INITIAL COMMENTS
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This report is a result of an on-site inspection conducted for the approval to use a narcotic agent, specifically buprenorphine, in the residential detoxification from opioid dependence. This inspection was conducted on August 7, 2008 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Gaudenzia Erie Inc. Crossroads 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 September 5, 2008.
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Plan of Correction
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715.6(b)(1-9) LICENSURE Physician Staffing
(b) A narcotic treatment program may employ narcotic treatment physicians to assist the medical director. A narcotic treatment physician 's responsibilities include:
(1) Performing a medical history and physical exam.
(2) Determining diagnosis and determining narcotic dependence.
(3) Reviewing treatment plans.
(4) Determining dosage and all changes in doses.
(5) Ordering take-home privileges.
(6) Discussing cases with the treatment team.
(7) Issuing verbal orders pertaining to patient care.
(8) Assessing coexisting medical and psychiatric disorders.
(9) Treating or making appropriate referrals for treatment of these disorders.
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Observations
Based on a review of the administrative information on 8-7-08, the facility failed to document Narcotic Treatment Physician's responsibilities for the Medical Director and the three other narcotic treatment physicians.
Finding:
There was no documentation to demonstrate that the physicians had been made aware of the Narcotic Treatment Physician's responsibilities
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Plan of Correction
The Medical Director and the three Narcotic Treatment Physicians will sign job descriptions that outline all of their duties and responsibilities. The Division Director will ensure that there is always a current job description on file for the Medical Director and Narcotic Treatment Physicians. |
715.14(c) LICENSURE Urine testing
(c) A narcotic treatment program shall develop and implement policies and procedures to minimize misidentification of urine specimens and to ensure that the tested specimens can be traced to the donor.
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Observations
Based on a review of the policy and procedure manual on 8-7-08, the facility failed to provide the procedures for the process of the urine screens.
Finding:
The written procedures for the urine screen process failed to address labeling of the urine sample containers, bagging the urine sample containers and picking up the bagged urine sample containers.
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Plan of Correction
The Urine Testing Policy was updated on 8/28/08 to include the procedures for labeling, bagging and picking up the urine samples. The Division Director will ensure that policies are maintained and followed. |