INITIAL COMMENTS
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This report is a result of an on-site inspection conducted for the approval to use a narcotic agent, specifically buprenorphine, in the treatment of narcotic addiction. This inspection was conducted on February 5, 2010 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Livingrin Foundation, Inc. was found not to be in compliance with the applicable chapters of 4 PA Code and 28 PA Code which pertain to the facility. The following deficiencies were identified during this inspection and a plan of correction is due on March 6, 2010.
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Plan of Correction
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715.23(b)(15) LICENSURE Patient records
(b) Each patient file shall include the following information:
(15) Psychosocial evaluations of the patient.
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Observations
Based on the review of patient records, the facility failed to ensure the psychosocial evaluations were a clinical assessment of the historical data collected in four of four patient records.
The findings include:
Four patient records were reviewed on February 5, 2010. Four patient records were reviewed for psychosocial evaluations.
Patient records # 1, 2, 3 and 4 had psychosocial documents that contained a repeat of the data, patient reported commentary and no clinical assessment.
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Plan of Correction
In a meeting, on 3/4/10, the Clinical Director reviewed with counselors the need for the Detox Psychosocial Evaluation to contain an assessment of the data that has been gathered. The Cinical Supervisor will review charts on a monthly basis. Compliance will be monitored by the Clinical Director. Oversight will be provided by the Director, TQM. |
715.24(3) LICENSURE Narcotic detoxification
If a narcotic treatment program provides narcotic detoxification services, the narcotic treatment program shall develop and implement narcotic detoxification policies and procedures which include the following:
(3) A 1-year physiologic dependence is not required for narcotic detoxification although documentation of current dependency is required.
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Observations
Based on a review of patient records, the facility failed to ensure the physician documented current dependency in one of four patient records reviewed.
The findings include:
Four patient records were reviewed on February 5, 2010. Four patient records required documentation of the physician's determination of current dependency prior to the administration of the narcotic.
Patient # 2 was admitted on February 1, 2010 and the record contained a urine drug screen negative for opiates. The patient was administered 4 milligrams of Subutex for detoxification starting on February 4, 2010 without the physician documenting the rationale for determining current dependency other than checking off the patient had withdraw symptoms. There was other documentation in the patient record that the patient reported taking 16 milligrams of Suboxone as part of her drug history, but no one documented where she was getting this medication.
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Plan of Correction
In the future, if it is determined that a patient requires placement on subutex, and has a negative drug screen for opiates, documentation for justification for placement on subutex will be written by the physician on the physician certification form. Oversight will be conducted by the Director, TQM. |