Observations
Based on observation during a physical plant inspection conducted on April 6, 2016 at approximately 9:30 AM, the facility failed to ensure that exits from the nonresidential facility were unobstructed.
The entrance doors for Suites 202 and 203 have double keyed deadbolt locks. These two doors are also posted as emergency exits. The use of these double keyed deadbolt locks would prevent the emergency exit doors from being passable at all times.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Executive Director will ensure emergency exits are operable at all times by contacting a locksmith. The entrance doors for suites 202 and 203 have been inspected by a locksmith and fitted for the installation of a push bar type exit that will ensure unobstructed exits from the specified areas. Installation of push bar type devices will be completed by 4/30/16. |
Observations
Based on review of four patient records on April 6, 2016, the facility failed to document a complete initial drug screening urinalysis prior to the administration of buprenorphine, a narcotic agent, and a random urinalysis at least monthly thereafter in patient records # 1, 2, 3 and 7.
Patient # 1 was admitted into treatment on February 2, 2015 and was prescribed buprenorphine on January 19, 2016. The initial drug screen and March 2016 drug screen were completed by the facility using an onsite urine drug screen cup. However, there was no documentation these drug screens were sent out to a laboratory for urinalysis. One monthly drug screen was sent out to a laboratory for urinalysis in February 2016.
Patient #2 was admitted into treatment on March 1, 2016 and was prescribed buprenorphine on the same date. The initial drug screen was completed by the facility using an onsite urine drug screen cup. However, there was no documentation the drug screen was sent out to a laboratory for urinalysis.
Patient # 3 was admitted into treatment on September 8, 2015 and was prescribed buprenorphine on the same date. The initial drug screen and monthly drug screens for October 2015 through March 2016 were completed by the facility using an onsite urine drug screen cup. However, there was no documentation these drug screens were sent out to a laboratory for urinalysis.
Patient # 7 was admitted into treatment on October 1, 2014 and was discharged on December 2, 2015. Buprenorphine was prescribed during a time frame outside of the current licensing inspection. Monthly drug screens for January 2015 through November 2015 were completed by the facility using an onsite urine drug screen cup. However, there was no documentation these drug screens were sent out to a laboratory for urinalysis.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Regarding the deficiency noted in the provision of Medication-Assisted Treatment with Buprenorphine services relating to 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, specifically that "the facility failed to document a complete initial drug screening urinalysis prior to the administration of buprenorphine, a narcotic agent, and a random urinalysis at least monthly thereafter" in four patient records. As per our policy and procedures developed based upon this Agency's understanding the regulations, all prospective Buprenorphine patients are screened at the initial Intake, and then again the day of the appointment with the physician. Patients are screened at the time of every doctor's appointment typically weekly or biweekly and, in addition, are screened randomly at therapy appointments. All Buprenorphine patients are screened at least once a month. Most are screened weekly. This Agency has a CLIA-Waiver. Patients are screened using a multi-panel, CLIA-Waived Urine Point of Care Drug Screen. Urine specimens are sent out randomly to an external lab for confirmation urinalysis, however, not at the frequency of once per month for every patient. Following clarification of the regulations at the time of our site visit on 4/6/2016, we have changed our practices and updated our procedures to comply with Licensure regulations regarding Urine Testing, specifically that we will send our Point of Care Urine Drug Screen Specimens to an external lab for a confirmation urinalysis following Intake and at least once a month throughout the duration of treatment with Buprenorphine. Implementation of this change occurred effective Monday, April 11, 2016. The Executive Director is responsible for ensuring that the corrective action plan is implemented. Completion Date: 4/11/2016 |