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 23-24, 2012 by staff from the Division of Drug and Alcohol Program Licensure. 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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715.14(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 a review of the patient records, the facility failed to ensure that the patient was dosed following the completion of an initial drug-screen urinalysis.
The findings include:
Ten patient records were reviewed on July 23-24, 2012. All records required drug-screen urinalysis prior to the patient being dosed with Subutex. One of ten records failed to document that the narcotic treatment physician reviewed the urinalysis results prior to receiving their first dose.
Patient # 5 was admitted into treatment on April 25, 2012. Patient # 5 received a dose of 4 mg of Subutex on April 25, 2012 at 22:00 hours. The documented results of the urinalysis indicated that the report was reviewed by the doctor at 22:05 hours on April 25, 2012. There was no additional documentation that verified that the urinalysis results were reviewed prior to the administration of Subutex.
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Plan of Correction
The Nursing Coordinator will provide training by August 30, 2012, to all physicians regarding the requirement to review drug-screen urinalysis results prior to the patient being dosed with Subutex and the necessity to accurately document the time that the review is completed. The Nursing Coordinator will conduct quality assurance reviews on a weekly basis to ensure physicians are following this requirement and documenting accurately. |
715.17(c)(6)(i-iv) 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:
(6) Inventories. A narcotic treatment program shall conduct monthly inventories of agents and other controlled substances stored. Each inventory record shall include:
(i) The date the inventory was conducted.
(ii) The time of day it was conducted.
(iii) The name and amount of each product on hand at the time of the inventory.
(iv) The name of the individual conducting the inventory.
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Observations
Based on the review of the medication inventories, the facility failed to document the date and on the inventory forms and failed to follow their policy.
The findings include:
The facility's policy and procedures were reviewed on July 23, 2012. According to the facility's policy, the Subutex tabs will be reconciled to a physical count of the remaining tabs by at least two persons (the off-going and on-coming nurse). The count shall be maintained on the Narcotic Count Sheet. The medication inventory was reviewed on July 24, 2012 at approximately 9:15 a.m. Twelve narcotic count sheets were reviewed. Ten of the twelve count sheets failed to include dates which made it difficult to determine the dates on the sheet. Eight entries failed to have two nurses signatures. One entry failed to have the inventory documented.
The inventory conducted on the day shift of May 11, 2012 failed to have the off-going night shift nurse's signature on the inventory sheet.
The inventory conducted on the evening of May 16, 2012 failed to have the signature from the off-going day shift nurse documented on the inventory sheet.
The inventory conducted on May 18, 2012 failed to have the off-going nurse's signature from the evening shift on May 17, 2012 with the on-going night shift nurse's signature. Additionally, the off-going nurse for the day shift failed to sign the inventory with the on-coming evening nurse's signature on May 18, 2012.
The inventory conducted on May 25, 2012 failed to have the off-going day shift nurse's signature documented with the on-coming evening nurse's signature.
The inventory conducted on May 28, 2012 failed to have the off-going day shift nurse's signature documented with the on-coming evening nurse's signature.
The inventory conducted on July 14, 2012 failed to have two signatures for the night shift. The off-going nurse from their evening shift on July 13, 2012 failed to sign the inventory sheet.
The inventory conducted on July 24, 2012 failed to include a signature for the on-coming day shift nurse. The entry also did not include the amount of Subutex that was on hand at the change of shift.
These findings were reviewed with the director of nursing and was not disputed.
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Plan of Correction
The inventory log has been revised to include dates for every entry. The Nursing Coordinator will provide training to all nursing staff by August 25, 2012, regarding the facility policies and procedures as well as the regulatory requirements for conducting inventory. The Nursing Coordinator will conduct quality assurance audits on a weekly basis of the inventory log and promptly address any deficiencies that occur within a timely manner. |
709.32(b) LICENSURE Medication Control
709.32. Medication control.
(b) Verbal medication orders may be accepted but shall be put in writing and signed within 24 hours thereafter by the prescribing physician.
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Observations
Based on a review of the policy and procedure manual and patient records, the facility failed to ensure that verbal medication orders were put in writing and signed with 24 hours thereafter by the prescribing physician, as required by regulations, in two of two patient records.
The findings include:
Ten patient records were reviewed on July 23-24, 2012. All verbal medication orders are required to be signed within 24 hours by the prescribing physician. Patient records # 2 and 6 contained documentation of a verbal medication order that was not signed by the prescribing physician within 24 hours.
Patient record # 2 had verbal standing orders documented on July 20, 2012 from employee # 2. Employee # 3 signed off on employee # 2's verbal order on July 21, 2012. Employee # 3 was not the prescribing physician for the verbal orders.
Patient record # 6 had verbal standing orders documented on May 2, 2012 from employee # 2. Employee # 2 signed off on the verbal orders, however, they failed to date their signature. There was no way to determine whether the verbal order was signed off within the required 24 hours. The record also contained another a verbal order from employee # 2 on on May 2, 2012. The order stated for the patient to have Lisinopril 20 mg, take one tablet PO Daily. Employee # 2 signed off on this verbal order, however, they failed to date their signature. There was no way to determine whether the verbal order was signed off within the required time frame. Additionally, employee # 3 signed off on these verbal orders, however, they were not the prescribing physician.
These findings were reviewed with the Director of Nursing and were not disputed.
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Plan of Correction
The Nursing Coordinator will provide training to all physicians and nurses by August 25, 2012, regarding the regulatory requirement to ensure that the prescribing physician signs and dates all verbal orders within 24 hours. Procedures will be modified to require the nurse receiving the verbal order to immediately fax such order to the prescribing physician for signature and date. The night shift nurse will conduct daily chart audits to ensure that all verbal orders have received signatures and dates from prescribing physicians and will promptly notify the Nursing Coordinator of any outstanding signatures so that they may be obtained within the required timeframe. |