will schedule a treatment team meeting with the patient to review attendance policy and discuss a plan to maintain scheduled appointments for Psychotherapy or patients to maintain compliance with attendance. |