INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on May 11, 2015 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Familylinks, Inc 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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704.6(a) LICENSURE Clinical Supervisor Qualifications
704.6. Qualifications for the position of clinical supervisor.
(a) A drug and alcohol treatment project shall have a full-time clinical supervisor for every eight full-time counselors or counselor assistants, or both.
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Observations
Based on a review of Staffing Requirements Facility Summary Reports, the project failed to have a full-time clinical supervisor for every eight full-time counselors, counselor assistants or both.
The findings include:
The Staffing Requirements Facility Summary Reports for all three facilities were reviewed on May 13, 2015. There are 8.49 full time counselors project-wide, including all three facilities. As of the date of the inspections, the full-time clinical supervisor position is vacant.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Senior Program manager of AOD Services and Director of Behavioral Health are responsible for hiring the Clinical Supervisor. The compliance date should be 7.6.15. |
705.28 (d) (1) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(1) Conduct unannounced fire drills at least once a month.
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Observations
Based on a review of fire drill logs, the facility failed to conduct unannounced fire drills at least once a month and maintain a fire drill log which includes the exit route used.
The findings include:
The fire drill logs were reviewed on May 11, 2015. The period of June 2014 - May 2015 was reviewed. Unannounced fire drills are required to be conducted at least monthly and all fire drill logs are required to include the exit route used.
The fire drills conducted for the months of January, February and March 2015 did not include documentation of the exit route used. Also, there were no fire drills conducted for the months of June, October and December 2014 and April 2015.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
AOD-OP, Program Manager will conduct unannounced fire drills monthly and the exit route used and time log will be recorded and kept on site. |
715.14(a) LICENSURE Urine testing
(a) A narcotic treatment program shall complete an initial drug-screening urinalysis for each prospective patient and a random urinalysis at least monthly thereafter.
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Observations
Based on review of the patient records, the facility failed to obtain a complete drug screen urinalysis prior to the administration of buprenorphine, a narcotic agent. A complete drug screen includes receiving the results from the CLIA and Department of Health approved laboratory.
The findings include:
Four buprenorphine patient records were reviewed on May 11, 2015. All four patients were required to complete a drug screen urinalysis prior to the administration of buprenorphine, a narcotic agent. A complete urine drug screen includes receiving the results from the CLIA and Department of Health approved laboratory. The facility failed to obtain a complete drug screen urinalysis prior to the administration of buprenorphine, a narcotic agent in records # 1, 2, 3 and 7.
Patient #1 was admitted on 4/7/15 and received their first dose of buprenorphine on that same day. The patient provided their initial urine drug screen on 4/7/15; however, the facility did not receive the results until 4/10/15, after the initial dose was given.
Patient #2 was admitted on 4/7/15 and received their first dose of buprenorphine on that same day. The patient provided their initial urine drug screen on 4/7/15; however, the facility did not receive the results until 4/10/15, after the initial dose was given.
Patient #3 was admitted on 7/22/14 and received their first dose of buprenorphine on that same day. The patient provided their initial urine drug screen on 7/22/14; however, the facility did not receive the results until 8/7/14, after the initial dose was given.
Patient #7 was admitted on 9/9/14 and received their first dose of buprenorphine on that same day. The patient provided their initial urine drug screen on 9/9/14; however, the facility did not receive the results until 9/12/14, after the initial dose was given.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Medical staff will submit all urine drug screens to a laboratory for testing and analysis before prescribing buprenorphine treatment. |
715.15(b) LICENSURE Medication dosage
(b) The narcotic treatment physician shall determine the proper dosage level for a patient, except as otherwise provided in this section. If the narcotic treatment physician determining the initial dose is not the narcotic treatment physician who conducted the patient examination, the narcotic treatment physician shall consult with the narcotic treatment physician who performed the examination before determining the patient 's initial dose and schedule.
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Observations
Based on a review of patient records, the facility physician failed to adhere to the dosing protocol listed on the medication by ordering that single dose buprenorphine film be cut in one of four patient records. The medication packaging identifies this as a single dose medication.
The findings include:
Four buprenorphine patient records were reviewed on May 11, 2015. In patient record #7, the physician prescribed eleven Suboxone 8 mg/2 mg SL film, to last a period of seven days. This began on September 10, 2014 and lasted until the patient's discharge on December 4, 2014. This prescription would require that the patient would cut the film into smaller doses.
Suboxone film is not formulated to be cut into smaller doses. Prescriptions need to be for the manufactured quantities of 12 mg/3 mg, 8 mg/2 mg, 4 mg/1 mg or 2 mg/.5 mg doses.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
medical director will ensure Buprenorphine and combination buprenorphine/naloxone pills and films will be prescribed in full (not split) dosages. Titrations, tapers, and maintenance therapies will occur in this manner. |