INITIAL COMMENTS
|
Based on the concerns arising from COVID-19, The Department of Drug and Alcohol Programs, Bureau of Quality Assurance for Prevention and Treatment, has implemented temporary procedures for conducting an annual renewal inspection. The inspection will be divided into two parts. 1, an abbreviated off-site inspection, will be conducted off site, and will require the submission of administrative information via email to a Licensing Specialist. 2, an abbreviated on-site inspection, will be conducted on-site at a later date and will include a review of client/patient records, and a physical plant inspection.This report is a result of Part 2, an abbreviated on-site inspection, conducted on September 29, 2020 by staff from the Department of Drug and Alcohol Programs, Bureau of Quality Assurance for Prevention and Treatment. Not all regulations were reviewed, the remainder of the regulations were reviewed during Part 1.Based on the findings of Part 2, an abbreviated on-site inspection, Safe Harbor Behavioral Health at UPMC Hamot was found not to be in compliance with the applicable chapters of 28 PA Code which pertain to the facility. The following deficiencies were identified during this inspection:
|
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
The facility failed to document that it verified that each individual reached 18 years of age prior to administering buprenorphine.Client #1 was admitted on July 9, 2020 and was initially prescribed buprenoriphine on August 3, 2020. There was no documentation in client record #1 verifiying the client's age as there was no identification present.These findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
1. Upon first visit for a medication assisted treatment visit, the MAT nurse will verify an individual's identification if this has not already been done through the intake process through an acceptable US government issued ID, a US certificate of citizenship, US permanent resident other identification card issued by U.S. Citizenship and Immigration Services, US armed Forces card, non-drivers identification card, or Stated issued drivers licensed, passport, and US university identification card.
2. Clinical supervisor will begin auditing these elements in routine chart audits by 11/1/20 and reporting will begin to ensure clients in the MAT program are meeting the standards.
|
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
The facility failed to verify each individual's identity prior to the administration of an agent.Client #1 was admitted on July 9, 2020 and was initially prescribed buprenorphine on August 3, 2020. There was no documentation in client record #1 verifying the client's identity as there was no identification present.These findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
1. Upon first visit for a medication assisted treatment visit, the MAT nurse will verify an individual's identification if this has not already been done through the intake process through an acceptable US government issued ID, a US certificate of citizenship, US permanent resident other identification card issued by U.S. Citizenship and Immigration Services, US armed Forces card, non-drivers identification card, or Stated issued drivers licensed, passport, and US university identification card.
2. Clinical supervisor will begin auditing these elements in routine chart audits by 11/1/20 and reporting will begin to ensure clients in the MAT program are meeting the standards.
|