INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on February 9, 2016 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, SPHS Behavioral Health 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.
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Plan of Correction
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709.28(c) LICENSURE Confidentiality
709.28. Confidentiality.
(c) The project shall obtain an informed and voluntary consent from the client for the disclosure of information contained in the client record. The consent shall be in writing and include, but not be limited to:
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Observations
Based on a review of client records, the facility failed to obtain a written, informed and voluntary consent from the client prior to the disclosure of information contained in the client record in four of ten client records.
The findings include:
Ten client records were reviewed on February 9, 2016. Ten client records were required to include documentation of written, informed and voluntary consents from the client. The facility failed to obtain a written, informed and voluntary consent from the client prior to disclosing information contained in the client record in records # 1, 2, 3 and 4.
Client # 1 was admitted into treatment on September 14, 2015. The client's name, diagnosis and request for prescription authorization was faxed to the insurance company on September 24, 2015. There was no documentation of a written consent to release information to this insurance company in client record # 1, as of February 9, 2016.
Client # 2 was admitted into treatment on June 29, 2015. The client's name, diagnosis and request for prescription authorization was faxed to the insurance company on the following dates: 7/10/15, 1/14/16 and 2/4/16. There was no documentation of a written consent to release information to this insurance company in client record # 2, as of February 9, 2016.
Client # 3 was admitted into treatment on January 15, 2015. The client's name, diagnosis and request for prescription authorization was faxed to the insurance company on the following dates: 5/14/15, 6/15/15, 9/1/15, 10/14/15 and 1/21/16 . There was no documentation of a written consent to release information to this insurance company in client record # 3, as of February 9, 2016.
Client # 4 was admitted into treatment on March 4, 2015 and discharged on August 25, 2015. The client's name, diagnosis and request for prescription authorization was faxed to the insurance company on March 19, 2015. There was no documentation of a written consent to release information to this insurance company in client record # 4, as of February 9, 2016.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
A mandatory staff meeting will be held with all staff to review regulations and guidelines when completing consents to release information. There will be a particular focus on making sure that releases are obtained for medical departments of insurance when obtaining authorization for medication. The clinical supervisor will hold the staff meeting. In addition, staff members who were responsible for charts 1, 2, 3, and 4 will obtain proper consents for those clients where it is appropriate. To assure staff members are improving in this area internal chart reviews and supervision will take place by the Clinical Supervisor. This will occur no later than 3/31/16. |
715.9(a) 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:
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Observations
Based on review of patient records, the facility failed to document a complete initial drug screening urinalysis prior to the administration of buprenorphine, a narcotic agent, and a random urinalysis at least monthly thereafter in five of five patient records.
The findings include:
Ten client records were reviewed on February 9, 2016. Five patients were prescribed buprenorphine. Five patients were required to complete a drug screen urinalysis prior to the administration of buprenorphine, a narcotic agent and at least monthly thereafter. A complete drug screen urinalysis includes receiving the results from the CLIA and Department of Health approved laboratory. The facility failed to document a complete drug screen urinalysis prior to the administration of buprenorphine, a narcotic agent and monthly thereafter in records # 1, 2, 3, 4 and 5.
Patient # 1 was admitted into treatment on September 14, 2015. Patient # 1 was prescribed 8 mg/2 mg buprenorphine twice daily on September 24, 2015. An initial drug screen was completed by the facility using an onsite urine drug screen cup on September 24, 2015. However, there was no documentation the initial drug screen was sent out to a laboratory for urinalysis. The facility completed monthly drug screens using an onsite urine drug screen cup in October 2015, December 2015 and January 2016. There was no documentation these monthly drug screens were sent out to a laboratory for urinalysis. One monthly drug screen was sent out to a laboratory for urinalysis on November 19, 2015.
Patient # 2 was admitted into treatment on June 29, 2015. Patient # 2 was prescribed 8 mg/2 mg buprenorphine daily on August 6, 2015. An initial drug screen was completed by the facility using an onsite urine drug screen cup on August 6, 2015. However, there was no documentation the initial drug screen was sent out to a laboratory for urinalysis. The facility completed monthly drug screens using an onsite urine drug screen cup in September 2015, October 2015 and December 2015. There was no documentation these monthly drug screens were sent out to a laboratory for urinalysis. Two monthly drug screens were sent out to a laboratory for urinalysis on November 5, 2015 and January 14, 2016.
Patient # 3 was admitted into treatment on January 15, 2015. Patient # 3 was prescribed 8 mg/2 mg buprenorphine daily on January 20, 2015. An initial drug screen was completed by the facility using an onsite urine drug screen cup on January 20, 2015. However, there was no documentation the initial drug screen was sent out to a laboratory for urinalysis. The facility completed monthly drug screens using an onsite urine drug screen cup in February 2015, April 2015, May 2015, June 2015, July 2015, August 2015, September 2015, October 2015 and January 2016. There was no documentation these monthly drug screens were sent out to a laboratory for urinalysis. Three monthly drug screens were sent out to a laboratory for urinalysis on March 13, November 10 and December 1, 2015.
Patient # 4 was admitted into treatment on March 4, 2015 and discharged on August 25, 2015. Patient # 4 was prescribed 8 mg/2 mg buprenorphine daily on March 19, 2015. An initial drug screen was completed by the facility using an onsite urine drug screen cup on March 19, 2015. However, there was no documentation the initial drug screen was sent out to a laboratory for urinalysis. The facility completed monthly drug screens using an onsite urine drug screen cup in April 2015, May 2015, June 2015 and July 2015. There was no documentation these monthly drug screens were sent out to a laboratory for urinalysis.
Patient # 5 was admitted into treatment on October 12, 2015 and discharged on February 4, 2016. Patient # 5 was prescribed 8 mg/2 mg buprenorphine daily on November 12, 2015. . The facility completed monthly drug screens using an onsite urine drug screen cup in November 2015, December 2015 and January 2016. There was no documentation these monthly drug screens were sent out to a laboratory for urinalysis. The initial drug screen was the only one sent out to a laboratory for urinalysis.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
A mandatory staff meeting will be held with all clinical and psychiatric staff to review the regulations and guidelines for buprenorphine. There will be a particular focus on the requirement of sending a urinalysis drug screen to a lab prior to the initial administration of buprenorphine and at least monthly thereafter rather than the typical onsite drug test. The clinical supervisor will hold the staff meeting. To assure that all staff members are abiding by the process the supervisor will review records. This will occur no later than 3/31/16. |