INITIAL COMMENTS
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This report is a result of on-site complaint investigations conducted April 11-13, 2023 and May 16-18, 2023, by staff from the Bureau of Program Licensure. Based on the findings of the on-site complaint investigations, Avenues Recovery Medical Center at Valley Forge was found not to be in compliance with the applicable chapters of 28 PA Code which pertain to the facility.
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Plan of Correction
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704.5(a) LICENSURE Project/Facility Director
704.5. Qualifications for the positions of project director and facility director.
(a) A drug and alcohol treatment project shall have a project director responsible for the overall management of the project and staff and each drug and alcohol treatment facility shall have a facility director responsible for the overall management of the facility and staff unless the project has but one facility.
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Observations
Based on interviews with staff and management during the complaint investigation on April 11 through the 15, 2023 and May 16 through the 18, 2023, the facility failed to have a project director or facility director which was reviewed and approved by DDAP.
The Project Director/Facility Director that was documented as running the program was actually just the Program Director and only supervised clinical staff.
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Plan of Correction
The Project Director has been updated with DDAP as of 5/18/2023.
The role of Project Director/Facility Director has been defined in the job description of the Executive Director. Additionally, the the Governing Body will be responsible for annually re/appointment of Project Director/Facility Director along with other key positions. |
705.2 (2) LICENSURE Building exterior and grounds.
705.2. Building exterior and grounds.
The residential facility shall:
(2) Keep the grounds of the facility clean, safe, sanitary and in good repair at all times for the safety and well-being of residents, employees and visitors. The exterior of the building and the building grounds or yard shall be free of hazards.
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Observations
Based on a physical plant inspection that took place on April 11, 2023, the facility failed to keep the bedrooms clean and in good repair at all times.
The bedrooms floors were dirty, and trash filled and not empty.
In the following rooms these were the issues:
210 -
fan filter broken
closet door broken, off its hinges
219
drawers (2) broken
Counselor ' s office on 2nd floor
wires
Restroom 270 (training room)
not secure, coming off the tile
251
chair in office
207
drawer missing
203
drawer missing
329
tile in shower
Patient lounge on 3rd floor
machine - mildew like substance on the spout
not cleaned
312
damage - tile
Hallway between offices 310/312
wire
There were multiple safety concerns associated with the first floor of the facility as follows.
(1) Rooms were not clean, layers of dust everywhere on surfaces, trash cans half or completely full as a result of not being regularly emptied, debris and trash on the floor and windowsills, cob webs on the HVAC vents, dirty sheets on the floor in the one assessment room in the administrative area.
(2) Items left lying on and protruding from the floor presenting tripping hazards, ranging from extension cords, plastic items (assessment room in administrative area) and equipment.
(3) Carpet ripped up in the stairwell in most areas, stairs were chipped in several places along the edge of the stairs resulting in tripping hazards.
(4) Missing, broken or displaced drop ceiling panels.
(5) Bugs in light covers.
(6) Missing transitions from rooms or offices to the hallway resulting in tripping hazards.
(7) Gaps in tile resulting in tripping hazards.
(8) Broken hand sanitizer dispenser lying on windowsill outside of counseling offices.
(9) Randomly dangling extension and other cords protruding from the drop ceiling and extending to the floor resulting in a safety hazard.
(10) Worn, torn and broken office furniture.
(11) Improperly affixed light fixtures in the ceiling of the first floor ( " Basement " ).
(12) Broken or missing light fixture covers and plastic covering random light fixtures.
(13) Broken blinds in multiple offices throughout the first floor ( " Basement " ).
(14) Water damage on ceilings throughout the first floor ( " Basement " ).
(15) Hole in the ceiling of the bathroom on the first floor ( " Basement " ).
(16) Spoiled food laying on break room countertop.
(17) Spilled liquid on windowsill.
(18) Damage to various walls throughout the first floor ( " Basement " ) hallways and offices.
(19) Super sticky floor immediately outside of two actively used staff offices resulting in a tripping hazard. Inspector could not physically lift feet properly upon stepping on the floor in this area and tripped trying to free feet from the floor. Staff tripped as well.
(20) Peeling wallpaper in group rec room.
(21) Broken floor plate leading from group rec room to hallway.
The Lactation Room consisted of many excess items temporarily placed in the room during renovations, which create a safety hazard and is unsanitary due to dust and debris. This room was directed to be closed temporarily and not accessed by patients or staff except VFMC maintenance or facilities staff and/or a contracted housekeeping company and/or a contracted construction company.
The following rooms was directed to remain permanently locked and not accessed by patients or staff due to numerous safety issues as the result of planned renovations. These rooms may only be accessed by VFMC maintenance or facilities staff and/or a contracted construction company.
