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 Suboxone, in the residential detoxification from opioid dependence. This inspection was conducted on September 17- 18, 2012 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 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)(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 the review of clinical documentation, the facility physician failed to accurately document the basis for determining current opiate dependency in two of eight patient records.
The findings include:
Eight patient records were reviewed on September 17-18, 2012. Eight patient records were required to document the physicians' documentation of the basis for determining current opiate dependency. Two patient records failed to include documentation by the physician determining the basis for current opiate dependency, specifically records # 5 and 7.
Record #5 - Patient was admitted on 7-9-2012. The physician failed to document what information he used to determine the patient's current dependency.
Record #7 - Patient was admitted on 6-6-2012. The physician failed to document what information he used to determine the patient's current dependency.
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Plan of Correction
The Medical Director met with the NTP physicians on 10/10/2012 at the Medical Meeting to implement a new procedure that requires the NTP physician to clearly document under the "comments" section of the NTP MD/Nurse form their basis for determining the criteria for the patient's curent opiate dependency and eligibility for admission to the NTP program.
The PI department or nurse designee will monitr compliance and provide the Medical Director and Nurse Manager with a monthly compliance report. |
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 that a consultation took place between the physician who determined the initial dose and the Physician Assistant who completed the physical examination in five of eight records.
The findings include:
Eight patient records were reviewed September 17-18, 2012. Five records were reviewed for documentation that a consultation took place between the narcotic treatment physician and the Certified Registered Nurse Practitioner (CRNP) prior to the physician's determination of the patient's initial dose and schedule. Five of eight records had documented consultations, however, the physical examination was not completed prior to the face to face with the physician. The facility has a form that is specifically used to document the findings of the physician's face to face assessment of the patient as well as documenting that a consult took place between the physician who determined the initial dose and the physician or Certified Registered Nurse Practitioner (CRNP) who performed the physical examination. A review of the documentation revealed that, while the physician documented the face to face was complete and determined the patient's initial dose, the patient's physical examination had not yet been completed in records # 1, 2, 6, 7, and 8.
Patient # 1 was admitted 9/13/2012. The CRNP completed the history and physical examination on the patient on 9/14/2012 at 3:50 p.m. The doctor documented a face to face with the patient on 9/13/2012 at 4:45 p.m. The doctor checked "yes" next to the statement, "If you as the prescribing physician did not complete the PE (physical examination), have you consulted with the clinician that completed the PE?" However, the history and physical examination were not completed at the time this document was completed. The patient received their first dose of Suboxone on 9/14/2012 at 10:30 a.m.
Patient #2 was admitted on 9/13/2012. The CRNP completed the history and physical examination on the patient on 9/14/2012 at 3:12 p.m. The face to face was documented by the doctor on 9/14/2012 at 9:25 a.m. The doctor checked "yes" next to the statement, "If you as the prescribing physician did not complete the PE (physical examination), have you consulted with the clinician that completed the PE?" However, the history and physical examination were not completed at the time this document was completed. The patient received their first dose of Suboxone on 9/14/2012 at 10:00 a.m.
Patient # 6 was admitted on 9/15/2012 and discharged on 9/16/2012. The face to face was documented by the doctor on 9/15/2012 at 2:10 p.m. The doctor checked "yes" next to the statement, "If you as the prescribing physician did not complete the PE (physical examination), have you consulted with the clinician that completed the PE?" However, the history and physical examination were not completed at the time this document was completed. The patient received their first dose of Suboxone on 9/15/2012 at 5:00 p.m. There was no history and physical examination documented in the patient record.
Patient # 7 was admitted on 6/6/2012. The CRNP completed the history and physical examination on the patient on 6/7/2012 at 12:00 p.m. The face to face was documented by the doctor on 6/7/2012 at 10:00 a.m. The doctor checked "yes" next to the statement, "If you as the prescribing physician did not complete the PE (physical examination), have you consulted with the clinician that completed the PE?" However, the history and physical examination were not completed at the time this document was completed. The patient received their first dose of Suboxone on 6/7/2012 at 10:00 a.m.
Patient # 8 was admitted on 5/30/2012. The CRNP completed the history and physical examination on the patient on 5/31/2012 at 11:30 a.m. The face to face was documented by the doctor on 5/31/2012 at 11:10 a.m. The doctor checked "yes" next to the statement, "If you as the prescribing physician did not complete the PE (physical examination), have you consulted with the clinician that completed the PE?" However, the history and physical examination were not completed at the time this document was completed. The patient received their first dose of Suboxone on 5/31/2012 at 11:20 a.m.
This finding was confirmed by facility staff and was not disputed.
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Plan of Correction
The Medical Director implemented a procedure at the Medical meeting held 10/10/2012 that states the NTP physician may not complete the face-to-face to determine the proper initial dosing of a patient until the history and physical has been completed. The NTP completing the face-to-face must document on the MD/nurse form the date the H&P was completed and the date of the consultation in the "comments" section of the form.
The PI department or nurse designee will monitor compliance and provide the Medical Firector and Nurse Manager with a monthly report of compliance. |
715.23(b)(4) LICENSURE Patient records
(b) Each patient file shall include the following information:
(4) The results of an initial intake physical examination.
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Observations
Based on a review of patient records, the facility failed to complete an initial intake physical examination in one of eight records, as required.
The findings include:
Eight patient records were reviewed on September 17-18, 2012. All records required an initial intake physical examination. The facility failed to document a physical examination in patient record # 6.
