INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on February 14, 2019 by staff from the Department of Drug and Alcohol Programs, Bureau of Quality Assurance for Prevention and Treatment. Based on the findings of the on-site inspection, Pathway to Recovery Counseling and Educational Services was found to not be in compliance with the applicable chapters of 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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715.9(a)(1) 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:
(1) Verify that the individual has reached 18 years of age.
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Observations
During a review of seven outpatient records on February 14, 2019, the facility failed to document verification that the individual had reached 18 years of age in four out of seven records. Client #15 was admitted on November 14, 2018 was still active at the time of the inspection. The facility failed to document verification that the individual had reached 18 years of age prior to prescribing Suboxone. Client #16 was admitted on August 1, 2018 was still active at the time of the inspection. The facility failed to document verification that the individual had reached 18 years of age prior to prescribing Suboxone. Client #17 was admitted on September 14, 2018 was still active at the time of the inspection. The facility failed to document verification that the individual had reached 18 years of age prior to prescribing Suboxone. Client #18 was admitted on August 31, 2018 was still active at the time of the inspection. The facility failed to document verification that the individual had reached 18 years of age prior to prescribing Suboxone. These findings were reviewed with the facility staff during the licensing process.
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Plan of Correction
In a management meeting on 2/25/2019, the Clinical Case Manager has been directed to make certain that she obtains a copy of a driver's license or photo identification card containing the date of birth of each person requesting Suboxone, for the purpose of verifying that he/she is 18 years of age. The Facility Director will be responsible for making certain the plan is implemented by a chart review on March 25, 2019. Continued compliance will be monitored through quarterly chart reviews. |
715.9(a)(2) 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:
(2) Verify the individual 's identity, including name, address, date of birth, emergency contact and other identifying data.
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Observations
During a review of seven outpatient records on February 14, 2019, the facility failed to document verification of the individual's identity, including name, address, date of birth and other identifying data in four out of seven records. Client #15 was admitted on November 14, 2018 and was still active at the time of the inspection. The facility failed to document verification of the individual's identity, including name, address, date of birth and other identifying data before prescribing Suboxone. Client #16 was admitted on August 1, 2018 and was still active at the time of the inspection. The facility failed to document verification of the individual's identity, including name, address, date of birth and other identifying data before prescribing Suboxone. Client #17 was admitted on September 14, 2018 and was still active at the time of the inspection. The facility failed to document verification of the individual's identity, including name, address, date of birth and other identifying data before prescribing Suboxone. Client #18 was admitted on August 31, 2018 and was still active at the time of the inspection. The facility failed to document verification of the individual's identity, including name, address, date of birth and other identifying data before prescribing Suboxone. These findings were reviewed with the facility staff during the licensing process.
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Plan of Correction
In a management meeting on 2/25/2019, the Clinical Case Manager has been directed to make certain that she obtains a copy of a driver's license or photo identification card of the person requesting Suboxone, for the purpose of verifying the individual's identity, including name, address, date of birth and other identifying data. The Facility Director will be responsible for making certain the plan is implemented by a chart review on March 25, 2019. Continued compliance will be monitored through quarterly chart reviews by the Facility Director. |
715.13(a) LICENSURE Patient identification
(a) A narcotic treatment program shall use a system for patient identification for the purpose of verifying the correct identity of a patient prior to administration of an agent.
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Observations
During a review of seven outpatient records on February 14, 2019, the facility failed to use a system for patient identification for verifying the correct identity of a patient in four out of seven records. Client #15 was admitted on November 14, 2018 and was still active at the time of the inspection. The facility failed to use a system for patient identification for verifying the correct identity of the patient prior to prescribing Suboxone. Client #16 was admitted on August 1, 2018 and was still active at the time of the inspection. The facility failed to use a system for patient identification for verifying the correct identity of the patient prior to prescribing Suboxone. Client #17 was admitted on September 14, 2018 and was still active at the time of the inspection. The facility failed to use a system for patient identification for verifying the correct identity of the patient prior to prescribing Suboxone. Client #18 was admitted on August 31, 2018 and was still active at the time of the inspection. The facility failed to use a system for patient identification for verifying the correct identity of the patient prior to prescribing Suboxone. These findings were reviewed with the facility staff during the licensing process.
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Plan of Correction
In a management meeting on 2/25/2019, the Clinical Case Manager has been directed to make certain that she obtains a copy of a driver's license or photo identification card of the person requesting Suboxone, for the purpose of verifying the correct identity of the person. The Facility Director will be responsible for implementing and monitoring this process. The Facility Director will be responsible for making certain the plan is implemented by a chart review on March 25, 2019. Continued compliance will be monitored through quarterly chart reviews by the Facility Director. |
715.13(b) LICENSURE Patient identification
(b) A narcotic treatment program shall maintain onsite a photograph of each patient which includes the patient 's name and birth date. The narcotic treatment program shall update the photograph every 3 years.
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Observations
During a review of seven outpatient records on February 14, 2019, the facility failed to maintain onsite a photograph of each patient which included the patient's name and date of birth in four out of seven records. Client #15 was admitted on November 14, 2019 and was still active at the time of the inspection. The facility failed to maintain onsite a photograph of the client which included their name and date of birth prior to subscribing Suboxone. Client #16 was admitted on August 1, 2018 and was still active at the time of the inspection. The facility failed to maintain onsite a photograph of the client which included their name and date of birth prior to subscribing Suboxone. Client #17 was admitted on September 14, 2018 and was still active at the time of the inspection. The facility failed to maintain onsite a photograph of the client which included their name and date of birth prior to subscribing Suboxone.Client #18 was admitted on August 31, 2018 and was still active at the time of the inspection. The facility failed to maintain onsite a photograph of the client which included their name and date of birth prior to subscribing Suboxone. These findings were reviewed with the facility staff during the licensing process.
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Plan of Correction
In a management meeting on 2/25/2019, the Clinical Case Manager has been directed to make certain that she obtains a current copy of a driver's license or identification card containing a photo, name, and date of birth of each person requesting Suboxone. The photo ID's will be updated every three years. The Facility Director will be responsible for making certain the plan is implemented by a chart review on March 25, 2019. Continued compliance will be monitored through quarterly chart reviews by the Facility Director |