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 residential detoxification from opioid dependence. This inspection was conducted on September 11-12, 2012 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 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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715.9(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
Based on the review of patient records, the facility failed to document verification the patient and reached the age of 18 in one of ten patient records.
The findings include:
Ten patient records were reviewed September 11-12, 2102. All patient records were reviewed for documentation of verification of eligibility for services. The facility failed to verify that the patient reached the age of 18 in patient record # 8.
An interview with the facility director confirmed this finding.
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Plan of Correction
Pt did not have her ID which was documented. In the future, all patients will be asked to provide documentation other than photo license to verify age if they do not have ID. A letter from a family member stating the patient is who they say they are and their DOB will be accepted. In addition, we will accept birth certificates as well. Every patients' ID will be verified in some fashion and documented in the medical record system. The Director of Admissions will inform all Admissions staff of this process and ensure this occurs. This will be overseen by the Executive Director |
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
Based on the review of patient records, the facility failed to verify the patient's identity including the name, address, date of birth, emergency contact and other identifying data prior to the administration of an agent in one of ten patient records.
The findings include:
Ten patient records were reviewed on September 11-12, 2012. All patient records were specifically reviewed for patient identity information. Patient record # 8 did not contain documentation confirming the patient's identity prior to administration of an agent, specifically Subutex.
Patient # 8 was admitted on September 2, 2012. They received their first dose of Subutex on September 3, 2012. The record did not include any patient identity information.
The findings were confirmed by the facility director and were not disputed.
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Plan of Correction
ID for every patient will be confirmed with - photo ID, Driver license, letter from home, electric bill or other type of bill with name and address. Documentation of ID will be provided in the medical system. Director of Admissions will inform all Admissions staff of this process. Executive Director will ensure this occurs for every patient. |
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, the program failed to complete an initial drug-screening urinalysis in eight of nine records.
The findings include:
Ten patient records were reviewed on September 11-12, 2012. The program used an instant urine drug screen test result prior to the administration of a narcotic, specifically Subutex, in patient records #1, 2, 3, 5, 6, 7, 8, and 9. This is not a Clinical Laboratory Improvement Amendments of 1998 (CLIA) approved laboratory. The facility did obtain urinalysis test results from the laboratory after the patient's initial dose.
Patient # 1 was admitted on August 16, 2012. The patient had an instant drug screen completed on August 16, 2012. The CLIA approved test results were received by the facility on August 17, 2012 at 6:09 p.m. The patient received their first dose of Subutex on August 17, 2012 at 7:00 a.m., prior to receiving the results from the laboratory.
Patient # 2 was admitted on September 7, 2012. The patient had an instant drug screen completed on September 7, 2012. The CLIA approved test results were received by the facility on September 10, 2012 at 9:42 p.m. The patient received their first dose of Subutex on September 10, 2012 at 7:00 a.m., prior to receiving the results from the laboratory.
Patient # 3 was admitted on September 6, 2012. The patient had an instant drug screen completed on September 6, 2012. The CLIA approved test results were received by the facility on September 7, 2012 at 6:11 p.m. The patient received their first dose of Subutex on September 7, 2012 at 6:39 a.m., prior to receiving the results from the laboratory.
Patient # 5 was admitted on August 28, 2012. The patient had an instant drug screen completed on August 29, 2012. The CLIA approved test results were received by the facility on August 29, 2012 at 6:18 p.m. The patient received their first dose of Subutex on August 29, 2012 at 1:57 p.m., prior to receiving the results from the laboratory.
Patient # 6 was admitted on July 18, 2012. The patient had an instant drug screen completed on July 18, 2012. The CLIA approved test results were received by the facility on July 19, 2012 at 7:09 p.m. The patient received their first dose of Subutex on July 19, 2012 at 1:01 p.m., prior to receiving the results from the laboratory.
Patient # 7 was admitted on August 29, 2012. The patient had an instant drug screen completed on August 29, 2012. The CLIA approved test results were received by the facility on August 30, 2012 at 6:30 p.m. The patient received their first dose of Subutex on August 30, 2012 at 12:57 p.m., prior to receiving the results from the laboratory.
Patient # 8 was admitted on September 2, 2012. The patient had an instant drug screen completed on September 2, 2012. The CLIA approved test results were received by the facility on September 5, 2012 at 6:16 p.m.. The patient received their first dose of Subutex on September 3, 2012 at 1:05 p.m., prior to receiving the results from the laboratory.
Patient # 9 was admitted on August 6, 2012. The patient had an instant drug screen completed on August 6, 2012. The CLIA approved test results were received by the facility on August 8, 2012 at 7:15 p.m. The patient received their first dose of Subutex on August 7, 2012 at 7:56 p.m., prior to receiving the results from the laboratory.
These findings were discussed with the facility director and were not disputed.
