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 February 23-24, 2009 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Twin Lakes Center, 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 March 25, 2009.
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Plan of Correction
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Observations
Based on the review of patient records, the facility failed to include a tuberculosis Mantoux test in five of six patient records reviewed.
The findings include:
Six patient records were reviewed on February 24, 2009. Tuberculosis Mantoux tests were required in six patient records. The facility did not document tuberculosis Mantoux tests in patient records # 1, 2, 4, 5 and 6.
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Plan of Correction
Medication Administration Record has been changed to include a check off for "First step IPPD given to all opiate users" which is then signed off by the Nurse. Consent form has been changed to include "I agree to receive the IPPD test as a condition for buprenorphine administration as per federal regulation" If patients do not wish to have the IPPD test done then they will be ineligible to participate in the buprenorphine detox program. This will be monitored and reviewed by the Director of Nursing for the next 90 days and then on a random basis. She will report results in the monthly PI meetings. |