INITIAL COMMENTS
|
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 January 11, 2012 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Penn Foundation For Mental Health, 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.
|
Plan of Correction
|
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.
|
Observations
Based on a review of patient records, the facility failed to ensure that the patient was initially dosed following the completion of a drug-screen urinalysis in seven of seven patient records.
The findings included:
Seven patient records were reviewed on January 11, 2012; all ten patient records were reviewed for drug screen urinalysis results prior to a patient's initial dose. Per regulation, a narcotic treatment program shall complete an initial drug-screening urinalysis for each prospective patient prior to induction. A review of the seven patient records revealed that none of records included documentation of a drug-screening urinalysis prior to the initial dose. Discussions with staff confirmed that drug-screening urinalysis was not completed per regulation as the facility completed all initial drug testing via on-site drug testing.
Patient # 1 was admitted on December 27, 2011. There was no documentation of an initial drug-screening urinalysis in the patient record.
Patient # 2 was admitted on January 9, 2012. There was no documentation of an initial drug-screening urinalysis in the patient record.
Patient # 3 was admitted on January 4, 2012. There was no documentation of an initial drug-screening urinalysis in the patient record.
Patient # 4 was admitted on January 4, 2012. There was no documentation of an initial drug-screening urinalysis in the patient record.
Patient # 5 was admitted on November 1, 2011. There was no documentation of an initial drug-screening urinalysis in the patient record.
Patient # 6 was admitted on July 15, 2011. There was no documentation of an initial drug-screening urinalysis in the patient record.
Patient # 4 was admitted on October 24, 2011. There was no documentation of an initial drug-screening urinalysis in the patient record.
As noted, staff confirmed the findings.
|
Plan of Correction
Penn Foundation has requested a waiver from DOH to allow on-site urine drug testing. We have contacted our urine drug screen supplier and will be ordering CLIA waived 12 panel urine drug screens to be in compliance with the requirement of the DOH waiver. We will submit the application for the DOH waiver within 10 business days of receipt. Executive Director of the Recovery Center will oversee this POC. |
709.28(a)(1) LICENSURE Confidentiality
709.28. Confidentiality.
(a) A written procedure shall be developed by the project director which shall comply with 4 Pa. Code 255.5 (relating to projects and coordinating bodies: disclosure of client-oriented information). The procedure shall include, but not be limited to:
(1) Confidentiality of client identity and records.
|
Observations
Based on a review of policy and procedures and patient records, the facility failed to inform the client of the client's right to verbally revoke a consent to release information in seven of seven patient records.
The findings were:
A review of patient records on January 11, 2012 revealed that the facility failed to follow their procedure to advise the patient of the right to revoke a consent to release information by either written or verbal notification. Seven patient records were reviewed on January 11, 2012 and all of the releases of information in these records failed to include a statement that the patient could verbally revoke a consent to release information. All of the consents to release information contained a statement that specified that the releases could be revoked only in writing.
In discussions with staff, it was reported they were aware of the responsibility they had to advise the patient of the ability to revoke consents to release information both verbally and in writing. The facility disclosed their policy was consistent with the regulations but confirmed their consents to release information included the stipulation that consents could only be revoke in writing.
|
Plan of Correction
Our confidentiality policy and procedure clearly states that clients may revoke their consents both verbally and in writing. It was discovered during this visit that our actual release of information did not state that the release could be revoked verbally. We have added the following statement to all consents to release information: "I may revoke this consent by either written or verbal notification at any time except to the extent that action has been taken thereon." New releases are being used effective immediately. |