INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on May 16-17, 2016 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Butler Regional Recovery Day Program was found not to be in compliance with the applicable chapters of 28 PA Code which pertain to the facility.
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Plan of Correction
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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.
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Observations
The facility failed to document verification the individual has reached 18 years of age in three of three buprenorphine patient records reviewed during the course of the annual inspection on May 16 - 17, 2016.
Patient records, #11, #12 and #13, did not include the documentation of age verification.
Patient #11 was admitted on May 5, 2016.
Patient #12 was admitted on November 24, 2015
Patient #13 was admitted on December 29, 2015.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Intake personnel will be immediately advised to make a copy of a government issued photo ID with birthdate during the initial assessment appointment by to verify age. For current patients a copy of a government photo with birthdate will be collected at the next face to face interaction. Clinical Supervisor will review records for three months to verify compliance. |
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
The facility failed to document verification of the patient's identity in three of three buprenorphine patient records reviewed during the course of the annual inspection on May 16 - 17, 2016.
Patient records, #11, #12 and #13, did not include the documentation of the patient identity.
Patient #11 was admitted on May 5, 2016.
Patient #12 was admitted on November 24, 2015
Patient #13 was admitted on December 29, 2015.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Intake personnel will be advised immediately to make a copy of a photo ID with name, address and birthdate during the initial suboxone assessment appointment to verify identity. Identification will be obtained on current patients at the next face to face interaction. Emergency contact release of information will be obtain on all current patients at next face to face. Emergency contact releases of information will be obtained at initial assessment appointments. Clinical Supervisor will review records for three months to verify compliance. |
715.9(a)(4) 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:
(4) Have a narcotic treatment physician make a face-to-face determination of whether an individual is currently physiologically dependent upon a narcotic drug and has been physiologically dependent for at least 1 year prior to admission for maintenance treatment. The narcotic treatment physician shall document in the patient 's record the basis for the determination of current dependency and evidence of a 1 year history of addiction.
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Observations
The facility failed to document the narcotic treatment physician made a face-to-face determination of currently physiological dependence upon a narcotic drug and had been physiologically dependent for at least 1 year prior to admission for maintenance treatment in three of three buprenorphine patient records reviewed during the course of the annual inspection on May 16 - 17, 2016.
Patient records, #11, #12 and #13, did not include the documentation.
Patient #11 was admitted on May 5, 2016.
Patient #12 was admitted on November 24, 2015
Patient #13 was admitted on December 29, 2015.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Clinical Supervisor will advise Physician immediately of the need to document the face to face and certify the 1 yr of narcotic dependency immediately. A progress note will be immediately placed in all the current patients files to this effect. A progress note will also be place in all new patients admitted to the suboxone program confirming the face to face and the 1 yr of narcotic dependency. A form reviewing the face to face and 1 yr certification will be created by Clinical Supervisor by 6/15/16 to ensure compliance for the regulation. Clinical Supervisor will complete 3 mos of record review to monitor compliance. |
715.10(f) LICENSURE Pregnant patients
(f) The narcotic treatment program shall ensure that each female patient is fully informed of the possible risk to her or her unborn child from continued use of illicit drugs and from use of, or withdrawal from a narcotic drug administered or dispensed by the program in comprehensive maintenance or detoxification treatment.
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Observations
The facility failed to document each female patient was fully informed of the possible risk to her and her unborn child in three of three buprenorphine patient records reviewed during the course of the annual inspection on May 16 - 17, 2016.
Three buprenorphine patient records, #11, #12 & #13, were female patients and did not include the documentation.
Patient #11 was admitted on May 5, 2016.
Patient #12 was admitted on November 24, 2015.
Patient #13 was admitted on December 29, 2015.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Clinical Supervisor will add the pregnancy/unborn child education to the teaching sheet given to all patients about the various risks/side effects of buprenorphine treatment. Confirmation that the education was received by the patient will be added to the program agreement. This will be concluded by the Clinical Supervisor immediately. All current female patients will be given the education teaching sheet immediately. The patient will sign a confirmation sheet that it has been received. |