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 23, 2014 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 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 four of five patient records.
The findings include:
Five patient records were reviewed on January 23, 2014. Five patient records were specifically reviewed for patient identity information. Patient records # 1, 2, 3 and 4 did not contain any documentation to verify the individual's identity prior to the administration of the narcotic agent.
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Plan of Correction
During our recent site visit, it was discovered that we were not routinely verifying an individual's identity prior to start of suboxone. All admissions are processed through our intake office, so the intake workers were met with and it was explained to them that they are to tell clients who have any history of opiate use, that they must present to treatment with proof of ID and age. This will be added to the intake sheet as a question - do you have proof of ID and age? If a client does not have a driver's license we will accept alternative forms of ID, ie birth certificate, prison ID, etc. Staff who are admitting the client, will make a photocopy of the identification for the paper chart and scan the identification into the electronic health record. If a client is not able to produce any proof of identity, that client will not be eligible for suboxone treatment. Chart checks by the clinical supervisor will be used to ensure compliance with this regulation. Director of Inpatient will oversee this POC. |