INITIAL COMMENTS
|
This report is a result of an on-site inspection conducted for the approval to use a narcotic agent, specifically buprenorphine, in the treatment of narcotic addiction. This inspection was conducted on September 21, 2010 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Penn Foundation For Mental Health, Inc. was found not to be compliance with the applicable chapters of 28 PA Code which pertain to the facility. Deficiencies were identified during this inspection and a plan of correction is due on October 13, 2010.
|
Plan of Correction
|
715.9(a)(1) LICENSURE Intake
(a) Prior to administration of an agent, a narcotic treatment program shall screen each individual to determine eligibility for admission. The narcotic treatment program shall:
(1) Verify that the individual has reached 18 years of age.
|
Observations
Based on a review of policy and procedure and staff interviews, the facility failed to document a policy that identified that admission eligibility was limited to patients eighteen years of age and older.
The findings included:
Administrative materials, to include policy and procedure, were reviewed on September 21, 2010. The facility's policy pertaining to the age at time of admission specified that a "patient must be eighteen or an emancipated minor". A staff interview identified the issue as a policy that would need to be modified to reflect adherence to the regulations.
|
Plan of Correction
Policy and procedure will be changed, "emancipated minor" will be deleted. The new policy and procedure will state client must be at least 18 years of age. Director of the Recovery Center will oversee the implementation of this new policy. |
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.
|
Observations
Based on review of the patient records, the facility failed to obtain a complete urine drug screen urinalysis prior to the administration of buprenorphine, a narcotic agent in five of seven patient records. A complete urine drug screen includes receiving the results from the CLIA and Department of Health approved laboratory.
The findings include:
Seven patient records were reviewed on September 21, 2010. Six patient records were required to complete a urine drug screen urinalysis prior to the administration of buprenorphine, a narcotic agent. A complete urine drug screen includes receiving the results from a CLIA and Department of Health approved laboratory. The facility failed to obtain a complete urine drug screen urinalysis prior to the administration of buprenorphine in five of seven patient records.
Patient record # 2 - Patient was admitted on May 26, 2010; the patient received their initial dose of buprenorphine on May 27, 2010 @ 11:00 am. There was no documentation of drug-screening urinalysis
results for patient # 2.
Patient record # 3 - Patient was admitted on April 13, 2010; the patient received their initial dose of buprenorphine on April 15, 2010 @ 10:00 am. There was no documentation of drug-screening urinalysis results for Patient # 3.
Patient record # 4 - Patient was admitted on August 25, 2010; the patient received their initial dose of buprenorphine on August 26, 2010 at 1:00 PM. There was no documentation of drug-screening urinalysis results for Patient # 4.
Patient record # 5- Patient was admitted on September 15, 2010; the patient received their initial dose of buprenorphine on September 16, 2010 at 1:00 PM. There was no documentation of drug-screening urinalysis results for Patient # 5.
Patient record # 7- Patient was admitted on August 31, 2010; the patient received their initial dose of buprenorphine on September 1, 2010 at 1:00 PM. There was no documentation of drug-screening urinalysis results for Patient # 7.
|
Plan of Correction
Policy and procedure will be reviewed and ammended to include obtaining a complete drug screen urinalysis on all clients prior to the administration of buprenorphine. Director of Nursing will be responsible for overseeing that urinalysis is completed on all clients. Director of Nursing will be responsible for implementing this policy and procedure. |