INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on June 26 - 28, 2012 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Fayette County 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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709.26(d)(5)(i) LICENSURE Personnel Management
709.26. Personnel management.
(d) The personnel records shall include, but not be limited to:
(5) Work performance evaluation including the following:
(i) Individual staff performance shall be evaluated at least annually.
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Observations
Based on a review of personnel records, the facility failed to document staff work performance evaluations in two of six personnel records.
The findings include:
Nine personnel records were reviewed on June 26, 2012. Work performance evaluations were required in six personnel records. Three employees were newly hired and were not yet due for work performance evaluations. Per agency policy, staff work performance evaluations will be completed within 6 months of hire and annually, thereafter. The facility failed to document staff work performance evaluations within 6 months of hire in personnel records # 7 and 8.
Employee # 7 was hired on October 31, 2011. The 6 month work performance evaluation was due to be completed no later than May 1, 2012. The facility failed to document a work performance evaluation within 6 months of hire for employee # 7.
Employee # 8 was hired on October 30, 2011. The 6 month work performance evaluation was due to be completed no later than April 30, 2012. The facility failed to document a work performance evaluation within 6 months of hire for employee # 8.
The project/facility director and clinical supervisor were interviewed throughout the licensing inspection and confirmed the findings.
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Plan of Correction
FCDAC was unable to complete a six-month evaluation on Employee #7, due to that employee's resignation. The evaluation for Employee #8 will be completed by July 27, 2012. To ensure that further evaluations are conducted in a timely manner, the Treatment Supervisor will maintain a listing of evaluation due dates, for each treatment specialist. The treatment supervisor will schedule a date for each employee's performance review to be conducted within 6 months of hire (for new hires) and annually thereafter.
Project Director and Facility Director will ensure that performance evaluations are completed in a timely manner.
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709.32(c)(1) LICENSURE Medication Control
709.32. Medication control.
(c) The project shall have a written policy regarding all medications used by clients which shall include, but not be limited to:
(1) Administration of medication.
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Observations
Based on a review of client records, the facility and the facility's physician failed to adhere to the dosing protocol listed on the medication by ordering that single dose film be halved, quartered and cut into eighths. Medication packaging identifies this as a single dose medication.
The findings include:
The physician prescribed Suboxone 8 mg/2 mg SL film, 1/2 film two times per day for client # 8 on April 12, 2012. Client # 8 was then prescribed 8 mg/2 mg SL film, 1/4 film three times per day on May 3, 2012. On May 24, 2012, the physician prescribed 8 mg/2 mg SL film, 1/4 film two times per day for client # 8. Client # 8 was then prescribed 8 mg/2 mg SL film, 1/4 film and 1/8 film every day.
The physician prescribed Suboxone 8 mg/2 mg SL film, 1/4 film three times per day for client # 9 on April 19, 2012. Client # 9 was then prescribed 8 mg/2 mg SL film, 1/4 film two times per day on May 17, 2012. On June 14, 2012, the physician prescribed 8 mg/2 mg SL film, 1/4 film and 1/8 film every day for client # 9.
The physician prescribed Suboxone 8 mg/2 mg SL film, 1/2 film two times per day for client # 11 on December 29, 2011. Client #11 was then prescribed 8 mg/2 mg SL film, 1/4 film three times per day on January 26, 2012. On February 16, 2012, the physician prescribed 8 mg/2 mg SL film, 1/4 film two times per day for client # 11. Client # 11 was then prescribed 8 mg/2 mg SL film, 1/4 film and 1/8 film every day.
Suboxone film is not formulated to be cut into smaller doses. Prescriptions need to be for the manufactured quantities of 8 mg/2 mg or 2 mg/.5 mg doses. A 6 mg dose requires the patient be given three 2 mg/.5 mg film doses. A 4 mg dose requires the patient be given two 2 mg/.5 mg film doses.
The project/facility director and clinical supervisor were interviewed throughout the licensing inspection and confirmed the findings.
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Plan of Correction
The Project Director and the Facility Director have discussed and reviewed with the Fayette County Drug and Alcohol Commission's (FCDAC) physician that the Suboxone film is not formulated to be cut into smaller doses. Therefore, any Suboxone prescriptions that the Fayette County Drug and Alcohol Commission physician issues can only be written following the manufactured quantities of 8mg or 2mg. The treatment supervisor will ensure that the FCDAC physician is adhering to the manufacturer's recommendations by conducting Quality Assurance checks on all written prescriptions during the medication visits prior to the client leaving FCDAC. |