INITIAL COMMENTS
|
This report is a result of an on-site inspection conducted for the approval to use a narcotic agent, specifically Buprenorphine, in the residential detoxification from opioid dependence. This inspection was conducted on November 13, 2013, through November 15, 2013, by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Malvern Institute for Psychiatric and Alcoholic Studies, Inc., 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.
|
Plan of Correction
|
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.
|
Observations
Based on a review of patient records, the facility failed to document a complete drug screen urinalysis based on the facility protocol provided to the Department.
The findings included:
Three patient records were reviewed November 13-15, 2013. All patient records were reviewed for a complete drug screen urinalysis prior to the administration of a narcotic agent.
The facility provided a request and was given permission for an exception to use a dipstick, or instant, procedure for drug screen urinalysis. The facility policy presented for the exception stated "(t)he nurse will Xerox a copy of the actual drug screen and place this in the patient's medical record. The Xerox copy must contain the patient's name, date for birth, date of screening, lot number and expiration date of the instant drug screen." Based on the approval for the exception, the facility was not documenting per their identified procedure.
The findings were reviewed and confirmed with the director of quality assurance.
|
Plan of Correction
Malvern's Waived Testing policy and procedure was revised to state "two nurses will verify the results for all instant urine drug screens and this verification will be documented in the patient's medical record. In addition the Urine Dip Test Results form was revised to include two signature spaces for the two nurses to verify.
All nurses will be trained in this revised policy and in the use of the revised form. Training will be completed by 12/10/13 and will be documented.
The Assistant Director of Nursing will conduct monthly medical record reviews to monitor that the verification of instant urine drug screens is being completed per the revised policy.
|
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.
|
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 one of three records.
The findings included:
Three patient records were reviewed on November 13 and 14, 2013. In patient record # 12, the narcotic treatment physician determining the initial dose documented a consult on November 11, 2013, at 9:00 AM. The physical examination was not documented until November 11, 2013, at 9:37 AM. The physical examination was documented after the consultation.
|
Plan of Correction
All physicians will be re-educated
on the requirement for the physical examination to be completed prior to ordering the first dose of buprenorphine. Additionally, all physicians will be educated
on the requirement for the physician
who is ordering the first dose of
Bupronorphine to consult with the
physician who completed the
physical examination prior to ordering the first dose. This
physician education will be completed by
12/10/13 and will be
documented.
The Assistant Director of
Nursing will conduct monthly medical record reviews to
ensure the following:
--the physical examination is completed prior to the ordering of the first dose of buprenorphine
--the consultation is comleted between the ordering physician and the physician
completing the physical examination
These medical record reivews will begin with new admissions starting on 12/10/13. |