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, during the residential detoxification from opioid addiction. This inspection was conducted on March 13, 2008 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 28 PA Code which pertain to the facility. Deficiencies were identified during this inspection and plan of correction is due on April 21, 2008.
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Plan of Correction
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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
Based on a review of five patient records, the facility failed to obtain the results of a urine drug screen (complete urinalysis) prior to patient's initial dose for three of four records reviewed; specifically, patients # 1, 3, and 4.
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Plan of Correction
5/28/2008 - In a meeting, the Clinical Director will inform nursing staff of the need to receive verbal lab results, in the absence of a written report, before medicating opiate detox patients. This procedure will be in place by 6/2/2008. The Clinical Director will monitor compliance through random chart audits. Additional monitoring will be conducted by the Director,TQM.
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4/30/08-Revised POC-We do not agree with the citation.
5/8/2008 - We are currently researching other labratories who would send us lab results in a time frame that would allow us the meet the standard. |
715.23(b)(6) LICENSURE Patient records
(b) Each patient file shall include the following information:
(6) Results of laboratory tests or other special examinations given by the narcotic treatment program.
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Observations
Based on the review of five patient records, there was no documentation the facility had completed a tuberculosis Mantoux test (PPD test) for one of the five patients reviewed, record # 1. In addition, patient record # 2 had documentation of the patient having previously tested positive and that the last chest x-ray had been obtained from the prior year without any documentation of a referral for medical follow-up or request for additional information.
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Plan of Correction
The Clinical Director will remind nursing staff that a Mantoux test must be given to each patient, if applicable. The Clinical Director will also instruct nursing staff to make a referral for medical follow-up for patients who have previously tested positive. The Nurse Manager will conduct random chart audits to insure compliance. Compliance will also be monitored by the TQM Director. |
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 review of five patient records, the psychosocial evaluation in four of four patient records (# 1,2,3, and 4) consisted primarily of the statements reported by the patient rather than a clinical assessment of information obtained about the patient.
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Plan of Correction
The Clinical Director will amend the detox psychosocial to include a clinical assessment of the information obtained about the patient. The Clinical Director will conduct random chart audits to insure compliance. Compliance will be monitored by the TQM Director. |
715.23(b)(23) LICENSURE Patient records
(b) Each patient file shall include the following information:
(23) Discharge summary.
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Observations
Based on a review of five patient records, the discharge summaries did not provide the specific reason(s) for the patient entering treatment. they also did not provide the client's response to treatment beyond that they were stabilized in four of four patient records reviewed. Specifically, # 1, 3, and 5 stated that the patient was tired of using as the reason for seeking treatment and # 1, 3, 4, and 5 listed "stabilized" in the response to treatment area.
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Plan of Correction
In a meeting, the Clinical Director will remind counselors that discharge summaries must contained all required elements, and that the elements must be individualized to each patient. The Clinical Director will also instruct counselors that the word "stabilized" may no longer be used as the patient's response to treatment. The Clinical Director will conduct random chart audits to insure compliance. Compliance will also be monitored by the TQM Director. |