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 treatment of narcotic addiction. This inspection was conducted on September 4 -5, 2013 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Retreat at Lancaster County - PA, LLC 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 patient records and discussion with administrative staff, the facility failed to obtain an initial drug-screening urinalysis prior to the initial dose in five of eight patient records as required.
The findings include:
Nine patient records were reviewed September 4-5, 2013. Eight prospective patients required a completed initial drug-screening urinalysis. Five patients did not have a completed initial drug-screening urinalysis prior to the initial dose.
Patient # 3 was admitted June 30, 2013. The patient was given an instant urinalysis on June 30, 2013. The urine was sent to the laboratory for completion July 1, 2013 and the results were returned July 3, 2013. The patient was initially dosed July 2, 2013, prior to the completion by the laboratory.
Patient # 5 was admitted June 14, 2013. The patient was given an instant urinalysis on June 14, 2013. The urine was sent to the laboratory for completion June 17, 2013 and the results were returned June 19, 2013. The patient was initially dosed June 16, 2013, prior to being sent for completion by the laboratory.
Patient # 8 was admitted August 16, 2013. The patient was given an instant urinalysis on August 16, 2013. The urine was sent to the laboratory for completion August 19, 2013 and the results were returned August 20, 2013. The patient was initially dosed August 17, 2013, prior to being sent for completion by the laboratory.
Patient # 5 was admitted June 26, 2013. The patient was given an instant urinalysis on June 26, 2013. The urine was sent to the laboratory for completion June 28, 2013 and the results were returned July 1, 2013. The patient was initially dosed June 27, 2013, prior to being sent for completion by the laboratory.
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Plan of Correction
Medical staff/physicians were trained and informed not to dose patients with bup until UDS is screened and reviewed and noted for a positive result for opiate substances - this will be monitored by the exec dir |
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 patient records, the narcotic treatment program failed to document the consultation between the narcotic treatment physician determining the initial dose and the narcotic treatment physician performing the physical examination in two patient records, as required. In addition, a patient record had a consultation statement dated prior to the physical and two patient records had the physical and consultation documented by a nurse and not a physician.
Findings
Nine patient records were reviewed September 4-5, 2013. Three patient records contained documentation of one physician conducting the physical exam and another determining the patient's initial dose and schedule.
Patient # 3 was admitted June 30, 2013. A physical exam was conducted July 1, 2013 by one physician and the patient's initial dose and schedule was written as a medication order by a second physician on July 2, 2013. There was no documentation of a consultation between the two narcotic treatment physicians.
Patient # 5 was admitted June 14, 2013. A physical exam was conducted June 17, 2013 by one physician, but the patient's initial dose and schedule was written as a verbal medication order by a second physician on June 16, 2013, prior to the physical exam. The initial dose and schedule included a statement that a consultation had taken place. However, the physical had not been done until after this statement.
Patient # 8 was admitted August 16, 2013. A physical exam was conducted August 17, 2013 and the patient's initial dose and schedule was written as a verbal medication order on August 16, 2013. The documentation was completed by a staff nurse. There was no documentation of who actually completed the physical exam. There was no documentation of a consultation prior to the determination of patient's dose and schedule for medication.
Patient records # 1 and 8 contained documentation by a nurse of the physical and the consultation and not by a physician. A physician was not identified as partaking in the physical and consultation.
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Plan of Correction
Medical staff were informed and trained to ensure there are consultation notes for those that provide the H/P and the dosing schedule. the consultation will occur after the History and Physical is completed. This will be monitored by the exec dir. |
715.17(b) LICENSURE Medication control
(b) A narcotic treatment program shall develop policies and procedures regarding verbal medication orders, including the issuing and receiving of orders, identifying circumstances when orders are appropriate and documenting orders, in accordance with applicable Federal and State statutes and regulations.
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Observations
Based on the review of patient records, the facility failed to ensure the physician signed the verbal order issued within 24 hours as required.
The findings include:
Nine patient records were reviewed September 4-5, 2013. Four patient records contained documentation of a physician's verbal orders.
Patient # 4 was admitted July 1, 2013. There was documentation of a verbal order on July 1, 2013 and another on July 3, 2013. Neither verbal order had been signed by the issuing physician.
Patient # 5 was admitted June 14, 2013. There were two verbal orders issued June 16, 2013. Neither were signed by the issuing physician.
Patient # 6 was admitted August 11, 2013. There was a verbal order issued August 11, 2013 that was not signed until September 4, 2013, more than 24 hours after the order was issued.
Patient # 8 was admitted August 16, 2013. There was a verbal order issued August 16, 2013 that was not signed until September 2, 2013, more than 24 hours after the order was issued.
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Plan of Correction
All verbal orders will be signed within 24 hours of the order. All medical staff were informed of this. The exec dir will review charts daily to ensure that all VO are signed in the proper time frame. |
709.17(a)(1) LICENSURE Subchapter B.Licensing Procedures.Refusal/rev
709.17. Refusal or revocation of license.
(a) The Department may revoke or refuse to issue a license for any of the following reasons:
(1) Failure to comply with a directive issued by the Department.
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Observations
Based on the review of unusual incident documentation and discussion with administration staff, the facility failed to file a written Unusual Incident Report with the Department within 24 hours by phone and 72 hours in writing as required.
The findings include:
Unusual incident reports documented by the facility were reviewed September 5, 2013. A discussion with the executive director occurred September 4, 2013 regarding the recent termination of an employee who was purported to have been involved in inappropriate contact with a patient. This was not reported to the Department as required.
A licensing alert directive was issued to all licensed facilities in May 1997 describing the the procedure for reporting to the Department.
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Plan of Correction
Incident report will be sent to the DDAP. Executive Dir understands that all incidents that are noted in regulations are to be fowarded to DDAP and will be monitored accordingly. |