Patient #6 was admitted to detoxification program on September 15, 2012 and left against medical advice on September 16, 2012. The facility's policy states that the history and physical will be completed within 24 hours. However, the standards require a physical examination to be completed prior to the patient's initial dose of a narcotic medication. The patient received their first dose of Suboxone on September 15, 2012 at 5:00 p.m. prior to a physical examination being completed.
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Plan of Correction
The Medical Director implemented a procedure at the Medical meeting held 10/10/2012 that states the NTP physician may not initiate any NTP treatment- the face-to-face iterview or the initial dosing of medication until the H&P is completed. The nurses will document all new admissions on the medical daioy work log to ensure that all history and physicals are completed within 24hours of admission.
The PI department or nurse designee will monitor compliance and provide the Medical Firector and Nurse Manager with a monthly report of compliance.
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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 facility's policy and procedures, 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 regulation in three of three patient records.
The findings include:
Eight detoxification patient records were reviewed on September 17-18, 2012. All verbal medication orders are required to be signed within 24 hours by the prescribing physician. Patient records # 4, 5, and 6 contained documentation of verbal medication orders that were not signed by the prescribing physician within 24 hours of issuance.
Patient # 4 was admitted on June 17, 2012 and discharged June 28, 2012. Verbal orders from the physician were documented in the patient record dated June 20, 2012 at 10:00 a.m. The verbal orders were signed off by the Certified Registered Nurse Practitioner (CRNP) on June 21, 2012, however, the CRNP was not the prescribing physician.
Patient #5 was admitted on July 9, 2012 and discharged on July 22, 2012. A televideo medicine verbal order dated July 10, 2012 at 9:50 a.m. was not signed by the prescribing physician as of the date of the inspection.
Patient #6 was admitted on September 15, 2012 and discharged on September 16, 2012. Verbal orders from the physician dated September 15, 2012 were not signed by the physician as of the date of the inspection.
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Plan of Correction
Mirmont instituted a policy on 10/17/2012 after the Medical meeting that requires all verbal orders to be signed by the prescribing physician/CRNP within 24 hours. To ensure that this occurs the Prescribing physician/CRNP giving the verbal orders will be the phycian/CRNP who is rounding and signing any verbal orders that he/she gave.
The PI department or nursing designee will monitor compliance and generate a monthly report for the Medical Director and Nurse Manager.
Mirmont will also investigate the use of E-Prescribe and an EMR system for future use. |
704.7(b) LICENSURE Counselor Qualifications
704.7. Qualifications for the position of counselor.
(a) Drug and alcohol treatment projects shall be staffed by counselors proportionate to the staff/client and counselor/client ratios listed in 704.12 (relating to full-time equivalent (FTE) maximum client/staff and client/counselor ratios).
(b) Each counselor shall meet at least one of the following groups of qualifications:
(1) Current licensure in this Commonwealth as a physician.
(2) A Master's Degree or above from an accredited college with a major in chemical dependency, psychology, social work, counseling, nursing (with a clinical specialty in the human services) or other related field which includes a practicum in a health or human service agency, preferably in a drug and alcohol setting. If the practicum did not take place in a drug and alcohol setting, the individual's written training plan shall specifically address a plan to achieve counseling competency in chemical dependency issues.
(3) A Bachelor's Degree from an accredited college with a major in chemical dependency, psychology, social work, counseling, nursing (with a clinical specialty in the human services) or other related field and 1 year of clinical experience (a minimum of 1,820 hours) in a health or human service agency, preferably in a drug and alcohol setting. If a person's experience did not take place in a drug and alcohol setting, the individual's written training plan shall specifically address a plan to achieve counseling competency in chemical dependency issues.
(4) An Associate Degree from an accredited college with a major in chemical dependency, psychology, social work, counseling, nursing (with a clinical specialty in the human services) or other related field and 2 years of clinical experience (a minimum of 3,640 hours) in a health or human service agency, preferably in a drug and alcohol setting. If a person's experience was not in a drug and alcohol setting, the individual's written training plan shall specifically address a plan to achieve counseling competency in chemical dependency issues.
(5) Current licensure in this Commonwealth as a registered nurse and a degree from an accredited school of nursing and 1 year of counseling experience (a minimum of 1,820 hours) in a health or human service agency, preferably in a drug and alcohol setting. If a person's experience was not in a drug and alcohol setting, the individual's written training plan shall specifically address a plan to achieve counseling competency in chemical dependency issues.
(6) Full certification as an addictions counselor by a statewide certification body which is a member of a National certification body or certification by another state government's substance abuse counseling certification board.
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Observations
Based on a review of five counselor's qualifications on September 18, 2012, the facility failed to ensure that each counselor met the qualifications for the position in one of five records, as required.
The findings include:
Employee # 3 was hired on November 14, 2011 as a counselor. The counselor did not meet the qualifications for the position of counselor based on Bachelors of Arts in English Education.
This finding was discussed with facility staff and was not disputed.
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Plan of Correction
The Clinical Director has changed the job title for employee #3 to counselor assistant until she completes her Masters in Clinical Psychology from West Chester University, which will be by the end of Fall Semester 2012. Please note since employee 3# is a bachlor's prepared counselor assistant, she will receive close supervision for six months or until such time that she receives her Masters degree.
Employee 3# was also an intern at Mirmont for a year prior to hire with a Masters level clinician.
To prevent this from occurring again, the Clinical Director will review all candidates qualifications, instead of Human Resources, and have the potential employee bring in an actual copy of their degrees and transcripts to ensure their qualifications as a counsler are correct. |