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 April 2, 2009 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 May 12, 2009.
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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 the review of patient records, the facility failed to obtain a complete screening urinalysis prior to the administration of Subutex, a narcotic agent, in three of four patient records. A complete urine drug screen includes receiving the results from the CLIA and Department of Health approved laboratory.
The findings include:
Four patient records were reviewed on April 2, 2009. A completed drug screening urinalysis was required in four patient records. The screening urinalysis was completed after the patient was admitted and administered a narcotic agent, Subutex, in patient records # 1, 2 and 3.
Patient # 1 was admitted and dosed with Subutex on October 3, 2008. An initial screening urinalysis was obtained on October 3, 2008, but it was not completed with the results until October 4, 2008.
Patient # 2 was admitted and dosed with Subutex on June 20, 2008. An initial screening urinalysis was obtained on June 20, 2008, but it was not completed with the results until June 21, 2008.
Patient # 3 was admitted on August 4, 2008 and dosed with Subutex on August 5, 2008. An initial screening urinalysis was obtained on August 4, but it was not completed with the results until August 6, 2008.
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Plan of Correction
In a meeting, the clinical director will educate nursing staff that a complete screening urinalysis must be obtained prior to the administration of Subutex. To ensure compliance, the clinical director will conduct random chart audits. Compliance will also be monitored by the TQM director. |
715.21(1)(i-iv) LICENSURE Patient termination
A narcotic treatment program shall develop and implement policies and procedures regarding involuntary terminations. Involuntary terminations shall be initiated only when all other efforts to retain the patient in the program have failed.
(1) A narcotic treatment program may involuntarily terminate a patient from the narcotic treatment program if it deems that the termination would be in the best interests of the health or safety of the patient and others, or the program finds any of the following conditions to exist:
(i) The patient has committed or threatened to commit acts of physical violence in or around the narcotic treatment program premises.
(ii) The patient possessed a controlled substance without a prescription or sold or distributed a controlled substance, in or around the narcotic treatment program premises.
(iii) The patient has been absent from the narcotic treatment program for 3 consecutive days or longer without cause.
(iv) The patient has failed to follow treatment plan objectives.
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Observations
Based on the review of patient records, the facility failed to restrict the reasons for involuntary termination to those reasons allowed by regulation.
The findings include:
Four patient records were reviewed on April 2, 2009. Three patient records were reviewed for involuntary, or therapeutic, discharge. Two patient records contained documentation of the patient being discharged for reasons other than those listed by regulation.
Patient # 1 was discharged for kissing.
Patient # 2 was discharged for not providing information of his prescribing physician for the coordination of care.
There was no documentation in either record of efforts to retain the patient in the program.
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Plan of Correction
In a meeting, the clinical director will educate clinical and nursing staff on the need to restrict the reasons for involuntary terminations to those reasons allowed by regulation. The clinical director will conduct random chart audits to ensure compliance. Compliance will also be monitored by the TQM director. |
715.22(c) LICENSURE Patient grievance procedures
(c) Penalties may not be initiated prior to final resolution with the exception that penalties may be initiated against patients who have committed acts of physical violence or who have threatened to commit acts of physical violence in or around the narcotic treatment program premises.
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Observations
Based on the review of patient records, the facility initiated the penalty prior to final resolution of the grievance in one of one patient record reviewed.
The findings include:
Four patient records were reviewed on April 2, 2009. One record was reviewed for a grievance/appeal of a therapeutic discharge. Patient record # 1 was discharged October 5, 2008 for a rule infraction committed on October 4, 2008. The patient filed a grievance appeal in writing in an effort to remain in treatment. The patient was discharged prior to a resolution of the appeal. There was no documentation of a resolution.
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Plan of Correction
The clinical director will develop a procedure to ensure that resolution to a grievance/appeal has been obtained prior to discharge. The clinical director will educate nursing and clinical staff about the procedure. The clinical director will monitor compliance by conducting random chart audits. 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 the review of patient records, the narcotic treatment program failed to document an evaluative psychosocial in four of four patient records.
The findings include:
Four patient records were reviewed on April 2, 2009. Psychosocial evaluations were required in four patient records. The narcotic treatment program did not include evaluations in all the required areas in the psychosocial evaluation in patient records #1, 2, 3 and 4.
In patient records 1, 2, 3 and 4 the psychosocial evaluations did not include an evaluative summary. Instead, the evaluation consisted of the repetition of the historical data in records # 1, 2 and 4. Record # 3 contained documentation of what the patient reported without a clinical analysis of the information.
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Plan of Correction
The clinical director will amend the detox psychosocial evaluation to include a clinical assessment as required by detoxification regulation 709.62(3)(vi). The clinical director will educate clinical staff about the amendment to the psychosocial evaluation. The clinical director will conduct random chart audits to ensure compliance. Compliance will also be monitored by the TQM director. |