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 methadone and buprenorphine, in the treatment of narcotic addiction. This inspection was conducted on May 13-14, 2014 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, BGI of Brandywine was found not to be in compliance with the applicable chapters of 4 PA Code and 28 PA Code which pertain to the facility.
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Plan of Correction
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715.21 LICENSURE Patient termination
A narcotic treatment program shall develop and implement policies and procedures regarding involuntary terminations. Involuntary terminations shall be initiated only when all other efforts to retain the patient in the program have failed.
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Observations
Based on the review of patient records and policies and procedures, the facilty failed to demonstrate the implementation of the policies and procedures in initiating the involuntary termination only after all other efforts to retain the patient had failed.
The findings include:
Sixteen patient records were reviewed May 13-16, 2014. Patient's # 7 and 8 were involuntarily terminated, but the facility failed to provide written documentation identifying the a notice to the patient or what efforts had been initiated to retain the patients.
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Plan of Correction
The administrative discharge policy and procedure will be reviewed with all clinical staff by 6/19/14. All clinical staff will sign off that they understand this policy. Medical records will audit all administrative discharge charts for the next 3 months to ensure compliance. |