INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on December 19-20, 2018 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, Family Service Association of Bucks County 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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705.23 (3) LICENSURE Counseling or activity areas and office space
705.23. Counseling or activity areas and office space.
The nonresidential facility shall:
(3) Ensure privacy so that counseling sessions cannot be seen or heard outside the counseling room. Counseling room walls shall extend from the floor to the ceiling.
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Observations
The facility failed to ensure privacy so that counseling sessions could not be heard outside of counseling rooms for rooms 114, 117, and 127.
These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
The Clinical Director will ensure that white noise generators are plugged in and placed outside each office door when office is in use. |
705.28 (c) (3) LICENSURE Fire safety.
705.28. Fire safety.
(c) Fire extinguishers. The nonresidential facility shall:
(3) Ensure fire extinguishers are inspected and approved annually by the local fire department or fire extinguisher company. The date of the inspection shall be indicated on the extinguisher or inspection tag. If a fire extinguisher is found to be inoperable, it shall be replaced or repaired within 48 hours of the time it was found to be inoperable.
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Observations
The facility failed to ensure that all fire extinguishers were inspected and approved annually by the fire department as the fire extinguisher located near one of the lobby entrances was last inspected September 2017.
These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
The fire inspector inspected the fire extinguisher that was missed during last inspection, and the attached card is now up-to-date. The facilities coordinator will ensure that each fire extinguisher is checked at monthly safety inspection. |
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 secure all client records within locked storage containers as there were many client records containing client-identifying information found in an unlocked cabinet in a hallway closet that was also unsecured.
These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
Staff member had forgotten to lock cabinet that day. Cabinet was locked by end of day. COE Coordinator will reinforce with staff that cabinet must be locked at all time. |
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 keep disclosures of client identifying information within the limits established by 4 Pa Code 255.5 for releases of information in four of eleven client records reviewed. Additionally, the facility failed to document the witness signature, specific information to be released, and/or purpose of disclosure on consent forms for three of eleven client records reviewed.
Client #4 was admitted on June 14,2018 and was discharged on October 12, 2018. A release of information to the emergency contact signed and dated by client on June 14, 2018 was missing the specific information to be released. Additionally, the release of information to a hospital signed and dated by the client on June 14, 2018 was missing the purpose of disclosure.
Client #5 was admitted on December 7, 2017 and discharged on November 5, 2018. A release of information to the emergency contact that was signed and dated by the client on January 1, 2018 was missing the specific information to be disclosed.
Client #7 was admitted on September 24, 2018 and was active at the time of inspection. The release of information to the funding source signed and dated on 10/16/18 allowed access to information regarding current medication and prescription records, which exceeded 4 Pa Code 255.5.
Client #8 was admitted on October 2, 2018 and was active at the time of inspection. The release of information to the funding source signed and dated on October 16, 2018 allowed access to information regarding current medication and prescription records, which exceeded 4 Pa Code 255.5.
Client #9 was admitted on July 11, 2018 and was discharged on September 17, 2018. The release of information to the funding source signed and dated on July 18, 2018 allowed access to screening and lab results, current medication and prescription records, evaluation and assessments, and treatment and discharge recommendations, which exceeded 4 Pa Code 255.5.
Client #10 was admitted on June 14, 2018 and was active at the time of inspection. The release of information to the funding source signed and dated by staff on June 14, 2018 was missing a witness signature and date. Additionally, the release of information signed and dated on July 25, 2018 allowed access to evaluations and assessments and treatment and discharge recommendations, which exceeded 4 Pa Code 255.5.
These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
Client # 4: Front desk office manager and Intake Supervisor will train staff on filling out all portions of the release.
Clinical Director will reinforce staff to contact Electronic Health Record Administrator if there is a technical problem with signatures and/or scan and attach a paper signature page.
Client # 5: Front desk office manager and Intake Supervisor will train staff on filling out all portions of the release.
Client # 7: Facility Director will speak to Nursing Manager and COE Coordinator to ensure all out-of-date paper release forms are destroyed, and staff are using the correct paper release form.
Staff who haven't attended will attend the DDAP Confidentiality training (DDAP will be holding training at Family Service approx. 4/2019).
ADDITIONAL INFO: Proper releases were obtained electronically. The paper releases were removed from the chart.
Client # 8: Facility Director will speak to Nursing Manager and COE Coordinator to ensure all out-of-date paper release forms are destroyed, and staff are using the correct paper release form.
Staff who haven't attended will attend the DDAP Confidentiality training (DDAP will be holding training at Family Service approx. 4/2019).
ADDITIONAL INFO: Proper releases were obtained electronically. The paper releases were removed from the chart.
Client #9: Facility Director will speak to Nursing Manager and COE Coordinator to ensure all out-of-date paper release forms are destroyed, and staff are using the correct paper release form.
Staff who haven't attended will attend the DDAP Confidentiality training (DDAP will be holding training at Family Service approx. 4/2019).
