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 Subutex, in the treatment of narcotic addiction. This inspection was conducted on July 1-2, 2013 by staff from the Program Licensure Division . Based on the findings of the on-site inspection, White Deer Run of York was found not to be in compliance with the applicable chapters of 4 PA Code and 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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715.17(c)(3)(i-v) LICENSURE Medication control
(c) A narcotic treatment program shall develop and implement written policies and procedures regarding the medications used by patients which shall include, at a minimum:
(3) Inspection of storage areas. A narcotic treatment program shall inspect all drug storage areas and the dispensing station at least quarterly to ensure that the areas are maintained in compliance with Federal, State and local laws and regulations. A narcotic treatment program shall develop and implement written policies and procedures regarding who performs the inspections, how often, and in what manner the inspections are to be documented. The policies and procedures shall include the following:
(i) Disinfectants and drugs for external use shall be stored separately from oral and injectable drugs.
(ii) Drugs requiring special conditions for storage to insure stability shall be properly stored.
(iii) Outdated and contaminated drugs shall be removed and destroyed according to Federal and State regulations.
(iv) Administration of controlled substances shall be documented.
(v) Controlled substances and other abusable drugs shall be stored in accordance with Federal and State regulations.
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Observations
Based on the review of administrative documentation, the facility failed to document quarterly inspections of the drug storage areas.
The findings include;
The pharmacy inspection reports were reviewed on July 1, 2013. The facility failed to document a quarterly inspection for the second quarter of 2013 (April, May and June).
This finding was confirmed by the Facility Director on July 1, 2013 at 3:09 p.m.
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Plan of Correction
At the time of each inspection, the Nurse Manager will schedule the next inspection with the vendor to ensure that it is completed within the required timeframe. Quarterly pharmacy inspections will be added to the checklist of the facility's other quarterly reports to ensure that it is accounted for each quarter by the Campus Director.
The most recent inspection was conducted on 7/21/2013. |
715.23(b)(24) LICENSURE Patient records
(b) Each patient file shall include the following information:
(24) Follow-up information regarding the patient.
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Observations
Based on the review of patient records, the facility failed to document the attempt or completion of patient follow up contact in five of seven patient records reviewed.
The findings include:
Eleven patient records were reviewed July 1-2, 2013. Seven patient records required documentation of an attempt or completion of a follow up contact. Per the facility's policy, if the patient is referred to another agency, within seven business days following the patient's continuing care appointment, staff will attempt to contact the provider to determine if the patient attended the scheduled appointment. All other discharges will have an attempt to contact the patient within 30 business days after discharge. The documentation in placed in the patient's medical record.
Patient # 4 completed treatment and was discharged on March 4, 2013. The follow-up contact was required within 30 days of discharge. There was no follow-up documented at the time of the inspection.
Patient # 7 left against facility advice on February 5, 2013. The follow-up contact was required within 30 days of discharge. There was no follow-up documented at the time of the inspection.
Patient # 8 completed treatment on February 6, 2013. An aftercare appointment was set up for February 14, 2013. Follow-up was required to be documented by February 21, 2013. There was no follow-up documented at the time of the inspection.
Patient #9 completed treatment on April 13, 2013. An aftercare appointment was set up for April 16, 2013. Follow-up was required to be documented by April 23, 2013. There was no follow-up documented at the time of the inspection.
Patient #10 left against facility advice on April 27, 2013. The follow-up contact was required within 30 days of discharge. There was no follow-up documented at the time of the inspection.
Patient #11 completed treatment on May 3, 2013. An aftercare appointment was set up for May 8, 2013. Follow-up was required to be documented by May 15, 2013. There was no follow-up documented at the time of the inspection.
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Plan of Correction
To ensure full compliance with the company policy regarding follow ups, the facility will implement the following:
1) Clinical staff will be trained on the company follow up policy and thier responsibility to submit a follow up form to the Office Manager no later than the date of discharge to conduct the follow up contact.
2) The Office Manager will implement a system to include a complete list of all clients discharged from the program and the results of thier follow up contacts. The Office Manager will notify the Campus Director if a client has discharged in the last 24 hours and a follow up form was not received from the clinical staff. Campus Director will assist in obtaining the proper documentation from the clinical staff so that the follow up contact is made. System will be implemented no later than 8/1/2013. Responsible Party: Office Manager, Campus Director
3) Monthly internal audits will be conducted by the Lead Counselor and Nurse Manager to ensure follow up forms are present in all charts in accordance with company policy. Audits will begin no later than August 1, 2013. Responsible Party: Nurse Manager, Lead Counselor |