(1) Room 136
(2) Lab Room (two doors)
(3) Employee Health Record Room
(4) Room directly next to the Employee Health Record Room
The following items, which are necessary for safe occupancy of the first floor, were directed to be completed immediately:
(1) The shredding box in Hematology Room must be moved to allow a clear path to the doorway of the room.
(2) All hallways and rooms accessed by patients or staff must be cleaned. Specifically, all floors must be free of debris, trash cans must be empty, and there should be no visible dust on surfaces.
(3) All lighting fixtures must be covered and clean from insect infestation.
(4) All exposed wires must be covered or properly contained within the area above the drop-down ceiling panels.
The following items, which are necessary for safe occupancy of the first floor, were directed to be completed within 30 days, or no later Friday, May 19, 2023:
(1) The middle set of blinds in the Spirituality Room is in poor condition and needs replacing.
(2) Ceiling tiles in the Electrical Room are stained due to water damage and must be replaced.
(3) One ceiling tile in the hallway outside of Room 141 is not the correct size, resulting in a gap in the ceiling and must be replaced with a tile of the correct size for the opening.
(4) The floor outside of the two staff offices at the end of the hall must be cleaned thoroughly to remove the sticky glue that remains following the removal of the previous flooring, which results in the inability to walk safely into and out of these offices.
There were multiple safety concerns associated with the Ranch Houses at the facility as follows.
(1) Plastic piping in the yard between the women ' s and men ' s houses, and two pot holes approximately 3 inches deep and 12 inches in diameter, which were partially covered by grass and leaves in the front yard of the men ' s house, all resulting in a tripping hazards.
(2) Cob webs on the HVAC vents at the women's house.
(3) Broken-down, flattened box immediately walking into the front door of the men's house, resulting in a tripping hazard.
(4) Rm 401 at the men's house - observed a potential ligature device (multiple shoelaces tied together) measuring approximately 24-30 inches in length hanging on the hinge on the backside of the main door.
(5) Plastic rings large enough to fit over someone ' s head were observed throughout the men's house on the hallway floor, the closet floor and in several of the bedrooms, some in illogical or hidden areas, which could be a ligature hazard.
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Plan of Correction
The hospital has repair all deficiencies. The Director of Facilities reviewed all of the listed items as of 8/25/23 and confirmed that the following items had been repaired. The hospital is unable to provide exact dates because the Director of Facilities joined the hospital team after 5/18/2023.
210 -
fan filter broken
closet door broken, off its hinges
219
drawers (2) broken
Counselor ' s office on 2nd floor
wires
Restroom 270 (training room)
not secure, coming off the tile
251
chair in office
207
drawer missing
203
drawer missing
329
tile in shower
Patient lounge on 3rd floor
machine - mildew like substance on the spout
not cleaned
312
damage - tile
Hallway between offices 310/312
wire
There were multiple safety concerns associated with the first floor of the facility as follows.
(1) Rooms were not clean, layers of dust everywhere on surfaces, trash cans half or completely full as a result of not being regularly emptied, debris and trash on the floor and windowsills, cob webs on the HVAC vents, dirty sheets on the floor in the one assessment room in the administrative area.
(2) Items left lying on and protruding from the floor presenting tripping hazards, ranging from extension cords, plastic items (assessment room in administrative area) and equipment.
(3) Carpet ripped up in the stairwell in most areas, stairs were chipped in several places along the edge of the stairs resulting in tripping hazards.
(4) Missing, broken or displaced drop ceiling panels.
(5) Bugs in light covers.
(6) Missing transitions from rooms or offices to the hallway resulting in tripping hazards.
(7) Gaps in tile resulting in tripping hazards.
(8) Broken hand sanitizer dispenser lying on windowsill outside of counseling offices.
(9) Randomly dangling extension and other cords protruding from the drop ceiling and extending to the floor resulting in a safety hazard.
(10) Worn, torn and broken office furniture.
(11) Improperly affixed light fixtures in the ceiling of the first floor ( " Basement " ).
(12) Broken or missing light fixture covers and plastic covering random light fixtures.
(13) Broken blinds in multiple offices throughout the first floor ( " Basement " ).
(14) Water damage on ceilings throughout the first floor ( " Basement " ).
(15) Hole in the ceiling of the bathroom on the first floor ( " Basement " ).
(16) Spoiled food laying on break room countertop.
(17) Spilled liquid on windowsill.
(18) Damage to various walls throughout the first floor ( " Basement " ) hallways and offices.
