INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on January 5-6, 2015 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, SPHS Behavioral Health (Greensburg) was found not to 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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705.24 (1) LICENSURE Bathrooms.
705.24. Bathrooms.
The nonresidential facility shall:
(1) Provide bathrooms to accommodate staff, clients and other users of the facility.
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Observations
Based on a physical plant inspection, the facility failed to ventilate bathrooms by exhaust fan or window.
The findings include:
A physical plant inspection was conducted on January 6, 2015. At the time of the inspection, three of the restroom exhaust fans were not functional.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The fans that were identified to be not working will be fixed by 2/15/15. The Program Supervisor will follow up with Landlord/maintenance to make sure this issue is rectified. |
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
Based on a review of patient records, the facility failed to document that prior to the administration of an agent, verification was made that the individual reached 18 years of age.
The findings include:
Three patient records were reviewed on January 5-6, 2015. All three patient records were required to include verification that the patient had reached 18 years of age. Patient records #4, 7 and 8 did not have patient identification or any other form of verification that the patient reached 18 years of age.
Patient #4 was admitted on November 19, 2014 and was given a prescription for Suboxone on December 11, 2014. There was no identification or verification of age documented in patient record #4.
Patient #7 was admitted on June 3, 2014 and was given a prescription for Suboxone on June 30, 2014. There was no identification or verification of age documented in patient record #7.
Patient #8 was admitted on April 17, 2014 and was given a prescription for Suboxone on May 29, 2014. There was no identification or verification of age documented in patient record #8.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The facility will obtain proper verification that an individual reached 18 years of age and document this in the record of individuals seeking to be admitted in a narcotic treatment program. The clinical supervisor will review the procedure of obtaining the driver license or state id for all individuals seeking to participate in suboxone treatment with current clinician, nurses, physicians, and clerk typists. The staff will obtain the missing driver's license or state ID of all current clients that were participating in suboxone treatment. This will be completed by 2/15/15. |
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
Based on a review of patient records, the facility failed to document that prior to the administration of an agent, verification was made of the individual's identity, including name, address, date of birth, emergency contact and other identifying data.
The findings include:
Three patient records were reviewed on January 5-6, 2015. All three patient records were required to include verification of the individual's identity, including name, address, date of birth, emergency contact and other identifying data . Patient records #4, 7 and 8 did not include patient identification or any other form of verification of the patient's identity including name, address, date of birth and other identifying data.
Patient #4 was admitted on November 19, 2014 and was given a prescription for Suboxone on December 11, 2014. There was no identification or any other form of verification of the patient's identity including name, address, date of birth and other identifying data documented in patient record #4.
Patient #7 was admitted on June 3, 2014 and was given a prescription for Suboxone on June 30, 2014. There was no identification or any other form of verification of the patient's identity including name, address, date of birth and other identifying data documented in patient record #7.
Patient #8 was admitted on April 17, 2014 and was given a prescription for Suboxone on May 29, 2014. There was no identification or any other form of verification of the patient's identity including name, address, date of birth and other identifying data documented in patient record #8.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The facility will verify the individuals name, address, and date of birth of all individuals who are seeking to be admitted in a narcotic treatment program. This will be documented in the record. The clinical supervisor will review the procedure of verifying the individuals name, address, and date of birth by obtaining a copy of the individual's driver's license or state id for all individuals seeking to participate in suboxone treatment with current clinician, nurses, physician, and clerk typist. The staff will obtain the missing driver's license or state ID of all current clients participating in suboxone treatment. This will be completed by 2/15/15. |
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
Based on a review of patient records, the facility failed to use a system for patient identification for the purpose of verifying the correct identity of a patient prior to the administration of an agent.
The findings include:
Three patient records were reviewed on January 5-6, 2015. All three patient records required the use of a system for patient identification for the purpose of verifying the correct identity of a patient prior to the administration of an agent. Patient records #4, 7 and 8 did not include documentation of patient identification for the purpose of verifying the correct identity prior to the administration of an agent.
Patient #4 was admitted on November 19, 2014 and was given a prescription for Suboxone on December 11, 2014. There was no photograph, identification or any other form of verification of the patient's identity documented in patient record #4.
Patient #7 was admitted on June 3, 2014 and was given a prescription for Suboxone on June 30, 2014. There was no photograph, identification or any other form of verification of the patient's identity documented in patient record #7.
