INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection and methadone monitoring conducted on August 16, 2021 through August 18, 2021 by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, Eagleville Hospital 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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715.11 LICENSURE Confidentiality of patient records
A narcotic treatment program shall physically secure and maintain the confidentiality of all patient records in accordance with 42 CFR 2.22 (relating to notice to patients of Federal confidentiality requirements) and § 709.28 (relating to confidentiality).
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Observations
Based on a review of patient records, the narcotic treatment program failed to ensure that all informed and voluntary consent to release information forms included the name of the person, agency or organziation to whom the disclosure would be made to in two of twenty-eight patient records reviewed.
Patient #11 was admitted into the Inpatient Non-Hospital Residential level of care on March 3, 2021 and was discharged March 30, 2021. A release of information form, with a purpose of funding, did not include the name of the person, agency, or organization.
Patient #12 was admitted into the Inpatient Non-Hospital Residential level of care on March 10, 2021 and was discharged April 22, 2021. A release of information form, with a purpose of funding, did not include the name of the person, agency, or organization.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
On July 13, 2021, all Admission Staff and Nurse Supervisors were trained on the completion of all consent forms, including the Consent For Release to Insurance and Funding Sources. A "Consent Form Re-Education" training document was prepared and circulated to all staff involved in assisting patients to properly complete the consents to release of information in admission paperwork.
The Chief Operating Officer will conduct audits of the documents completed at the time of admission to monitor compliance with the appropriate completion of the consents for release of information to insurance and funding sources. The weekly audits will include ten randomly selected charts. The COO has responsibility for the completion of this plan by 10/31/2021.
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715.12(1-5) LICENSURE Informed patient consent
A narcotic treatment program shall obtain an informed, voluntary, written consent before an agent may be administered to the patient for either maintenance or detoxification treatment. The following shall appear on the patient consent form:
(1) That methadone and LAAM are narcotic drugs which can be harmful if taken without medical supervision.
(2) That methadone and LAAM are addictive medications and may, like other drugs used in medical practices, produce adverse results.
(3) That alternative methods of treatment exist.
(4) That the possible risks and complications of treatment have been explained to the patient.
(5) That methadone is transmitted to the unborn child and will cause physical dependence.
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Observations
Based on a review of patient records, the narcotic treatment program failed to obtain an informed, voluntary, written consent before an agent may be administered to the patient in one of fourteen applicable patient records reviewed.
Patient #11 was admitted into the Inpatient Non-Hospital Residential level of care on March 3, 2021 and was discharged March 30, 2021. There was no documentation of an informed consent to treat in the record as of the date of the inspection.
These findings were reviewed with the facility staff during the licensing process.
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Plan of Correction
On September 9, 2021, the Chief Nursing Officer inserviced RN nurses on the need to provide the informed patient consent to all patients who are receiving methadone and buprenorphine for detoxification or maintenance.
The Chief Nursing Officer will perform weekly audits to determine that all pertinent patients signed the form when given the first dose. The CNO will audit 10 randomly selected charts per week The CNO has responsibility for the completion of this plan by 10/31/2021.
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