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 treatment of narcotic addiction. This inspection was conducted on December 1, 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 in compliance with the applicable chapters of 4 PA Code and 28 PA Code which pertain to the facility. The following deficiencies were identified during this inspection and a plan of correction is due on December 23, 2010.
|
Plan of Correction
|
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.
|
Observations
Based on the review of patient records, the facility failed to document verification of the individual 's identity, including name, address, date of birth, emergency contact and other identifying data in three of eight patient records.
The findings include:
Eight patient records were reviewed December 1, 2010. Eight patient records were reviewed for documentation of verification of the individual 's identity, including name, address, date of birth, emergency contact and other identifying data. Prior to administration of an agent, a narcotic treatment program shall screen each individual to determine eligibility for admission. Patient records # 2, 3, and 6 did not include verification of patient identity.
Facility policy states that "a photo ID, a drivers license, a state ID, college ID, passport, or some other form of ID such as a birth certificate," may be used to verify identity." Patient records # 2, 3, and 6 did not contain this documentation.
|
Plan of Correction
The Director of Admissions revised the identification policy on 12/15/10 to include alternate acceptable forms of ID when no photo ID is available. The admission staff was re-educated on the changes to the policy as of 12/21/10. The policy states that if the client does not have a photo ID, he/she must present 2 alternative, consistent forms of ID along with signing the MLH Patient Identification form. Copies of all ID will reside in the chart. The Admissons Director will monitor compliance. |
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 narcotic treatment program failed to complete an initial drug-screening urinalysis for each patient in seven of eight patient records, as required.
The findings include:
Eight patient records were reviewed on December 1, 2010. Eight records were required to contain documentation of drug-screen urinalysis for the patient. Patient record # 1, 2, 3, 4, 6, 7, and 8 did not contain results from an approved laboratory. A complete urine drug screen includes receiving the results from the CLIA, Clinical Laboratory Improvement Amendments of 1998 (CLIA).
|
Plan of Correction
Mirmont has amended it's current procedure on 12/6/10 to not initiate the administration of medication until the initial drug-screening urinalysis results are obtained from an approved CLIA laboratory. Compliance will be monitored by the Nurse Manager and Medical Director until such time as Mirmont's request for exception to the licensing regulation for the initial drug-screening urinalysis obtained. |
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 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 one of five records.
The findings include:
Eight patient records were reviewed on December 1, 2010. Five patient records were required to document a consult between the narcotic treatment physician determining the initial dose and the narcotic treatment physician performing the physical examination in one of five patient records.
Patient #1 was admitted on November 28, 2010. The patient was initially seen by a CRNP who completed the patient examination on November 29, 2010. The physician issued an order to initiate narcotic treatment, however there was no record of consultation with the CRNP.
|
Plan of Correction
The Medical Director has changed the Buprenorphine Detox Physician/Nurse Review form as of December 13, 2010 to include documentation that the prescribing Narcotic Treatment Physician has consulted with the clinician who has performed the physical examination if he/she is not the same clinician. The prescribing Narcotic Treatment Physician shall document in the comment section of the form that he/she consulted with the clinician who completed the history and physical.Copmliance will be monitored by Performance Improvement Coordinator as part of Mirmont's monthly chart monitor. |