(19) Super sticky floor immediately outside of two actively used staff offices resulting in a tripping hazard. Inspector could not physically lift feet properly upon stepping on the floor in this area and tripped trying to free feet from the floor. Staff tripped as well.
(20) Peeling wallpaper in group rec room.
(21) Broken floor plate leading from group rec room to hallway.
The Lactation Room consisted of many excess items temporarily placed in the room during renovations, which create a safety hazard and is unsanitary due to dust and debris. This room was directed to be closed temporarily and not accessed by patients or staff except VFMC maintenance or facilities staff and/or a contracted housekeeping company and/or a contracted construction company.
The following rooms was directed to remain permanently locked and not accessed by patients or staff due to numerous safety issues as the result of planned renovations. These rooms may only be accessed by VFMC maintenance or facilities staff and/or a contracted construction company.
(1) Room 136
(2) Lab Room (two doors)
(3) Employee Health Record Room
(4) Room directly next to the Employee Health Record Room
The following items, which are necessary for safe occupancy of the first floor, were directed to be completed immediately:
(1) The shredding box in Hematology Room must be moved to allow a clear path to the doorway of the room.
(2) All hallways and rooms accessed by patients or staff must be cleaned. Specifically, all floors must be free of debris, trash cans must be empty, and there should be no visible dust on surfaces.
(3) All lighting fixtures must be covered and clean from insect infestation.
(4) All exposed wires must be covered or properly contained within the area above the drop-down ceiling panels.
The following items, which are necessary for safe occupancy of the first floor, were directed to be completed within 30 days, or no later Friday, May 19, 2023:
(1) The middle set of blinds in the Spirituality Room is in poor condition and needs replacing.
(2) Ceiling tiles in the Electrical Room are stained due to water damage and must be replaced.
(3) One ceiling tile in the hallway outside of Room 141 is not the correct size, resulting in a gap in the ceiling and must be replaced with a tile of the correct size for the opening.
(4) The floor outside of the two staff offices at the end of the hall must be cleaned thoroughly to remove the sticky glue that remains following the removal of the previous flooring, which results in the inability to walk safely into and out of these offices.
There were multiple safety concerns associated with the Ranch Houses at the facility as follows.
(1) Plastic piping in the yard between the women ' s and men ' s houses, and two pot holes approximately 3 inches deep and 12 inches in diameter, which were partially covered by grass and leaves in the front yard of the men ' s house, all resulting in a tripping hazards.
(2) Cob webs on the HVAC vents at the women's house.
(3) Broken-down, flattened box immediately walking into the front door of the men's house, resulting in a tripping hazard.
(4) Rm 401 at the men's house - observed a potential ligature device (multiple shoelaces tied together) measuring approximately 24-30 inches in length hanging on the hinge on the backside of the main door.
(5) Plastic rings large enough to fit over someone ' s head were observed throughout the men's house on the hallway floor, the closet floor and in several of the bedrooms, some in illogical or hidden areas, which could be a ligature hazard.
All cleaning and housekeeping issues identified in this survey have been addressed. The hospital has implemented additional oversight and monitoring of housekeeping services, including ongoing auditing and monitoring to ensure that all deficiencies are identified and corrected quickly. The Director of Facilities confirms this had been completed prior to 8/25/2023.
Ongoing environmental surveys of the facility have been implemented to quickly identify deficiencies and report such deficiencies for repair. Results of audits, along with the status of repair requests are ongoingly monitored under the hospital's Quality Assurance and Performance Improvement Program.
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705.2 (4) LICENSURE Building exterior and grounds.
705.2. Building exterior and grounds.
The residential facility shall:
(4) Store all trash, garbage and rubbish in noncombustible, covered containers that prevent the penetration of insects and rodents, and remove it, at least once every week.
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Observations
Based on a physical plant inspection on April 11, 2023, the facility failed to store all trash and garbage in a covered container.
Trash was seen stored outside the dumpster in the morning of the tour and after Waste Management came to pick up the trash and garbage in the afternoon, trash that was outside the container was still sitting outside the empty container.
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Plan of Correction
Since the date of the survey, the facility has increased the number of dumpsters to ensure that there is adequate storage room for refuge. If trash is found to be outside the approved disposal containers, the Director of Facilities addresses immediately with staff and corrects on the spot. The hospital is committed to ensuring that this standard is met ongoingly.
The Director of Facilities reviewed all of the list item as of 8/25/23 and confirmed that the following items had been repaired. The hospital is unable to provide exact dates because the Director of Facilities joined the hospital team after 5/18/2023.
The hospital has plans to create an enclosed garage collection area within the next year, when renovations have been completed and temporary storage pods are no longer needed to be housed in the vicinity.
