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 30- October 2, 2013 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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715.15(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 two of two records reviewed.
The findings include:
Five patient records were reviewed on October 1-2, 2013. In patient records # 9 and 12, the Certified Registered Nurse Practitioner completed the history and physical. The narcotic treatment physician that determined the initial dose failed to document the consultation with the narcotic treatment physician completing the physical examination in these records.
This finding was discussed with the facility staff and was not disputed.
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Plan of Correction
The Medical Director will review the policy and procedure on the completion of all NTP paperwork with the NTP physicians at the November medical meeting. This will include documenting the NTP's consultation with the physician who completed the H&P exam when determining the initial dose of medication if he/she did not complete the H&P.
Nursing will monitor completion of all NTP paperwork as part of their daily chart checks and report any deficiencies to the Medical Director. |
715..23(b)(1) LICENSURE Patient records
(b) Each patient file shall include the following information:
(1) A complete personal history.
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Observations
Based on a review of the patient records, the facility failed to document a detailed drug and alcohol history that included the patient's progression of drug or alcohol use in one of five records reviewed. Additionally, five of five records reviewed failed to include a complete personal history that included the patient's prior treatment, patient's perception of drug and alcohol use, family, legal, employment/vocation, educational, military, recreational and sexual history.
The findings include:
Twenty-one patient records were reviewed October 1-2, 2013. Five detoxification patient records were reviewed for drug and alcohol histories and personal histories that included prior treatment, patient's perception of drug and alcohol use, family, legal, employment/vocational, educational, military, recreational, and sexual history. Patient records # 9, 10,11,12 and 13 did not include all required information in the personal histories.
Patient record # 10 failed to include a drug and alcohol history that included the client's progression of drug or alcohol use.
Patient record # 9 failed to include a detailed legal history and employment/vocational history.
Patient record # 10 failed to include the client's progression of drug and alcohol use, the patient's perception of drug and alcohol use, a detailed employment/vocational history and detailed educational history.
Patient record # 11 failed to include a detailed legal history, a detailed employment/vocational history and sexual history.
Patient record # 12 failed to include a detailed legal history, a detailed employment/vocational history and sexual history.
Patient record # 13 failed to document a detailed recreational history and sexual history.
These findings were reviewed with the facility staff and were not disputed.
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Plan of Correction
The Clinical Director along with the Clinicnal Supervisors will re-educate the counseling staff on the Biopsychosocial policy. This will include an emphasis on providing detail for each category of the patient's history.
To assist with this, the Clinical Supervisors will revise the Biopsychosocial to include more cues to ensure a complete history. The revised Biopsychosoical will also be reviewed with staff at the November staff meeting
The Clinical Directors will monitor a minimum of 1 chart for each counselor on a weekly basis to ensure compliance and report their finding weekly to the Clinical Director. |
715.28(a)(1-10) LICENSURE Unusual incidents
(a) A narcotic treatment program shall develop and implement policies and procedures to respond to the following unusual incidents:
(1) Physical assault by a patient.
(2) Inappropriate behavior by a patient causing disruption to the narcotic treatment program.
(3) Selling of drugs on the premises.
(4) Complaints of patient abuse (physical, verbal, sexual and emotional).
(5) Death or serious injury due to trauma, suicide, medication error or unusual circumstances.
(6) Significant disruption of services due to disaster such as fire, storm, flood or other occurrence.
(7) Incident with potential for negative community reaction or which the facility director believes may lead to community concern.
(8) Theft, burglary, break-in or similar incident at the facility.
(9) Drug related hospitalization of a patient.
(10) Other unusual incidents the narcotic treatment program believes should be documented.
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Observations
Based on the review of patient records, the facility failed to document unusual incidents in two of two records reviewed.
The findings include:
Five patient record were reviewed. Two of these records had documented progress notes that revealed unusual incidents occurred with the patients, however, proper documentation was not available.
Patient record # 14 had documentation in the progress notes that indicated the patient destroyed facility property. When asked for an incident report that would provide for the reason the patient was being terminated from treatment, no documentation could be presented. This patient was receiving Suboxone services and information was required to determine whether or not the patient could be immediately terminated. Based on staff interviews, the patient's behavior did warrant immediate discharge. However, the reason for the termination was not documented in the patient record.
Patient record # 19 had documentation in patient record that revealed the patient was terminated from treatment for having medication in his possession while in treatment. When asked for an incident report in reference to this incident, documentation could not be presented. Based on documentation included in the patient record, it was determined medication was found on the patient during a room inspection. No other written information was available on this incident.
This finding was discussed with facility staff and was not disputed.
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Plan of Correction
The Clinical Director,the Clinical Supervisors, and Nurse Manager will review Mirmont's Unusual Incident policy with their staff during their November staff meetings. This training will also include the NTP standards for Unusual Incidents and Patient Terminations including what is to be documented on the Incident Report as well as in the chart.
The PI Director or designee will review all Involuntary Discharge charts for: complete and accurate detailed documentation as to the reason for discharge from the NTP program and the completion of an incident report |