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 methadone and buprenorphine, in the treatment of narcotic addiction. This inspection was conducted on July 10-13, 2012 by staff from the Division of Drug and Alcohol 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 4 PA Code and 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 include the basis for determining current opiate dependency in four of eight patient records.
The findings include:
Sixteen patient records were reviewed July 10-13, 2012. Eight patient records were required to document the physician's documentation of the basis for determining current opiate dependency.
Patient # 1 was admitted May 31, 2012. The nurse practitioner (CRNP) completed the history and physical. There was no documentation the physician completed a face to face determination of current dependency at the time of the monitoring survey.
Patient # 6 was admitted September 26, 2011. The nurse practitioner (CRNP) completed the history and physical. There was no documentation the physician completed a face to face determination of current dependency at the time of the monitoring survey.
Patient # 7 was admitted May 9, 2012. The nurse practitioner (CRNP) completed the history and physical. There was no documentation the physician completed a face to face determination of current dependency at the time of the monitoring survey.
Patient # 12 was admitted April 11, 2012. There was no documentation the physician completed a face to face determination of current dependency at the time of the monitoring survey.
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Plan of Correction
# M059
Prior to administration of an agent, a narcotic treatment program shall screen each individual to determine eligibility for admission. The narcotic treatment program physician did not document the basis for determining dependency.
The Director of Medical of Service will re-educate medical staff on the documentation requirements for determination of dosing.
By :Director of Medical Service
Documentation of the basis for determining current opiate dependency and determination of dose will be added to the existing Quality Management chart review processes.
Quality Management Chart Review processes completed monthly and reported quarterly to the Quality Management Committee
Director of Quality Management |
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 three patient records reviewed.
The findings include:
Sixteen patient records were reviewed July 10-13, 2012. Three 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.
Patient # 1 was admitted on May 31, 2012. The Certified Registered Nurse Practitioner (CRNP) completed the physical examination on May 31, 2012. The narcotic treatment physician determined the initial dose to begin June 1, 2012, but failed to document the consultation with the Certified Registered Nurse Practitioner who completed the physical examination.
Patient # 7 was admitted May 9, 2012. The Certified Registered Nurse Practitioner (CRNP) completed the physical examination on May 9, 2012. The narcotic treatment physician determined the initial dose on May 9, 2012, but failed to document the consultation with the Certified Registered Nurse Practitioner who completed the physical examination.
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Plan of Correction
# M115
The Director of Medical of Service will re-educate staff on the documentation requirements for consultation between the narcotic treatment physician determining the initial dose and the narcotic treatment physician or LIP performing the physical examination.
Documentation of the consultation will be added to the existing Quality Management chart review processes.
Quality Management Chart Review processes completed monthly and reported quarterly to the Quality Management Committee
By Director of Quality Management
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