Ongoing environmental surveys of the facility have been implemented to quickly identify deficiencies and report such deficiencies for repair. Results of audits, along with the status of repair requests are ongoingly monitored under the hospital's Quality Assurance and Performance Improvement Program. |
705.4 (2) LICENSURE Counseling areas.
705.4. Counseling areas.
The residential facility shall:
(2) Maintain counseling areas with furnishings which are in good repair.
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Observations
During a complaint investigation it was observed that the facility failed to maintain counseling areas with furnishings which are in good repair. Specifically, excess items were temporarily placed in the following rooms during renovations creating a safety hazard. In addition, the rooms were unkempt and unsanitary due to dust, dirt, and debris. Two chairs, one in each of the rooms, were torn. These rooms were directed to be closed temporarily and not accessed by patients or staff except VFMC maintenance or facilities staff and/or a contracted housekeeping company and/or a contracted construction company.
1. Wolf Conference Room
2. Rittenhouse Conference Room
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Plan of Correction
No corrective action date prior to 05/16/2023 is permitted by POC form; therefore, items completed prior to 05/16/2023 are being submitted with corrective action date of 05/16/2023.
On 4/27/23 Both rooms were approved to be reopened by DDAP.
Ongoing environmental surveys of the facility have been implemented to quickly identify deficiencies and report such deficiencies for repair. Results of audits, along with the status of repair requests are ongoingly monitored under the hospital's Quality Assurance and Performance Improvement Program. |
705.6 (4) LICENSURE Bathrooms.
705.6. Bathrooms.
The residential facility shall:
(4) Provide privacy in toilets by doors, and in showers and bathtubs by partitions, doors or curtains. There shall be slip-resistant surfaces in all bathtubs and showers.
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Observations
Based on a physical plant tour on April 11, 2023, the facility failed to provide slip resistant mats or surfaces in all bathtubs and showers in the following rooms:
212, 216, 217, 219, 223, 220, 218, 206, 204, 203, 201, 321, 323, 325, 326, 327, 329 and 331.
During the complaint investigation and physical plant inspection, it was observed that the facility failed to ensure there were slip-resistant surfaces in all bathtubs and showers in the Ranch Houses as follows:
(1) Nonslip mats were missing from two of the walk-in showers in the women's house.
(2) Nonslip mats were missing from three of the walk-in showers in the men's house.
(3) The bathroom near Room 403 was missing the nonslip mat.
In addition, the facility failed to provide privacy in showers and bathtubs by curtains. The bathroom near Room 403 was missing several shower hooks in the one bathroom with a walk-in shower.
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Plan of Correction
Following the survey, the hospital replaced slip resistant mats in all showers. Newly renovated bathrooms are equipped with non-slip surfaces.
Ongoing environmental surveys of the facility have verified that non-slip surfaces and shower curtains are in place and in good condition in all bathrooms.
Ongoing environmental surveys of the facility have been implemented to quickly identify deficiencies and report such deficiencies for repair. Results of audits, along with the status of repair requests are ongoingly monitored under the hospital's Quality Assurance and Performance Improvement Program.
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705.6 (5) LICENSURE Bathrooms.
705.6. Bathrooms.
The residential facility shall:
(5) Ventilate toilet and wash rooms by exhaust fan or window.
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Observations
Based on a physical plant inspection conducted on April 11, 2023, the facility failed to ensure that each bathroom was properly ventilated by either an exhaust fan or window.
The following bathrooms did not have a working exhaust fan or working window:
210 -
fan filter broken
213 -
exhaust fan and the window doesn ' t stay open on its own.
Employee Restroom
exhaust fan
206
exhaust fan working
207
exhaust fan
204
exhaust fan
203
exhaust fan
202
exhaust fan
243 storage room with a bathroom
exhaust fan and the window doesn ' t stay open
325
exhaust fan and window would not open
327
exhaust fan
328
exhaust fan
331
exhaust fan
The men ' s bathroom on the first floor next to the central nurse ' s station ( " fishbowl " ) was directed to remain permanently locked and not accessed by patients or staff due to strong odor emanating from the room, which induced dizziness and nausea within seconds of entering.
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Plan of Correction
No corrective action date prior to 05/16/2023 is permitted by POC form; therefore, items completed prior to 05/16/2023 are being submitted with corrective action date of 05/16/2023.
The hospital is unable to provide exact dates because the Director of Facilities joined the hospital team after 5/18/2023.
Hospital renovations have resulted in the replacement and repair of numerous bathroom fans. The permanently closed bathroom continues to remain permanently closed until such time as planned renovations are completed in that area.
