INITIAL COMMENTS
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This report is a result of an on-site inspection conducted for the licensure renewal and the approval to use a narcotic agent, specifically buprenorphine, in the treatment of narcotic addiction. This inspection was conducted on April 7 - 8, 2015 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Retreat at Lancaster County PA, LLC 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:
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Plan of Correction
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705.8 (2) LICENSURE Heating and cooling.
705.8. Heating and cooling.
The residential facility:
(2) May not permit in the facility heaters that are not permanently mounted or installed.
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Observations
Based on observation during a physical plant inspection, the facility failed to ensure that there were no heaters located within the facility that were not permanently mounted or installed.
The findings include:
A physical plant inspection was conducted on 4/7/2014 at approximately 2:00 PM.
A portable space heater that was not permanently mounted or installed was observed in the therapist office directly across from the massage therapy room.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The heater was brought in by a patient and turned over to the Evening Supervisor who located it in his office. This writer spoke to the supervisor to inform him that the heater should have been removed from the property and not on the grounds. All staff have been informed via staff meetings that there are to be no portable heating units on the grounds. The heater is no longer on the grounds and has been removed. |
705.10 (a) (1) (i) LICENSURE Fire safety.
705.10. Fire safety.
(a) Exits.
(1) The residential facility shall:
(i) Ensure that stairways, hallways and exits from rooms and from the residential facility are unobstructed.
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Observations
Based on observation during a physical plant inspection, the facility failed to ensure that all exits from the facility were unobstructed.
The findings include:
A physical plant inspection was conducted on 4/7/2015 at approximately 2:00 PM.
A 5' X 2.5' folding table that was in an upright position was obstructing the pathway to the exit door within the dry food storage area.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The table was moved and will not be set up again. All staff were informed via meetings that all fire exits must be cleared at all times. The safety director is also aware to note this during any walk-thru's of the facility. This will be monitored by the Safety Director. |
715.9(a)(4) 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:
(4) Have a narcotic treatment physician make a face-to-face determination of whether an individual is currently physiologically dependent upon a narcotic drug and has been physiologically dependent for at least 1 year prior to admission for maintenance treatment. The narcotic treatment physician shall document in the patient 's record the basis for the determination of current dependency and evidence of a 1 year history of addiction.
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Observations
Based on a review of patient records, the narcotic treatment program failed to have a narcotic treatment physician make a face-to face determination of a patient's physiological dependency upon a narcotic drug prior to the patient's initial dose in one of five patient records reviewed.
The findings include:
Five patient records requiring documentation of a face to face determination of a patient's physiological dependency upon a narcotic drug prior to the patient's initial dose were reviewed during the onsite inspection on 4/7/2015 - 4/8/2015. The facility failed to ensure that a narcotic treatment physician conducted a face to face determination of an patient's physiological dependency upon a narcotic drug prior to the initial dose in patient record # 3.
Patient # 3 was admitted for narcotic detoxification on 1/9/2015. The narcotic treatment physician completed a face to face determination of the patient's physiological dependency upon a narcotic drug on 1/10/2015. The patient's initial dose of Subutex was administered on 1/9/2015.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Medical and Nursing staff were informed to ensure that any subutex or suboxone cannot be administered until the face to face has occurred as of this date. This will be monitored by the Director of Nursing via chart checks and floor rounds on a bi-daily basis. |
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 patient records and discussion with administrative staff, the facility failed to obtain an initial drug-screening urinalysis prior to the initial dose in five of five patient records reviewed.
The findings include:
Five patient records of perspective narcotic detoxification patients requiring a completed initial drug-screening urinalysis were reviewed during the onsite inspection on 4/7/2015 - 4/8/2015. Five patients did not have a completed initial drug-screening urinalysis prior to the initial dose.
Patient # 1 was admitted for narcotic detoxification on 11/19/2014. The patient was given an instant urinalysis on 11/19/2014. The urine was sent to the laboratory for completion on 11/19/2014 and the results were returned 11/21/2014. The patient's initial dose of Subutex was administered on 11/20/2014, prior to the results being returned from the laboratory.
Patient # 2 was admitted for narcotic detoxification on 11/4/2014. The patient was given an instant urinalysis on 11/5/2014. There was no documentation that the urine was sent to the laboratory for completion. The patient's initial dose of Subutex was administered on 11/5/2014.
Patient # 3 was admitted for narcotic detoxification on 1/9/2015. The patient was given an instant urinalysis on 1/9/2015. The urine was sent to the laboratory for completion on 1/9/2015 and the results were returned on 1/13/2015. The patient's initial dose of Subutex was administered on 1/10/2015, prior to the results being returned from the laboratory.
Patient # 4 was admitted for narcotic detoxification on 12/8/2014. The patient was given an instant urinalysis on 12/8/2014. The urine was sent to the laboratory for completion on 12/8/2014 and the results were returned 12/10/2014. The patient's initial dose of Subutex was administered on 12/9/2014, prior to the results being returned from the laboratory.
Patient # 5 was admitted for narcotic detoxification on 12/30/2014. The patient was given an instant urinalysis on 12/30/2014. The urine was sent to the laboratory for completion on 12/30/2014 and the results were returned 1/2/2015. The patient's initial dose of Subutex was administered on 12/31/2014, prior to the results being returned from the laboratory.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Until the testing waiver is in place for using UDS on site, the Med Staff will wait for lab results before ordering suboxone/subutex for patients. The DON has informed the Medical team and the nursing team as of this date. This will be monitored by Director of Nursing via chart checks and floor rounds on a bi-daily basis.
The waiver is being completed by the DON and will be submitted the week of May 4 |