INITIAL COMMENTS
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This report is a result of an on-site inspection conducted for the approval to use a narcotic agent, specifically buprenorphine, in the residential detoxification from opioid dependence. This inspection was conducted on April 21, 2009 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Gateway Rehabilitation Center, was found not to be in compliance with the applicable chapters of 28 PA Code which pertain to the facility. Deficiencies were identified during this inspection and plan of correction is due on May 22, 2009.
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Plan of Correction
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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 the patient records, the facility failed to include verification of the patients age in two of five patient records.
The findings include:
Five patient records were reviewed on April 21, 2009. Verification that the patient was at least 18 years old was required in five patient records. The facility did not include verification of the patients age in patient records #3 and #5.
This has been an area of non-compliance in the previous two monitoring surveys dated
5-11-07 and 7-31-08.
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Plan of Correction
All involved departments will participate in a Performance Improvement Process on June 1, 2009. The Manager of Nursing, Manager of Admissions Services and the Director of Evaluation Services and Utilization Review will be responsible for foolproofing the process for documenting verification that an individual is at least 18 years old. Gateway will be in full compliance with the standard by July 1, 2009. All appropriate managers will continue to audit charts for compliance. |
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 the patient records, the facility failed to include verification of the patients identity in two of five patient records.
The findings include:
Five patient records were reviewed on April 21, 2009. Verification of the patients identity was required in five records. The facility did not include verification of the patients identity in patient records #3 and #5.
This has been an area of non-compliance in the previous two monitoring surveys dated
5-11-07 and 7-31-08.
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Plan of Correction
All involved departments will participate in a Performance Improvement Process on June 1, 2009. The Manager of Nursing, Manager of Admissions Services and the Director of Evaluation Services and Utilization Review will be responsible for foolproofing the process for documenting verification of the patient's identity. Gateway will be in full compliance with the standard by July 1, 2009. All appropriate managers will continue to audit charts for compliance. |