As of 08/25/2023, the Director had verified that bathroom fans were working to sufficiently provide ventilation to the bathrooms. Third floor bedrooms and bathrooms were approved by DOH for occupancy 08/17/2023. During the cosmetic renovations, bathroom fans were replaced if needed. DDAP staff expressed verbal satisfaction with third floor bedrooms and bathrooms as of 08/31/2023. Second floor bedroom and bathroom renovations are scheduled to start 11/01/2023.
The hospital has identified the following tentative timeline for renovation start dates for second floor bedrooms and bathrooms. The tentative timeline is subject to change for a number of reasons including: (1) reprioritization of specific rooms (2) patient needs (3) changes in material availability (4) unforeseen circumstances:
Room Numbers Tentative Timeline
201 11/1/2023
202 11/1/2023
203 11/22/2023
204 11/22/2023
205 12/13/2023
206 12/13/2023
207 1/3/2024
208 1/3/2024
209 1/24/2024
210 1/24/2024
211 2/14/2024
212 2/14/2024
213 3/6/2024
214 3/6/2024
215 3/27/2024
216 3/27/2024
217 4/17/2024
218 4/17/2024
219 5/8/2024
220 5/8/2024
221 5/29/2024
222 5/29/2024
223 6/19/2024
224 6/19/2024
225 7/10/2024
226 7/10/2024
227 7/10/2024
Ongoing environmental surveys of the facility have been implemented to quickly identify deficiencies and report such deficiencies for repair. Results of audits, along with the status of repair requests are ongoingly monitored under the hospital's Quality Assurance and Performance Improvement Program.
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705.6 (7) LICENSURE Bathrooms.
705.6. Bathrooms.
The residential facility shall:
(7) Maintain each bathroom in a functional, clean and sanitary manner at all times.
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Observations
During the complaint investigation, it was observed that the facility failed to maintain each bathroom in a functional, clean and sanitary manner at all times. The following were observed in the first floor bathrooms:
1. The Staff bathroom had a change in floor level and did contain signage with to alert clients or staff to " Step Up " / " Step Down " .
2. One toilet seat and seat cover in the women ' s bathroom next to the central nurse ' s station ( " fishbowl " ) is in poor condition and must be replaced.
In addition, the facility failed to maintain each bathroom in a functional, clean and sanitary manner at all times. The bathroom near Room 403 was dirty and the grout was coming apart between the tub and tile wall.
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Plan of Correction
No corrective action date prior to 05/16/2023 is permitted by POC form; therefore, items completed prior to 05/16/2023 are being submitted with corrective action date of 05/16/2023.
On 4/21/23 the hospital provided evidence to DDAP that these issues were addressed.
Ongoing environmental surveys of the facility have been implemented to quickly identify deficiencies and report such deficiencies for repair. Results of audits, along with the status of repair requests are ongoingly monitored under the hospital's Quality Assurance and Performance Improvement Program. |
705.10 (a) (1) (iv) LICENSURE Fire safety.
705.10. Fire safety.
(a) Exits.
(1) The residential facility shall:
(iv) Clearly indicate exits by the use of signs.
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Observations
During the complaint investigation it was observed that the facility failed to prominently post fire evacuation route signage on the first floor.
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Plan of Correction
No corrective action date prior to 05/16/2023 is permitted by POC form; therefore, items completed prior to 05/16/2023 are being submitted with corrective action date of 05/16/2023.
On 4/21/23 the hospital provided evidence to DDAP that these issues were addressed.
Ongoing environmental surveys of the facility have been implemented to quickly identify deficiencies and report such deficiencies for repair. Results of audits, along with the status of repair requests are ongoingly monitored under the hospital's Quality Assurance and Performance Improvement Program. |
705.10 (c) (1) LICENSURE Fire safety.
705.10. Fire safety.
(c) Fire extinguisher. The residential facility shall:
(1) Maintain a portable fire extinguisher with a minimum of an ABC rating, which shall be located on each floor. If there is more than 2,000 square feet of floor space on a floor, the residential facility shall maintain an additional fire extinguisher for each 2,000 square feet or fraction thereof.
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Observations
During the complaint investigation it was observed that the fire extinguisher located on the floor of the Facility Director ' s office was not properly mounted and/or stored in accordance with applicable regulations.
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Plan of Correction
No corrective action date prior to 05/16/2023 is permitted by POC form; therefore, items completed prior to 05/16/2023 are being submitted with corrective action date of 05/16/2023.
On 4/21/23 the hospital provided evidence to DDAP that these issues were addressed.
Hospital Policy "Life Safety Management Plan", which defines the hospital's requirements to adhere to the applicable provisions of NFPA Life Safety Code, was last approved by the Safety Committee on July 12. The Director of Facilities is responsible for ensuring that the hospital's compliance with inspection and testing of Life Safety Systems. The hospital has a full inventory of fire extinguishers that are checked monthly. The inventory was validated in August 2023.
