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 November 13, 2013 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.
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Plan of Correction
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Observations
Based on a review of the facility policy and procedures, and discussions with the nurse supervisor, the facility failed to provide complete procedures.
The findings include:
The facility updated this policy and procedure in August 2013. The updated procedures failed to include reasons that a facility may involuntary discharge patients. The procedure is missing (ii) patient possessed a controlled substance, (iii) absent from the narcotic treatment program, and (iv) the patient has failed to follow the treatment plan objectives.
The findings were reviewed with the nurse supervisor and were not disputed.
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Plan of Correction
The Director of Nursing will update the policy to include reasons that Twin Lakes Center may involuntary discharge patients. Parts that will be added are (ii) patient possessed a controlled substance, (iii) absent from the narcotic treatment program, and (iv) the patient has failed to follow the treatment plan objectives.
This will be completed prior to 11/30/13. |