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 provision of outpatient maintenance treatment for opioid dependence. This inspection was conducted on January 16, 2008 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Gateway Rehabilitation Center 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 February 29, 2008. .
|
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 patient record review on 1-16-08, the facility failed to document the verification that the patient is 18 years or older. Refer to patient record # 1 and 2.
|
Plan of Correction
All evaluation and admissions staff have been trained about the requirement to document that patients being considered for administration of buprenorphine for detox must show documentation that they are 18 years or older. The admissions checklist has been updated to reflect this requirement and to reflect possible forms of verification. Department internal audits and supervision will monitor for compliance. |
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.
|
Observations
Based on a patient record review on 1-16-08, the facility failed to document the verification of the patient's identity. Refer to patient records # 1 and 2.
|
Plan of Correction
All evaluation and admissions staff have been trained about the requirement to document a patient's identity when they may be considered for administration of buprenorphine for detox. The admissions checklist has been updated to reflect this requirement and to reflect possible forms of verification. Department internal audits and supervision will monitor for compliance. |
715.21(1)(i-iv) 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.
(1) A narcotic treatment program may involuntarily terminate a patient from the narcotic treatment program if it deems that the termination would be in the best interests of the health or safety of the patient and others, or the program finds any of the following conditions to exist:
(i) The patient has committed or threatened to commit acts of physical violence in or around the narcotic treatment program premises.
(ii) The patient possessed a controlled substance without a prescription or sold or distributed a controlled substance, in or around the narcotic treatment program premises.
(iii) The patient has been absent from the narcotic treatment program for 3 consecutive days or longer without cause.
(iv) The patient has failed to follow treatment plan objectives.
|
Observations
Based on a patient record review on 1-16-08, the facility failed to provide written notification of an involuntary discharge in patient record #2.
|
Plan of Correction
The patient from the record designated as #2 was a regular discharge. However, it is possible that another record had an involuntary discharge without the appropriate documentation so we conducted a staff refresher training and are monitoring detox records for compliance. |