Patient #8 was admitted on April 17, 2014 and was given a prescription for Suboxone on May 29, 2014. There was no photograph, identification or any other form of verification of the patient's identity documented in patient record #8.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The facility will maintain onsite photograph of each patient which includes the patient's name and birth date of all individuals who are seeking to be admitted in a narcotic treatment program. This will be documented in the record. The clinical supervisor will review the procedure obtaining a copy of the individual's driver's license or state id for all individuals seeking to participate in suboxone treatment with current clinician, nurses, physicians, and clerk typist. The staff will obtain the missing driver's license or state ID of all current clients participating in suboxone treatment. This will be completed by 2/15/15. |
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
Based on a review of patient records, the facility failed to maintain a photograph of each patient which includes the patient's name and birth date.
The findings include:
Three patient records were reviewed on January 5-6, 2015. All three patient records required to include a photograph of each patient which includes the patient's name and date of birth. Patient records #4, 7 and 8 did not include documentation of a photograph or identification which included the patient's name and date of birth.
Patient #4 was admitted on November 19, 2014 and was given a prescription for Suboxone on December 11, 2014. There was no photograph or identification which included the patient's name and date of birth, in patient record #4.
Patient #7 was admitted on June 3, 2014 and was given a prescription for Suboxone on June 30, 2014. There was no photograph or identification which included the patient's name and date of birth, in patient record #7.
Patient #8 was admitted on April 17, 2014 and was given a prescription for Suboxone on May 29, 2014. There was no photograph or identification which included the patient's name and date of birth, in patient record #8.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The facility will maintain onsite photograph of each patient which includes the patient's name and birth date of all individuals who are seeking to be admitted in a narcotic treatment program. This will be documented in the record. The clinical supervisor will review the procedure obtaining a copy of the individual's driver's license or state id for all individuals seeking to participate in suboxone treatment with current clinician, nurses, physicians, and clerk typist. The staff will obtain the missing driver's license or state ID of all current clients participating in suboxone treatment. This will be completed by 2/15/15. |
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, the facility failed to document an initial drug-screening urinalysis for each prospective patient and a random urinalysis at least monthly thereafter.
The findings include:
Three patient records were reviewed on January 5-6, 2015. All three patient records required to include an initial drug-screening urinalysis for each prospective patient and a random urinalysis at least monthly thereafter. Patient records #4, 7 and 8 did not include the results of any drug-screening urinalysis.
Patient #4 was admitted on November 19, 2014 and was given a prescription for Suboxone on December 11, 2014. There was no initial or monthly urinalysis results, in patient record #4.
Patient #7 was admitted on June 3, 2014 and discharge on November 20, 2014. Patient #7 was given a prescription for Suboxone on June 30, 2014. There was no initial or monthly urinalysis results in patient record #7.
Patient #8 was admitted on April 17, 2014 and discharged on October 4, 2014. Patient #8 was given a prescription for Suboxone on May 29, 2014. There was no initial or monthly urinalysis results in patient record #8.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The facility will document initial drug screening and continue random urinalysis at least monthly thereafter. The clinical supervisor will review the policy and procedure for obtaining and documenting urinalysis with physicians, clinicians, and nurses. A urine drug screening will be given to individuals during the initial screening process prior to prescribing suboxone. A urine drug screen will continue at random and at the minimum of monthly afterwards. This will be complete by 2/15/15 |
709.91(b)(5) LICENSURE Intake and admission
709.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(5) Physical examination, if applicable.
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Observations
Based on a review of client records, the facility failed to document a physical examination including the patient's vital signs in two of two patient records.
The findings include:
Ten client records were reviewed on January 5-6, 2015. Two client records were reviewed for physical examinations. The facility failed to document a physical examination including the patient's vital signs in patient records # 7 and 8.
Patient # 7 was admitted into treatment on June 3, 2014. A physical examination was completed on June 19, 2014. The physical examination for client # 7 did not include the patient's vital signs.
Patient # 8 was admitted into treatment on April 17, 2014. A physical examination was completed on May 29, 2014. The physical examination for client # 8 did not include the patient's vital signs.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The facility will document a physical examination including patient's vital signs. The clinical supervisor will review the policy and procedure for obtaining and documenting a physical exam with vital signs with physicians, and nurses. All individuals seeking to participate in suboxone treatment will have their vitals taken and documented during their physical examination prior to being given suboxone. This will be complete by 2/15/15 |