INITIAL COMMENTS
|
This report is a result of an on-site licensure renewal inspection conducted on June 4, 2014 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Familylinks, 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.
|
Plan of Correction
|
705.28 (d) (5) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(5) Prepare alternate exit routes to be used during fire drills.
|
Observations
Based on a review of fire drill records, the facility failed to prepare alternate exit routes to be used during fire drills.
The findings include:
Fire drill records for June 2013 through May 2014 were reviewed on June 4, 2014. The front door was the only exit route utilized during every fire drill from June 2013 through May 2014. The facility failed to prepare alternate exit routes to be used during fire drills.
The findings were confirmed by the Senior Program Manager on June 4, 2014.
|
Plan of Correction
Facility Director with the assistance of the Senior Program Manager will ensure that fire drill exits are rotated monthly using the fire drill log as documentation of the rotating exit strategies. |
715.6(a)(1)(i)-(iii) LICENSURE Physician staffing
(a) A narcotic treatment program shall designate a medical director to assume responsibility for administering all medical services performed by the narcotic treatment program
(1) A medical director shall be a physician and shall have obtained one of the following:
(i) Three years documented experience in the provision of services to persons who are addicted to alcohol or other drugs, including at least 1 year of experience in the treatment of narcotic addiction with a narcotic drug.
(ii) Certification in addiction medicine by the American Society of Addiction Medicine.
(iii) A certificate of added qualifications in addiction psychiatry by the American Board of Psychiatry and Neurology, Inc.
|
Observations
Based on a review of personnel records, the facility failed to designate a qualified medical director to assume responsibility for administering all medical services performed by the program.
The findings include:
The qualifications of the medical director were reviewed on June 4, 2014. The facility has received approval by the Department to prescribe buprenorphine. The facility has designated a medical director to assume responsibility for administering all medical services performed by the program. The medical director has not obtained the experience or certifications that are required for the position.
The findings were confirmed by the medical director.
|
Plan of Correction
The facility director and Sr. Program Manager under the direction of the Director of Behavioral Health will submit in writing a comprehensive training plan for the interim medical director for state approval and will ensure they meet the qualifications for the position of medical director. This training plan will outline the state requirements for a medical practitioner to prescribe medication detox therapy related drugs to clients. This training plan will be submitted to the state via mail by 7/18/14. |