INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on June 23-24, 2015 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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705.28 (d) (4) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(4) Maintain a written fire drill record including the date, time, the amount of time it took for evacuation, the exit route used, the number of persons in the facility at the time of the drill, problems encountered and whether the fire alarm or smoke detector was operative.
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Observations
Based on the review of the fire drill logs, the facility failed to maintain a written fire drill record that included the the amount of time it took for evacuation.
The findings include:
The fire drill logs from July 2014 to May 2015 were reviewed on June 23-24, 2015. All of the fire drill logs from July 2014 to May 2015 did not document the amount of time it took for evacuation.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
705.28(d)(4) Fire Safety
The Fire Drill Log was corrected on 6/25/15 to include the date, time, the amount of time it took for the evacuation, exit route used, number of persons in the facility at the time of the drill, problems encountered and whether the fire alarm or smoke detector was operative. The Administrative Assistant corrected the form and confirmed disposal of old forms. The Facility Director will ensure ongoing compliance.
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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 the review of patient records, the facility failed to document a complete initial urinalysis for each prospective patient in three of three patient records.
The findings include:
Twelve patient records were reviewed on June 23-24, 2015. Three records were reviewed as buprenorphine patients. All patients are required to complete a drug screen urinalysis prior to the administration of buprenorphine, a narcotic agent and at least monthly thereafter. A complete urine drug screen includes receiving the results from the CLIA and Department of Health approved laboratory. The facility did not document a complete an initial drug-screening urinalysis in patient records # 1, 2, and 3.
Patient # 1 was admitted on May 1, 2015. The patient received their first dose of buprenorphine on May 4, 2015. The initial urine screen had been completed by the facility on May 1, 2015 using the dip stick method. However, there was no documentation that the initial urine screen had been sent out to a laboratory for urinalysis.
Patient # 2 was admitted on April 24, 2015. The patient received their first dose of buprenorphine on April 27, 2015. The initial urine screen had been completed by the facility on April 24, 2015 using the dip stick method. However, there was no documentation that the initial urine screen had been sent out to a laboratory for urinalysis.
Patient # 3 was admitted on May 27, 2015 and discharged on June 10, 2015. The patient received their first dose of buprenorphine on June 1, 2015. The initial urine screen had been completed by the facility on May 27, 2015 using the dip stick method. However, there was no documentation that the initial urine screen had been sent out to a laboratory for urinalysis.
These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
715.14(a) Urine Testing
The Clinical Supervisor has developed a written policy regarding initial drug-screening urinalysis for each prospective client entering the narcotic detoxification program and random urinalysis at least monthly thereafter. As part of the initial intake interview for the narcotic detoxification treatment, an initial urinalysis shall be sent to a clinical laboratory that performs testing that is in compliance with Federal requirements. The results of the urinalysis will be reviewed by the medical director prior to the initial prescription of a narcotic agent. Clients who participate within the narcotic detoxification program will also receive random monthly urinalysis that will be sent to a clinical laboratory. It shall be the responsibility of the Clinical Supervisor to issue a ?memo? notifying FCDAC staff and prescribing physician of the policy changes regarding urinalysis drug screenings. Clinical Supervisor will ensure ongoing compliance with this regulation through weekly clinical supervision and review of admissions with Facility Medical Director.
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715.15(b) LICENSURE Medication dosage
(b) The narcotic treatment physician shall determine the proper dosage level for a patient, except as otherwise provided in this section. If the narcotic treatment physician determining the initial dose is not the narcotic treatment physician who conducted the patient examination, the narcotic treatment physician shall consult with the narcotic treatment physician who performed the examination before determining the patient 's initial dose and schedule.
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Observations
Based on a review of patient records, the facility physician failed to adhere to the dosing protocol listed on the medication by ordering that single dose Suboxone film/tablets or Zubsolv tablets be quartered or halved in three of three patient records. The medication packaging identifies these medications as a single dose medications.
The findings include:
Patient # 1 was admitted on May 1, 2015.
The physician's medication order, dated 5/11/2015, documented- Suboxone 8 mgs film strip #7 1/2 film B.I.D.
The physician's medication order, dated 5/18/2015, documented- Suboxone 8 mgs film strip #3 3/4 Q.D SL.
The physician's medication order, dated, 5/21/2015, documented- Suboxone 8 mgs film strip #3 1/2 filmstrip Q.D SL.
The physician's medication order, dated 5/28/2015, documented- Suboxone 8 mgs film #1 1/4 Q.D. S.L. x 4 days.
Patient # 2 was admitted on April 24, 2015.
The physician's medication order, dated 5/7/2015, documented- Zubsolv 5.7/1.4 mg #4 1/2 tablet SL QD.
The physician's medication order, dated 5/18/2015, documented- Zubsolv 5.7/1.4 mg #2 1/2 tablet SL QD.
The physician's medication order, dated 5/21/2015, documented- Zubsolv 5.7/1.4 mg #6 1/2 tablet SL QD.
The physician's medication order, dated 5/28/2015, documented- Zubsolv 5.7/1.4 mg #1 1/2 tablet SL QD. x 2 days.
The physician's medication order, dated 6/1/2015, documented- Zubsolv 5.7/1.4 mg #2 1/2 tablet SL QD.
The physician's medication order, dated 6/42015, documented- Zubsolv 5.7/1.4 mg #2 1/2 tablet SL QD.
Patient # 3 was admitted on May 27, 2015 and discharged on June 10, 2015.
The physician's medication order, dated 6/1/2015, documented- Suboxone tablet 8 mgs #6 CSIA 3/4 tablet once daily S.L.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
715.15(b) Medication Dosage
The Project Director and Clinical Supervisor have discussed and reviewed with the Fayette County Drug and Alcohol Commission?s (FCDAC) Medical Director that the Medical Director will adhere to dosing protocol for Suboxone film strip and Zubsolv prescriptions.. Therefore, any Suboxone or Zubsolve prescriptions FCDAC?s Medical Director will be written to follow the manufactured quantities of 8mg, 4mg or 2mg. The lead counselor 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. The Clinical Supervisor and Lead Counselor will review dosing protocol with FCDAC?s Medical Director to include single dosing of medication. The Lead counselor will notify the clinical supervisor if dosing issues continue. Auditing of charts will be completed by the clinical supervisor, lead counselor and treatment therapists to ensure appropriate dosing is occurring. Any issues that are identified will be brought to the attention of the prescribing physician.
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