INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on January 11-12, 2018 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Alpine Springs Rehabilitation & Recovery Center, LLC 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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705.10 (d) (1) LICENSURE Fire safety.
705.10. Fire safety.
(d) Fire drills. The residential facility shall:
(1) Conduct unannounced fire drills at least once a month.
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Observations
The facility failed to document the amount of time for evacuation, exit route used, number of persons in the facility, problems encountered and whether the fire alarm / smoke detector was operative on the fire drill log forms for drills conducted October 2017 - December 2017. In addition, since the exit route used was not documented, it was unable to be determine if alternate exits were used.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Fire drill record sheet was updated to include the time (am/pm), time it took to evacuate facility, exit route used, number of people in the facility when drill occurred, problems encountered during the drill, and which evacuation route was used. Designated safety person and Executive Director will ensure compliance. Will be in full compliance 1/22/2018 |
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
The facility failed to document that each buprenorphine client's identity, including name, address and date of birth was verified prior to the administration of an agent (buprenorphine).
Five buprenorphine client records were reviewed on January 11-12, 2018. Each of the five records included documentation of insurance verification; however, there was no additional information documented to verify each client's identity.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
prior to the administration of suboxone a clients identity will be verified with: picture ID (drivers license, VA card, Passport); or combination of a birth certificate, social security card, verbal verification from professional referral source, court order for treatment, insurance verification may all be used if no photo ID is available. Nurse Manager and Clinical Director will ensure compliance with Patient ID. We will be in full compliance 1/22/2018 |
715.12(1-5) LICENSURE Informed patient consent
A narcotic treatment program shall obtain an informed, voluntary, written consent before an agent may be administered to the patient for either maintenance or detoxification treatment. The following shall appear on the patient consent form:
(1) That methadone and LAAM are narcotic drugs which can be harmful if taken without medical supervision.
(2) That methadone and LAAM are addictive medications and may, like other drugs used in medical practices, produce adverse results.
(3) That alternative methods of treatment exist.
(4) That the possible risks and complications of treatment have been explained to the patient.
(5) That methadone is transmitted to the unborn child and will cause physical dependence.
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Observations
The facility failed to document that it obtained an informed, voluntary, written consent, including required buprenorphine information, before an agent (buprenorphine) was administered to the patient for detoxification treatment.
Five buprenorphine client records were reviewed on January 11&12, 2018. None of the clients reviewed signed a consent with the required buprenorphine information.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
EMR will have an informed consent for all clients to sign prior to administration of Suboxone. The consent will contain the 5 points required by 715.12(1-5). Also, each client will be given an informational handout explaining the potential harmful consequences of suboxone. the Nurse Manager and Clinical Director will monitor compliance and we will be in compliance 1/22/2018. |