The fire extinguisher monthly inspection protocol will be reviewed and revised as needed to ensure that clearly states that the mounting of the fire extinguisher is included in the inspection protocol. All facilities staff will receive retraining on fire extinguisher monthly inspections prior to the October 6 Safety Committee meeting. Evidence of the retraining will be required to be presented to the Safety Committee on October 6.
The Safety Committee ongoingly reviews all completed and upcoming testing and inspection of environment of care and life safety systems as a standing agenda item at all meetings. The results of inspection reports and compliance with NFPA Life Safety Code will be added as standing agenda items for the committee to review. All findings of deficiencies in the life safety systems will be reported to the Director of Facilities for remediation and corrective actions will be documented in the meeting minutes. The agenda will be amended to include reviewing the status of compliance with NFPA life safety code as of the October 6 Safety Committee meeting.
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709.34 (b) (2) LICENSURE Reporting of unusual incidents
§ 709.34. Reporting of unusual incidents.
(b) Policies and procedures must include the following:
(2) Prompt review and identification of the causes directly or indirectly responsible for the unusual incident.
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Observations
During a review of incident reports and patient records during the complaint investigation, it was noted that an alleged sentinel event did occur resulting in a confirmed death after a fall occurred with head injury. While a root cause analysis was conducted on this case, there was minimal detail related to potential systemic issues that might have contributed to the event. For example, the fall risk assessment documented in the nursing assessment was scored as "0- Low Risk" even though the patient presented with a subdural hematoma from a previous fall and had multiple comorbid conditions.
In addition, it was noted that a second, separate, alleged sentinel event did occur resulting in a patient being transported to a local ED for emergency medical treatment related to suspected drug use. Leadership had not completed a root cause analysis for the incident, even though another patient was observed entering and leaving the patient's room which is against organization policy.
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Plan of Correction
The Patient Safety Plan was most recently approved by the Patient Safety Committee on 5/30/23 and again 6/28/23 with revisions. This policy addresses reporting to DDAP for unusual events as defined by regulation. Additionally, the policy defines the review and investigation process, including triggers for root cause analysis. Unusual events are reviewed monthly by the Patient Safety Committee. |
715.6(e) LICENSURE Physician Staffing
(e) A physician assistant or certified registered nurse practitioner may perform functions of a narcotic treatment physician in a narcotic treatment program if authorized by Federal, State and local laws and regulations, and if these functions are delegated to the physician assistant or certified registered nurse practitioner by the medical director, and records are properly countersigned by the medical director or a narcotic treatment physician. One-third of all required narcotic treatment physician time shall be provided by a narcotic treatment physician. Time provided by a physician assistant or certified registered nurse practitioner may not exceed two-thirds of the required narcotic treatment physician time.
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Observations
Based on a review of client charts, the facility failed to ensure that Federal, State and local laws and regulations were followed and that records are properly countersigned by the medical director or a narcotic treatment physician in twelve out of fourteen charts. Client charts contained orders for methadone and buprenorphine without the required authorization.
Patient # 1 was admitted on 3/18/23 and was a current client at the time of the investigation. This chart contained suboxone orders from medical providers other than the medical director or narcotic treatment physicians.
Patient # 2 was admitted on 4/26/23 and was a current client at the time of the investigation. This chart contained methadone orders from medical providers other than the medical director or narcotic treatment physicians.
Patient # 3 was admitted on 5/5/23 and was a current client at the time of the investigation. This chart contained methadone and suboxone orders from medical providers other than the medical director or narcotic treatment physicians.
Patient # 4 was admitted on 3/5/23 and discharged on 3/17/23. This chart contained a suboxone order from a medical provider other than the medical director or narcotic treatment physician.
Patient # 5 was admitted on 3/10/23 and discharged 4/7/23. This chart contained a suboxone order from a medical provider other than the medical director or narcotic treatment physician.
Patient # 6 was admitted on 4/21/23 and discharged on 5/17/23. This chart contained methadone orders from a medical provider other than the medical director or narcotic treatment physician.
Patient # 7 was admitted on 5/11/23 to 4B rehab and was a current patient at the time of the investigation. This chart contained a suboxone order from a medical provider other than the medical director or narcotic treatment physician.
Patient # 8 was admitted on 4/28/23 and discharged on 5/8/23. This chart contained methadone orders from a medical provider other than the medical director or narcotic treatment physician.
Patient # 10 was admitted on 5/12/23 and was a current patient at the time of investigation. This chart contained methadone orders from a medical provider other than the medical director or narcotic treatment physician.
