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 treatment of narcotic addiction. This inspection was conducted on January 3, 2013 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, UHS Recovery Foundation, Inc. was found not to be in compliance with the applicable chapters of 4 PA Code and 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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715.9(a)(2) 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:
(2) Verify the individual 's identity, including name, address, date of birth, emergency contact and other identifying data.
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Observations
Based on the review of patient records, the facility failed to verify the identity of the patient prior to the administration of an agent in two of six patient records.
The findings include:
Six patient records were reviewed on January 3, 2013. Six patient records required patient identity information.
Patient # 1 was admitted November 11, 2012. There was no documentation that the facility identified the patient's identity prior to the administration of the agent.
Patient # 4 was admitted August 1, 2012. There was no documentation that the facility identified the patient's identity prior to the administration of the agent.
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Plan of Correction
Admissions Director held training on January 23, 2013 to review procedures. All Suboxone detoxification candidates must provide two forms of identification prior to commencement of Suboxone induction. One form needs to be a State issued photo identification and one form needs to be either a social security card, birth certificate or insurance card. Copies will be kept in the patient's medical record. Admissions Director will perform monthly open chart audits and report results to PI Committee to ensure compliance. |
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 the review of patient records, the facility failed to ensure the psychosocial evaluations were a clinical assessment of the historical data collected in six of six patient records.
The findings include:
Six patient records were reviewed on January 3, 2013. Six patient records were reviewed for psychosocial evaluations. The psychosocial evaluations of patients # 1, 2, 3, 4, 5 and 6 were a repeat of the collected historical data and not a clinical assessment of the data collected.
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Plan of Correction
Clinical Director will conduct a training for all clinical staff who complete psychosocial assessments. Training will be held on February 13, 2013. Staff will be instructed that the summary needs to be a clinical assessment based on the data collected. Compliance will be monitored through regular monthly open chart audits conducted by the Clinical Director. Audits monitor for both timeliness of completion and quality of summary. |