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Plan of Correction
UDS will be conducted upon admission and sent to the lab. Subutex will not begin until results are posted from the lab. All nursing and medical staff are informed of this process. Executive Director will ensure this occurs going forward via chart checks on a daily basis. |
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 the review of patient records, the facility failed to document a consultation took place between the physician who determined the initial dose and the physician who completed the physical examination in two of two records.
The findings include:
Ten patient records were reviewed September 11-12, 2012. Two records reviewed were required to document a consultation took place between the narcotic treatment physician who completed the patient's physical examination and the narcotic treatment physician who determined the patient's initial dose and schedule. A review of the documentation revealed the narcotic treatment physician who completed the history and physical examination was not the narcotic treatment physician who determined the patient's initial and subsequent dose in patient records # 1 and 2.
Patient # 1 was admitted August 16, 2012. Employee # 1 documented the patient's history and physical examination on August 17, 2012. Employee # 2 determined the patient's initial dose and schedule at 8:17 a.m. on August 17, 2012. Employee # 2 failed to document that he consulted with employee # 1 who completed the history and physical examination on the patient. The patient received their first dose of 8 mg of Subutex at 7:00 a.m. August 17, 2012.
Patient # 2 was admitted September 7, 2012. Employee # 1 documented the patient's history and physical examination on September 10, 2012 at 8:42 a.m.. Employee # 2 determined the patient's initial dose and schedule on September 8, 2012 at 11:20 a.m.. Employee # 2 determined the patient's dose and schedule prior to the patient's physical examination and was unable to document a consultation took place. The patient received their first dose of 4 mg of Subutex on September 10, 2012 at at 6:39 a.m., prior to the patient examination being complete.
This finding was discussed with the facility director and was not disputed.
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Plan of Correction
A medical team meeting will be held to discuss the importance and the requirement for documentation of consults between 2 different physicians that are involved with patients on subutex protocols. If a physician does the HnP and a different phys does the prescribing of Subutex, then a note will be entered into the medical record system documenting this. This will be ensured by the Executive Director via Medical Team meetings and chart checks done weekly. |
715.15(f) LICENSURE Medication dosage
(f) The narcotic treatment program shall develop written policies and procedures relating to narcotic treatment medication dosage which includes the requirements of subsections (a)--(e).
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Observations
Based on the review of the facility's policy and procedures, the facility failed to have a policy in place for the procedures relating to narcotic treatment medication dosage which includes how 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.
The findings include:
The facility's policy and procedures were reviewed on September 11, 2012. The facility failed to have a policy and procedure in place for how 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.
This finding was discussed with the facility director and was not disputed.
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Plan of Correction
A medical team meeting will be held to discuss dosing schedule and following a prescribed and determined protocol for buprenorphine. Protocols will be established and all physicians will be expected to follow and suscribe to it. Anytime there is more than one physician involved in prescribing a pt this protocol, a note will be entered into the medical record system to ensure documentation of the consultation. Policy will be updated to reflect this process. Executive Director will oversee this process and ensure compliance via medical team meetings and weekly chart checks. |
715.20 LICENSURE Patient transfers
A narcotic treatment program shall develop written transfer policies and procedures which shall require that the narcotic treatment program transfer a patient to another narcotic treatment program for continued maintenance, detoxification or another treatment activity within 7 days of the request of the patient.
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Observations
Based on the review of the facility's policy and procedures, the facility failed to have a policy in place for the transfer of a patient to another narcotic treatment program for continued maintenance, detoxification or another treatment activity within 7 days of the request of the patient.
The findings include:
The facility's policy and procedures were reviewed on September 11, 2012. The facility failed to have a policy and procedure in place for the transfer of a patient to another narcotic treatment program for continued maintenance, detoxification or another treatment activity within 7 days of the request of the patient.
This finding was reviewed with the facility director and was not disputed.
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Plan of Correction
Policy regading patient transfers to another buprenorphine treatment program has been updated to ensure that patients may be transferred at their requests. All staff were notified of this policy update by the Executive Director. Exec Dir will ensure this policy is followed by all staff members at all times |
709.91(b)(5) LICENSURE Intake and admission
709.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(5) Physical examination, if applicable.
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Observations
Based on the review of patient records, the facility failed to document a patient physical examination that included the patient's general appearance and vital signs in 9 of 9 records reviewed.
The findings include:
Ten patient records were reviewed on September 11-12, 2012. Nine records were reviewed for a physical examination that included documentation of the patient's general appearance and vital signes. The facility failed to document the general appearance and vitals signs on the physical examination in patient records # 1, 2, 3, 4, 5, 6, 7, 8, and 9.
This finding was discussed with the facility director and was not disputed.
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Plan of Correction
The history and physical document has been updated to include General Appearance and Vital Signs for all patients that are seen prior to buprenorphine dosing. All medical staff are made aware of the change and understand it must be completed. Executive Director will ensure compliance via weekly chart checks. |