INITIAL COMMENTS
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This report is a result of an on-site inspection conducted for the approval to use a narcotic agent, specifically buprenorphine, in the residential detoxification from opioid dependence. This inspection was conducted on August 4 - 6, 2008 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Center for Behavioral Health - NPA, Inc. was found not to be in compliance with the applicable chapters of 28 PA Code which pertain to the facility. Deficiencies were identified during this inspection and plan of correction is due on September 5, 2008.
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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 19 patient records on 8-5-08 and 8-6-08, the facility failed to document a monthly urine screen for one of fifteen records where this standard applies.
Finding:
Patient record #11 did not have a urine screen documented for April 2008.
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Plan of Correction
Program Director will reinforce to the medical associates the requirement for monthly urine testing. Program Director will be responsible. |
715.20(1) LICENSURE Patient transfers
A narcotic treatment program shall develop written transfer policies and procedures which shall require that the narcotic treatment program transfer a patient to another narcotic treatment program for continued maintenance, detoxification or another treatment activity within 7 days of the request of the patient.
(1) The transferring narcotic treatment program shall transfer patient files which include admission date, medical and psychosocial summaries, dosage level, urinalysis reports or summary, exception requests, and current status of the patient, and shall contain the written consent of the patient.
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Observations
Based on a review of 19 patient records on 8-6-08, the facility failed to document that required information was transferred to the other methadone treatment facility in two of two patient records where required.
Finding:
Documentation of the transfer of information to the other methadone facility was missing from patient records #16 and 19.
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Plan of Correction
The Program Director and Clinical Supervisor will inservice the associates on the documention need when transfering a patient to another facility, and keeping a record in the chart. Program Director and Clinical Supervisor will be responsible. |
715.23(b)(4) LICENSURE Patient records
(b) Each patient file shall include the following information:
(4) The results of an initial intake physical examination.
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Observations
Based on a review of 19 patient record on 8-5-08, the facility failed to have the physician's assistant's signature on a physical examination document that she completed.
Finding:
The physician's assistant's signature was missing from a physical exam document for a physical examination conducted by the physician's assistant in patient record #2.
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Plan of Correction
The Program Director will instruct the Physician Assistant to make sure and sign all physicial examinations upon completion. The program director will be responsible. |
715.23(b)(5) LICENSURE Patient records
(b) Each patient file shall include the following information:
(5) The results of all annual physical examinations given by the narcotic treatment program which includes an annual reevaluation by the narcotic treatment physician.
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Observations
Based on a review of 19 patient records 8-5-08, the facility failed to appropriately provide the physician's countersignature on the physical examination document completed by the physician's assistant.
Finding:
In patient record #10, the physical examination was conducted and signed by the physician's assistant on 5-30-08, but the supervising physician signed the document on 5-21-08.
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Plan of Correction
Program Director will instruct the supervising physician to sign the proper date when co-signing the physical examinations. The Program Director will be responsible. |
715.23(b)(22) LICENSURE Patient records
(b) Each patient file shall include the following information:
(22) Aftercare plan, if applicable.
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Observations
Based on a review of 19 patient records on 8-6-08, the facility failed to provide an aftercare plan in one of one record where aftercare plans were required.
Finding:
The aftercare plan was missing from patient record # 17.
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Plan of Correction
Clinical Associates will be instruct to complete aftercare plans and have them in all charts. Clinical Supervisor will be responsible |
715.28(c)(1-5) LICENSURE Unusual incidents
(c) A narcotic treatment program shall file a written Unusual Incident Report with the Department within 48 hours following an unusual incident including the following:
(1) Complaints of patient abuse (physical, verbal, sexual and emotional).
(2) Death or serious injury due to trauma, suicide, medication error or unusual circumstances.
(3) Significant disruption of services due to a disaster such as a fire, storm, flood or other occurrence.
(4) Incidents with potential for negative community reaction or which the facility director believes may lead to community concern.
(5) Drug related hospitalization of a patient.
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Observations
Based on a review of the incident reports on 8-4-08, the facility failed to file incident reports with the Department of Health when required.
Finding:
The facility did not consistently file incident reports in accordance with the regulation.
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Plan of Correction
All critical incidents that happen at the clinic will be reported to the state immeadiately and documentaion and fax transmital will be retained in our records as proof that the report was made. Program Director will be responsible |