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 July 15, 2010 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Mirmont Treatment Center was found not to be compliance with the applicable chapters of 28 PA Code which pertain to the facility. Deficiencies were identified during this inspection and a plan of correction is due on August 9, 2010.
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Plan of Correction
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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 and a staff interview, the facility failed to document information verifying the identity of the patient prior to the administration of an agent in 5 of 7 records.
The findings include:
Seven patient records were reviewed on July 15, 2010; all were reviewed for verification of patient identity prior to admission. Patient records # 1, 4, 5, 6 and 7 did not include verification of patient identity to include photo identification. In a staff interview, it was verified that facility policy required photo identification as verification of patient identity
prior to admission.
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Plan of Correction
The Admissions Director has developed a policy stating that each client admitted to Mirmont shall provide the following information to verify his/her identification: a picture ID with address and date of birth. He/she shall also provide an emergency contact's name and phone number. It the client cannot provide said picture ID, he/she will complete and sign a Photo Identification/Insurance Card Form. The completion of this form will be witnessed and signed by staff and filed in the consent section of the client chart. |
715.9(a)(4) 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:
(4) Have a narcotic treatment physician make a face-to-face determination of whether an individual is currently physiologically dependent upon a narcotic drug and has been physiologically dependent for at least 1 year prior to admission for maintenance treatment. The narcotic treatment physician shall document in the patient 's record the basis for the determination of current dependency and evidence of a 1 year history of addiction.
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Observations
Based on a review of patient records, the facility failed to provide documentation that the narcotic treatment physician made a face-to face determination of a patient's current drug and alcohol status and history in 7 of 7 records.
The findings include:
Patient records were reviewed on July 15, 2010; all were reviewed for documentation of a face-to-face assessment of history and current dependency by the narcotic treatment physician.
In patient records #1, 2, 3, 4, 5, 6 and 7, there was no documentation verifying that the narcotic treatment physician made a face-to-face determination of the patient's physiological dependence upon a narcotic drug. The documentation in the patient records indicated the Certified Registered Nurse Practitioner (CRNP) was assessing the patient and documenting the findings in the patient record. Only the physician may make this determination.
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Plan of Correction
The Medical Director has changed the Buprenorphine Detox Physicina/Nurse Review form to include documentation that the client has been physiologically dependent on a narcotic for at least 1 year. The above stated document has documentation of a face-to-face assessment of the history and current dependency of the client. The MD sahll document in the comment section of the form that he/she completed the face - to - face assessment of the history and current dependency of the client. The form shall now reside under the assessment section of the client chart instead of the physicina orders section, where it currently resides. |
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 narcotic treatment program failed to complete an initial drug-screening urinalysis for each patient in 7 of 7 patient records.
Findings:
Seven patient records were reviewed on July 17, 2010; all records were required to contain documentation of drug-screen urinalysis for the patient. A complete urine drug screen includes receiving the results from the CLIA and Department of Health approved laboratory. A review of the documentation revealed that the facility had utilized an instant urine drug screen test that did not have the required results provided by an approved laboratory.
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Plan of Correction
On admission of a client to Mirmont's Narcotic Treatment program, the admitting physician includes the ordering of an initial urine drug screen that is sent out to a laboratory approved by CLIA and the Department of Health. The results of the testing is placed under the laboratory section of the client chart after review/signature of the physician. Note: if the urine drug screen has several different components and the lab does not sned all the results at the same time, nursing will hold the test results on the unit until all components of the urine drug screens ahve been received before filinf them under the laboratory section in the client chart. |
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 of 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 7 of 7 records.
The findings include:
Seven patient records were reviewed on July 15, 2010; all were required to document a consult between the narcotic treatment physician determining the initial dose and the narcotic treatment physician performing the physical examination. Patients # 1, 2, 3, 4, 5, 6 and 7 were all initially seen by a CRNP who completed the patient examination. The physician issued an order to initiate narcotic treatment, however there was no record of consultation with the CRNP.
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Plan of Correction
The Medical Director has revised the Buprenorphine Detox Physician/Nurse Review form to include documentatin stating the Narcotic Treatment Physician has completed an examination of the client by the Narcotic Treatment Physician before determining the initial dose of the medication. |