INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on November 18, 2015 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Jefferson Outreach Drug and Alcohol Program Central 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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705.28 (d) (1) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(1) Conduct unannounced fire drills at least once a month.
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Observations
Based on a review of the facility's fire drill log, the facility failed to maintain a written fire drill record which included the amount of time it took for evacuation, the exit route used, the number of persons in the facility at the time of the drill, problems encountered and whether the fire alarm or smoke detector was operative.
The findings include:
The facility's fire drill log was reviewed on November 18, 2015, covering the period of December 2014 through October 2015. The facility failed to maintain a written fire drill record which included the amount of time it took for evacuation, the exit route used, the number of persons in the fallibility at the time of the drill, problems encountered and whether the fire alarm or smoke detector was operative.
In addition, the facility failed to set off a fire alarm or smoke detector during each fire drill. However, the facility has an exception to use an alternate means of announcing fire drills, but required to provide documentation that the fire alarm or smoke detector is in working order. This documentation must be updated on an annual basis. The facility failed to provide annual documentation that verified that the fire alarms and/or smoke detectors were in working order.
The findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
It shall be the responsibility of the Facility Director to ensure that fire drills logs include the amount of time it took for evacuation, the exit route used, the number of persons in the facility at the time of the drill, and problems encountered. In addition, it shall be the responsibility of the Facility Director to have available the annual documentation that the fire alarm or smoke detector is in working order. |
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 complete random drug-screening urinalysis at least monthly for each patient.
The findings include:
One narcotic treatment patient record was reviewed on November 18, 2015. The facility failed to provide monthly drug-screening urinalysis for patient # 6.
Patient # 6 was admitted to the program on February 9, 2009. The facility failed to provide and document a monthly drug-screening urinalysis for patient # 6 for the month of January 2015, February 2015, April 2015, May 2015, July 2015, September 2015 and October 2015.
The findings were reviewed with facility staff during the monitoring inspection.
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Plan of Correction
It shall be the responsibility of the Medical Director and Facility Director to ensure that monthly drug-screening urinalyses are collected from all patients who are prescribed Suboxone. To accomplish this, the Program Registrar, under the auspices of the Medical Director will provide Suboxone patients a lab slip calling for a standard panel drug screen urinalyses on a monthly basis. Compliance will be assessed via quarterly chart audit to be conducted by the Facility Director. |