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 for residential detoxification from narcotic addiction. This inspection was conducted on December 14, 2007 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Gaudenzia, Inc. Fountain Springs 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 January 17, 2008.
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Plan of Correction
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715.17(c)(1)(i-vi)) LICENSURE Medication control
(c) A narcotic treatment program shall develop and implement written policies and procedures regarding the medications used by patients which shall include, at a minimum:
(1) Administration of medication.
(i) A narcotic treatment physician shall determine the patient 's initial and subsequent dose and schedule. The physician shall communicate the initial and subsequent dose and schedule to the person responsible for the administration of medication. Each medication order and dosage change shall be written and signed by the narcotic treatment physician.
(ii) An agent shall be administered or dispensed only by a practitioner licensed under the appropriate Federal and State laws to dispense agents to patients.
(iii) Only authorized staff and patients who are receiving medication shall be permitted in the dispensing area.
(iv) There shall be only one patient permitted at a dispensing station at any given time.
(v) Each patient shall be observed when ingesting the agent.
(vi) Administering and dispensing shall be conducted in a manner that protects the patient from disruption or annoyance from other individuals.
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Observations
Based on review of administrative policy and procedures, nursing records and the patient records, as well as staff interviews, the facility failed to follow it's own detoxification protocol, which states the detoxification time frame will be three to seven days depending on patient need. However, patients #A and #B were tapered in two days per physician verbal orders. Nursing staff reported the physician states the protocol is to start on day 1 and the last dose on day 3 only giving 48 hours to taper.
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Plan of Correction
The physician and nursing staff will adhere to the detoxification protocol for buprenorphine and specifically the detoxification time frame which is three to seven days depending on patient need. The Program Director will meet with the physician and nursing staff on 1/15/08 to discuss protocol. Program Director will oversee and ensure compliance.
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715.23(b)(15) LICENSURE Patient records
(b) Each patient file shall include the following information:
(15) Psychosocial evaluations of the patient.
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Observations
Based on random review of two patient records, the facility failed to develop a complete and evaluative psychosocial assessment of the patient's historical data. The evaluation was missing an overall composite picture of the client, as well as the client's problems/needs, support systems and coping mechanisms. In addition, the client's strengths/assets and negative factors that may inhibit treatment were stated in terms of the client's opinion versus a clinical assessment by the counselor.
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Plan of Correction
The psychosocial evaluation will include a composite picture of the client, the client's problems/needs, support systems and coping mechanisms. The evaluation will also contain a clinical assessment of the client's strengths/assets and negative factors inhibiting treatment. The Program Director will provide training to the staff to detail how this is to be addressed and documented in the client file. The Program Director will review all psychosocials to ensure compliance.
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715.23(b)(24) LICENSURE Patient records
(b) Each patient file shall include the following information:
(24) Follow-up information regarding the patient.
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Observations
Based on documentation and staff interviews, the facility failed to provide follow-up services to three of three patient records reviewed, #A, B, and C.
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Plan of Correction
Follow-up contacts will be made and documented on every client. A specific form designed to gather and document follow-up information will be maintained in a separate binder. The Program Director will train all detox staff on the follow-up procedure in a meeting scheduled for 1/7/08. The Program Director will review the follow-up contacts to ensure compliance.
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