Observations
Based on a review of client records and a discussion with the Project Director and Facility Director, the facility failed to notify the Department of a change in activity.
The findings include:
On September 25, 2015, ten client records were reviewed for compliance with short-term detoxification and inpatient non-hospital licensure regulations. The facility documented that they were providing Buprenorphine (Suboxone) treatment services in their detoxification program, an activity for which they do not have Departmental authorization, in four of the ten records reviewed, specifically, client records # 2, 4, 5, and 8.
Client #2 was admitted into detox treatment on September 9, 2015, was transferred to inpatient treatment on September 15, 2015 and was still an active client at the time of the inspection. The facility included documentation in the client's medical records and physician/nurse's notes which indicated that client #2 had received Suboxone treatment while in the detoxification level of care.
Client #4 was admitted into detox treatment on September 11, 2015, was transferred to inpatient treatment on September 15, 2015 and was still an active client at the time of the inspection. The facility included documentation in the client's medical records and physician/nurse's notes which indicated that client #4 had received Suboxone treatment while in the detoxification level of care.
Client #5 was admitted into detox treatment on August 12, 2015 and was discharged on August 20, 2015. The facility included documentation in the client's medical records and physician/nurse's notes which indicated that client #5 had received Suboxone treatment while in the detoxification level of care.
Client #8 was admitted into detox treatment on April 29, 2015, was transferred to inpatient treatment on May 4, 2015 and was discharged on May 22, 2015. The facility included documentation in the client's medical records and physician/nurse's notes which indicated that client #8 had received Suboxone treatment while in the detoxification level of care.
The findings were discussed with facility staff during the licensing process.
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Plan of Correction
CLEARBROOK TREATMENT CENTER, LLC
PLAN OF CORRECTION
FACILITY NUMBER:
During a licensing inspection that was conducted at this facility on September 25, 2015, there was one deficiency noted due to providing Buprenorphine (Suboxone) treatment services in our detoxification program, an activity for which we do not have "Departmental Authorization", in four of the ten records reviewed by the surveyor, specifically, client records # 2, 4, 5, and 8. The following is Clearbrook's plan of correction, and actions taken to rectify the deficiency.
The specific course of action needed for this facility to receive Departmental Authorization to utilize Buprenorphine as a short term detoxification medication was outlined by the state surveyor at the time of inspection. The course of action the facility addressed was to complete the "Buprenorphine Waiver Form", and submit all required documentation. The clinical director was responsible for ensuring the request for departmental authorization was submitted. The time frame that this form was completed by the clinical director on September 28, 2015, and submitted to the surveyor before noon, along with all required licensing forms, and documents. The facility will be in compliance as soon as the waiver form is reviewed and accepted by the state.
In addition, to ensure that the facility remains in compliance, the Quality Assurance Director (QA Director) also reviewed Licensing Alert 04-12 "Use of Buprenophine Residential Facilities", and revised all policies and procedures related to Buprenophine. The facilities policies and procedures related to Buprenorphine use as detoxification drug are now in compliance with 28 Pa. Code Chapter 715. The QA Director met with the Medical Director, and all Detox Unit staff to conduct a training on 28 Pa. Code Chapter 715 Standards, and to outline documentation requirements for said policies. The QA Director will follow-up and monitor charts on a bi-weekly basis to ensure that new Standards are being used consistently.
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