Patient # 11 was admitted on 3/3/23 and discharged on 4/6/23. This chart contained a suboxone order from a medical provider other than the medical director or narcotic treatment physician.
Patient # 12 was admitted on 5/11/23 and was a current patient at the time of the investigation. This chart contained methadone orders from a medical provider other than the medical director or narcotic treatment physician.
Patient # 14 was admitted on 4/18/23 and discharged on 5/5/23. This chart contained a suboxone order from a medical provider other than the medical director or narcotic treatment physician.
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Plan of Correction
Under 28 PA Code § 715(e), CRNPs and PAs "may perform the function of a narcotic treatment physician if authorized by Federal, State, and local laws and regulations, and if these functions are delegated to the physician assistant or certified registered nurse practitioner by the medical director, and records are properly countersigned by the medical director or a narcotic treatment physician." DDAP has offered no guidance on the phrase "properly countersigned" since the 2003 enactment of this law, leaving providers to conclude that a countersignature is only required under the DDAP regulations if a countersignature is required by the CRNPs/PAs professional practicing regulations and/or Federal law. At the time Section 715(e) was promulgated in 2003, PAs were required to have a countersignature on all records under State laws, but due to changes in the law since that time, PAs are no longer required to have countersignature on all records under State law, except under limited conditions. Currently, there is no Pennsylvania restriction on CRNPs or PAs ordering buprenorphine in connection with maintenance treatment. At the time Section 715(e) was promulgated, both PAs and CRNPs were required to have countersignature for methadone and buprenorphine orders under Federal law. In 2016, however, the federal Controlled Substances Act was amended to no longer require countersignature for buprenorphine orders under Federal law provided that the CRNPs and PAs have a DEA waiver. The DEA waiver was held by each provider employed by the hospital prior to the 2023 elimination of the waiver requirement by SAMHSA. Hence, orders/entries by the hospital's PAs (except under limited circumstances) and CRNPs for buprenorphine do not require countersignature under Federal or State law, since the ordering of Schedule III controlled substances, which includes buprenorphine, was delegated to the CRNPs/PAs pursuant to their respective collaborative/supervisory agreements. Accordingly, since a countersignature for buprenorphine is not required under the CRNPs/PAs professional practicing regulations or federal law, the Section 715(e) "properly countersigned" requirement is not triggered and no countersignature is necessary when a PA/CRNP orders buprenorphine.
Restrictions under state law still apply to PAs/CRNPs ordering methadone for opioid use disorder, but PAs/CRNPs are permitted to prescribe methadone for pain. The hospital has engaged with the State Board of Nursing, the office of the governor, and numerous legislators to ensure that we understand and follow applicable state regulations. The hospital continues to receive conflicting guidance from legislators and governmental departments across the state, including the office of the governor, regarding the ordering of methadone. The most recent guidance received by the hospital from DDAP licensing division states that CRNPs and PAs may place methadone orders provided that the initial order is issued by a physician.
The hospital acknowledges that at the time of the DDAP survey, orders for methadone were not consistently countersigned in the prior EMR due to system limitations that have since been corrected. Since the date of the finding, the hospital has ceased the practice of CRNPs and PAs ordering methadone, even with the authorization and countersignature of a physician until such time that either (1) Pending legislation under Pennsylvania Senate Bill 25 of 2023 or similar legislation which significantly lessens the requirement of physician orders for methadone is enacted or (2) the hospital can consistently ensure that all applicable federal and state regulations are met for countersignature of methadone orders.
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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
Based on a review of unusual incidents during the compliant investigation on April 11 through the 25, 2023, the facility failed to ensure client's confidentiality.
3/5/23 client was give IPAD while in COVID and clients confidentiality was breached as the client had access to Teams and patient was able to read the confidential counseling chats containing other patient information
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Plan of Correction
The Director of IT is responsible for ensuring that all corrective actions are implemented and maintained. Patient IPads have been formatted and cleared to ensure that there is no access to any existing or new confidential chats not intended for the patients prior to receipt of this citation (and prior to the 8/25/23 due date). This has been verified by the Director of Quality & Compliance.
Creation of public teams the the environment is now blocked through security policy. Going forward, there is no ability for employees to accidently create a public team that contains PHI and there is no means for a patient to join a Teams group and view information. |
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
Based on a review of patient charts, the facility failed to obtain an informed, voluntary, written consent before any agent was administered to a patient in 3 out of 14 charts reviewed.
Patient # 2 was admitted on 4/26/23 and was a current client at the time of the investigation. A Consent to Treatment with an Approved Narcotic Drug was missing from this chart.
