INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on January 5, 2016, and January 6, 2016, by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Carbon Monroe Pike Drug And Alcohol Commission Inc 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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715.9(a)(4) 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:
(4) Have a narcotic treatment physician make a face-to-face determination of whether an individual is currently physiologically dependent upon a narcotic drug and has been physiologically dependent for at least 1 year prior to admission for maintenance treatment. The narcotic treatment physician shall document in the patient 's record the basis for the determination of current dependency and evidence of a 1 year history of addiction.
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Observations
Based on a review of client records, the facility failed to ensure client records contained the required documentation for admission for narcotic maintenance.
The findings include:
Ten client records were reviewed on 01/05/2016, and 01/06/2016. Three of the ten records reviewed required documentation from a physician of both current physiological dependence on a narcotic substance, and at least one year of physiological dependence on a narcotic substance, but the following two records did not have the required physician's documentation.
Client #7 began narcotic maintenance treatment at the facility on 12/01/2015, and was an active client at the time of the onsite inspection.
Client #8 began narcotic maintenance treatment at the facility on 1/20/2015, and was an active client at the time of the onsite inspection.
The findings were reviewed with the facility staff during the inspection process.
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Plan of Correction
Upon initial face to face meeting between prospective suboxone client and Suboxone prescribing doctor, the Suboxone prescribing doctor shall check off the appropriate box on initial face to face determination form whether the individual is currently physiologically dependent upon a narcotic drug. Suboxone prescribing physician will also check the appropriate box upon initial face to face determination form if the individual has been physiologically dependent to a narcotic drug for at least 1 year prior to admittance for suboxone maintenance. Suboxone prescribing physician shall also document on determination form the basis for his determination of current narcotic dependence for at least 1 year of history of addiction.
Development of form will be completed by February 9, 2016, at which time the form will be reviewed with both the Suboxone coordinator and Suboxone prescribing physician. Facility Director will be responsible for oversight and review files for all new individuals who are admitted into Suboxone program beginning February 23, 2016.
All existing suboxone clients will have the Suboxone determination form placed in file, this form will support the individual has been dependent to a narcotic drug for at least one year prior to their admittance to suboxone program. |
704.11(c)(1) LICENSURE Mandatory Communicable Disease Training
704.11. Staff development program.
(c) General training requirements.
(1) Staff persons and volunteers shall receive a minimum of 6 hours of HIV/AIDS and at least 4 hours of tuberculosis, sexually transmitted diseases and other health related topics training using a Department approved curriculum. Counselors and counselor assistants shall complete the training within the first year of employment. All other staff shall complete the training within the first 2 years of employment.
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Observations
Based on a review of personnel and training records, the facility failed to provide documentation of TB/STD training in one of seven reviewed
The findings include:
Seven personnel records which required documentation of mandatory communicable disease training were reviewed on January 5, 2016 and January 6, 2016. The facility failed to provide documentation of TB/STD training for employee #1.
Employee #1 was hired 1/05/2014 as a counselor. This employee was required to obtain 4 hours of TB/STD training by 1/05/2015. Employee #1 failed to obtain the training as of the date of the inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Employee #1 was scheduled for and attended required the minimum of 4hrs of TB/STD training on January 13, 2016. Outpatient Treatment Supervisor will be responsible for scheduling state required trainings for any new outpatient staff member hire and to assure training completions are conducted within the first year of the new outpatient staff member date of hire. |