INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on July 8, 2015 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, CPP Behavioral Health 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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715.14(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 review of patient records, the facility failed to document a complete initial drug screening urinalysis prior to the administration of buprenorphine, a narcotic agent, and a random urinalysis at least monthly thereafter in five of five patient records. The findings include:Eight client records were reviewed on July 8, 2015. Five patients were prescribed buprenorphine. Five patients were required to complete a drug screen urinalysis prior to the administration of buprenorphine, a narcotic agent and at least monthly thereafter. A complete drug screen urinalysis includes receiving the results from the CLIA and Department of Health approved laboratory. The facility failed to document a complete drug screen urinalysis prior to the administration of buprenorphine, a narcotic agent and monthly thereafter in records # 1, 2, 5, 6 and 7. Patient # 1 was admitted into treatment on November 26, 2014. Patient # 1 was prescribed 8 mg/2 mg buprenorphine once daily on December 5, 2014. An initial drug screen was completed by the facility on December 5, 2014 using the dipstick method. However, there was no documentation the initial drug screen was sent out to a laboratory for urinalysis. The facility completed monthly drug screens using the dipstick method in January, February and March 2015. There was no documentation these monthly drug screens were sent out to a laboratory for urinalysis.Patient # 2 was admitted into treatment on December 1, 2014. Patient # 2 was prescribed 8 mg/2 mg buprenorphine once daily on December 5, 2014. An initial drug screen was completed by the facility on December 5, 2014 using the dipstick method. However, there was no documentation the initial drug screen was sent out to a laboratory for urinalysis. The facility completed monthly drug screens using the dipstick method in January, February, March and April 2015. There was no documentation these monthly drug screens were sent out to a laboratory for urinalysis.Patient # 5 was admitted into treatment on January 4, 2015 and discharged on April 10, 2015. Patient # 5 was prescribed 8 mg/2 mg buprenorphine twice daily on January 16, 2015. An initial drug screen was completed by the facility on January 16, 2015 using the dipstick method. However, there was no documentation the initial drug screen was sent out to a laboratory for urinalysis. The facility completed monthly drug screens using the dipstick method in January, February and March 2015. There was no documentation these monthly drug screens were sent out to a laboratory for urinalysis.Patient # 6 was admitted into treatment on December 3, 2014 and discharged on March 9, 2015. Patient # 6 was prescribed 8 mg/2 mg buprenorphine once daily on December 12, 2014. An initial drug screen was completed by the facility on December 12, 2014 using the dipstick method. However, there was no documentation the initial drug screen was sent out to a laboratory for urinalysis. The facility completed monthly drug screens using the dipstick method in December 2014, January 2015 and February 2015. There was no documentation these monthly drug screens were sent out to a laboratory for urinalysis.Patient # 7 was admitted into treatment on March 31, 2015 and discharged on June 15, 2015. Patient # 7 was prescribed 8 mg/2 mg buprenorphine twice daily on April 1, 2015. An initial drug screen was completed by the facility on April 1, 2015 using the dipstick method. However, there was no documentation the initial drug screen was sent out to a laboratory for urinalysis. The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Project Director created a new policy and procedure requiring that all urinalysis be sent to a CLIA and Dept of Health approved laboratory.
All Staff was trained by the Project Director on the use of the new policy and procedure regarding the urinalysis to ensure all urine specimens are sent to a CLIA and a Dept of Health approved laboratory.
The Project Director will ensure ongoing compliance with this regulation through monthly chart audits to ensure compliance with the updated internal policies and procedures. |
709.91(b)(3)(iii) LICENSURE Intake and admission
709.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(3) Histories, which include the following:
(iii) Personal history.
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Observations
Based on a review of client records, the facility failed to document a personal history including a military and sexual history in eight of eight client records.The findings include:Eight client records were reviewed on July 8, 2015. Eight client records were reviewed for documentation of a personal history that included a military and sexual history. The facility failed to document a personal history including a military and sexual history in client records # 1, 2, 3, 4, 5, 6, 7 and 8.Client # 1 was admitted into treatment on November 26, 2014. A personal history completed on November 26, 2014 did not include a military and sexual history for client # 1.Client # 2 was admitted into treatment on December 1, 2014. A personal history completed on December 1, 2014 did not include a military and sexual history for client # 2.Client # 3 was admitted into treatment on March 25, 2015. A personal history completed on March 25, 2015 did not include a military and sexual history for client # 3.Client # 4 was admitted into treatment on October 28, 2014 and discharged on December 12, 2014. A personal history completed on October 28, 2014 did not include a military and sexual history for client # 4.Client # 5 was admitted into treatment on January 4, 2015 and discharged on April 10, 2015. A personal history completed on January 4, 2015 did not include a military and sexual history for client # 5.Client # 6 was admitted into treatment on December 3, 2014 and discharged on March 9, 2015. A personal history completed on December 3, 2014 did not include a military and sexual history for client # 6.Client # 7 was admitted into treatment on March 31, 2015 and discharged on June 15, 2015. A personal history completed on March 31, 2015 did not include a military and sexual history for client # 7.Client # 8 was admitted into treatment on October 13, 2014 and discharged on November 21, 2014. A personal history completed on October 13, 2014 did not include a military and sexual history for client # 8.The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Project Director modified the screening and assessment form and the intake form was revised to capture the military history and the sexual history of each client that enters the facility.
All Staff was trained by the Project Director on the use of the new forms to ensure client record compliance with stated regulations.
The Project Director will ensure ongoing compliance with this regulation through monthly chart audits. |