INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on January 14, 2015 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, SPHS Behavioral Health 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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715.14(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 document a random urinalysis at least monthly in two of five patient records.
The findings include:
Five patient records were reviewed on January 14, 2015. All five patient records required to include a random urinalysis at least monthly. Patient records #3 and 5 did not include the results of monthly drug-screening urinalysis.
Patient #3 was admitted on June 20, 2014 and was given a prescription for Suboxone on December July 15, 2014. There were no monthly urinalysis results for August and December 2014.
Patient #5 was admitted on June January 20, 2014 and was given a prescription for Suboxone on December March 19, 2014. There were no monthly urinalysis results for April 2014.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The facility will document random urinalysis at least monthly after the initial urinalysis prior to admission. The clinical supervisor will review the policy and procedure for obtaining and documenting urinalysis with physicians, clinicians, and nurses. A urine drug screening will be given to individuals during the initial screening process prior to prescribing suboxone. A urine drug screen will continue at random and at the minimum of monthly afterwards. This will be complete by 2/15/15 |
709.91(b)(5) LICENSURE Intake and admission
709.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(5) Physical examination, if applicable.
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Observations
Based on a review of client records, the facility failed to document a physical examination including the patient's vital signs in three of five patient records.
The findings include:
Ten client records were reviewed on January 14, 2015. Five client records were reviewed for physical examinations. The facility failed to document a physical examination including the patient's vital signs in patient records # 2, 3 and 5.
Patient # 2 was admitted into treatment on September 30, 2014. A physical examination was completed on November 18, 2014. The physical examination for client # 2 did not include the patient's vital signs.
Patient # 3 was admitted into treatment on June 20, 2014. A physical examination was completed on July 15, 2014. The physical examination for client # 3 did not include the patient's vital signs.
Patient # 5 was admitted into treatment on January 20, 2014. A physical examination was completed on March 19, 2014. The physical examination for client # 5 did not include the patient's vital signs.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The facility will document a physical examination including patient's vital signs. The clinical supervisor will review the policy and procedure for obtaining and documenting a physical exam with vital signs with physicians, and nurses. All individuals seeking to participate in suboxone treatment will have their vitals taken and documented during their physical examination prior to being given suboxone. This will be complete by 2/15/15 |