Client #10: Facility Director will speak to Nursing Manager and COE Coordinator to ensure all out-of-date paper release forms are destroyed, and staff are using the correct paper release form.
Staff who haven't attended will attend the DDAP Confidentiality training (DDAP will be holding training at Family Service approx. 4/2019).
ADDITIONAL INFO: Proper releases were obtained electronically. The paper releases were removed from the chart.
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715.9(a)(2) 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:
(2) Verify the individual 's identity, including name, address, date of birth, emergency contact and other identifying data.
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Observations
The facility failed to document that the client's name, address, and date of birth were verified prior to the administration of a narcotic agent in three of three applicable client records reviewed.
Client #6 was admitted on October 31, 2018 and was still active at the time of inspection.
Client #7 was admitted on September 24, 2018 and was still active at the time of the inspection.
Client #8 was admitted on October 2, 2018 and was still active at the time of the inspection.
These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
Client # 6: Designated Nurse will collect identification for all current and new clients prior to administration, and scan into record.
Nursing staff will verify identification and document verification each visit prior to administration of narcotic agent.
These steps will be added to the agency procedures.
Client # 7: Designated Nurse will collect identification for all current and new clients prior to administration, and scan into record.
Nursing staff will verify identification and document verification each visit prior to administration of narcotic agent.
These steps will be added to the agency procedures.
Client # 8: Designated Nurse will collect identification for all current and new clients prior to administration, and scan into record.
Nursing staff will verify identification and document verification each visit prior to administration of narcotic agent.
These steps will be added to the agency procedures.
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715.13(b) LICENSURE Patient identification
(b) A narcotic treatment program shall maintain onsite a photograph of each patient which includes the patient 's name and birth date. The narcotic treatment program shall update the photograph every 3 years.
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Observations
The facility failed to obtain and maintain in the client's record a photograph of each patient which is to include the patient's name and birth date during the intake process in three of three applicable client records reviewed.
Client #6 was admitted on October 31, 2018 and was still active at the time of inspection.
Client #7 was admitted on September 24, 2018 and was still active at the time of the inspection.
Client #8 was admitted on October 2, 2018 and was still active at the time of the inspection.
These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
Client # 6: Nursing staff will collect photo identification where possible (ex. Driver's license, student ID). If the client does not have a photo ID, nursing staff will take a picture of the client and ask for other verification of name, birth date (ex. Birth certificate). Photo identification, photo, and/or other identification will be uploaded to the client record.
Staff will refer client to resources if they are lacking identification.
ADDITIONAL INFO: This client was called on 1/14 and asked to bring in identification. Ct. said he will bring identification to his next appointment on 2/12/19.
Client #7: Nursing staff will collect photo identification where possible (ex. Driver's license, student ID). If the client does not have a photo ID, nursing staff will take a picture of the client and ask for other verification of name, birth date (ex. Birth certificate). Photo identification, photo, and/or other identification will be uploaded to the client record.
Staff will refer client to resources if they are lacking identification.
ADDITIONAL INFO: This client was called on 1/14 and asked to bring in identification. Ct. said he will bring identification to his next appointment on 2/12/19.
Client # 8: Nursing staff will collect photo identification where possible (ex. Driver's license, student ID). If the client does not have a photo ID, nursing staff will take a picture of the client and ask for other verification of name, birth date (ex. Birth certificate). Photo identification, photo, and/or other identification will be uploaded to the client record.
Staff will refer client to resources if they are lacking identification.
ADDITIONAL INFO: This client brought identification with the required elements which was added to the client chart on 1/16/19.
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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 facility failed to provide at least 2.5 hours of psychotherapy per month during the client's first 2 years of medicated-assisted treatment in two of three applicable records.
Client #7 was admitted on September 24, 2018 and was still active at the time of the inspection. The client began medication-assisted therapy on October 16, 2018; however, the client only received psychotherapy for 45 minutes in October, 0 minutes in November, and 45 minutes in December.
Client #8 was admitted on October 2, 2018 and was still active at the time of the inspection. The client began medication-assisted therapy on October 16, 2018; however, the client only received psychotherapy for 45 minutes in October, 45 minutes in November, and 0 minutes in December.
These findings were reviewed with facility staff during licensing inspection.
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Plan of Correction
Client # 7: Going forward, the required numbers of hours will be listed on the individual's treatment plan. Treatment plan reviews and 90 day consults shall contain adherence to therapy requirement. If ct. is not attending per requirement, case will be brought to treatment team for discussion and strategies to help with reengagement or discussion regarding discharge.
Client # 8: Going forward, the required numbers of hours will be listed on the individual's treatment plan. Treatment plan reviews and 90 day consults shall contain adherence to therapy requirement. If ct. is not attending per requirement, case will be brought to treatment team for discussion and strategies to help with reengagement or discussion regarding discharge.
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