Patient # 3 was admitted on 5/5/23 and was a current client at the time of the investigation. A Consent to Treatment with an Approved Narcotic Drug was missing from this chart.
Patient # 13 was admitted on 3/11/23 and discharged on 3/21/23. A Consent to Treatment with an Approved Narcotic Drug was missing from this chart.
This facility was previously cited for not having these consents in charts reviewed during the annual inspections conducted 3/1/23 and 3/10/22.
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Plan of Correction
The hospital's Quality Assurance & Performance Improvement Program approved the implementation of a Performance Improvement Project on 6/30/23 for the purpose of ensuring that narcotic treatment consents are completed prior to the administration of the first dose of a narcotic agent.
Training for staff related to the requirement to obtain written informed consent and verify that consent was obtained prior to first dose of a narcotic agent was developed and implemented as of 6/22/23.
Hospital Policy "Informed Consent for Narcotic Drug Administration" was most recently approved on 7/26/2023, which includes the following:
- Before the administration of narcotic drugs, specifically methadone and buprenorphine, a signed patient Consent for Treatment with an Approved Narcotic Drug must be obtained.
Hospital Policy "Medication Administration" was most recently approved 8/9/2023, which includes the following:
- obtain a signed patient Consent for Treatment with an Approved Narcotic Drug from each patient prior to the administration of methadone.
- obtain a signed patient Consent for Treatment with an Approved Narcotic Drug from each patient prior to the administration of buprenorphine.
Since July 2023, the hospital has implemented focused monitoring of this process to ensure that hospital policy and standards regarding obtaining informed consent for narcotic treatment administration is completed timely. The hospital uses the results of this monitoring for the purposes of oversight and improvement efforts around this Performance Improvement Project. The results of the monitoring were most recently presented to the hospital's Patient Safety Committee on 8/24/2023.
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715.17(c)(1)(i-vi)) LICENSURE Medication control
(c) A narcotic treatment program shall develop and implement written policies and procedures regarding the medications used by patients which shall include, at a minimum:
(1) Administration of medication.
(i) A narcotic treatment physician shall determine the patient 's initial and subsequent dose and schedule. The physician shall communicate the initial and subsequent dose and schedule to the person responsible for the administration of medication. Each medication order and dosage change shall be written and signed by the narcotic treatment physician.
(ii) An agent shall be administered or dispensed only by a practitioner licensed under the appropriate Federal and State laws to dispense agents to patients.
(iii) Only authorized staff and patients who are receiving medication shall be permitted in the dispensing area.
(iv) There shall be only one patient permitted at a dispensing station at any given time.
(v) Each patient shall be observed when ingesting the agent.
(vi) Administering and dispensing shall be conducted in a manner that protects the patient from disruption or annoyance from other individuals.
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Observations
Based on a review of patient charts, the facility failed to ensure that a narcotic treatment physician determined the patient's initial and subsequent dose and schedule in one out of fourteen charts reviewed.
Patient # 13 was admitted on 3/11/23 and discharged on 3/21/23. This patient was receiving buprenorphine with the first dose occurring on 3/12/23. The chart did not contain an authorized medical order for buprenorphine.
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Plan of Correction
Hospital Policy "Medication Administration" was most recently approved 8/9/2023, which includes the following:
- Medications will be administered by a licensed nurse per a practitioner's order
Staff are not permitted to dispense medications without an order, and staff are unable to enter information related to the dispensing of a medication without an authorized medical order.
The hospital identified that the order for the buprenorphine was written on 3/12/23 at 13:33 and the first dose of buprenorphine was administered on 3/12/23 at 13:54.
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715.22(b) LICENSURE Patient grievance procedures
(b) The procedure shall permit aggrieved patients a full and fair opportunity to be heard, to question and confront persons and evidence used against them and to have a fair review of their grievances by the narcotic treatment program director. If the grievance is filed against the narcotic treatment program director, the review of the case shall be conducted by either a multi-representative group of the narcotic treatment program or a subcommittee of the governing body instituted for the express purposes of grievance adjudication.
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Observations
Based on a review of the facility's grievances during the complaint investigation on April 11 through 15, 2023, the facility failed to follow-up with the grievances after they were submitted.
3/17/23
3/22/23
3/17/23
3/22/23
3/22/23
3/27/23 - part of the follow-up was complete, but not all.
4/7/23
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Plan of Correction
The Patient Compliant & Grievance Policy was approved by the Patient Safety Committee on 6/28/23. This policy addresses receipt and response to patient grievances. Additionally, the policy defines the review and investigation process, including triggers for root cause analysis. Patient grievances are reviewed by the Patient Safety Committee. |