INITIAL COMMENTS
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This report is a result of an on-site inspection conducted for the approval to use narcotic agents, specifically methadone and buprenorphine, in the treatment of narcotic addiction. This inspection was conducted on June 21-23, 2010 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 and a plan of correction is due on July 18, 2010.
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Plan of Correction
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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.
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Observations
Based on the review of patient records, the facility failed to verify the identity of the patient prior to the administration of an agent in nine of ten patient records.
The findings include:
Fourteen patient records were reviewed on June 22-23, 2010. Ten patient records were specifically reviewed for patient identity information. Patient records # 4, 6, 7, 8, 10, 11, 12, 13 and 14 did not contain documentation of the verification of patient's identifying information.
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Plan of Correction
1. Currently the admissions staff is verifying the identity of the patient prior to the patient being admitted to Eagleville; however, they are not consistently placing a photo copy of the patient's identification in the patient's medical record. The Director of Intake and Assessment will inform all admissions staff that they are to make a photo copy of the patient's photo identification and immediately place it in the patient's medical record. This communication to admissions staff will be completed by July 30, 2010 and will be documented.
2. The Chief Compliance Officer will monitor medical records on a weekly basis as of August 1, 2010 for a minimum period of two months to ensure the photo copy of the patient's photo identification is in the medical record.
3. The Director of Medical Records will monitor medical records through monthly reviews to ensure the photo copy of the patient's photo identification is in the medical record. Medical record reviews will be implemented beginning with August admissions.
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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 patient records, the facility failed to document in the patient's record the basis for determination of current dependency in four of nine patient records.
The findings include:
Fourteen patient records were reviewed June 22-23, 2010. Nine patient records were reviewed for documentation of current dependency.
Patient # 5 was admitted June 18, 2010. The space for the physician to document findings of current dependency was not completed at the time of the monitoring.
Patient # 6 was admitted December 4, 2009. The space for the physician to document current dependency it stated " 12 bags IV heroin" without any explanation of the stated information.
Patient # 9 had three separate admissions between October 28, 2009 and April 1, 2010. The October admission contained "8-10 bags IV heroin daily" without further information and the November 9, 2009 admission had nothing documented in the space for the physician to document the findings of current dependency.
Patient # 10 was admitted March 15, 2010. The space for the physician to document findings of current dependency was not completed at the time of the monitoring.
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Plan of Correction
1. Physicians will be re-educated on an individual basis by the Director of Physician Services on the need to document in the patient's record the basis for determination of current dependency. This re-education will be completed by July 30, 2010 and will be documented.
2. The Director of Physician Services will review data collected from medical records through medical record reviews to ensure that this requirement is being fulfilled. Monitoring of medical records will occur on a weekly basis as of August 1, 2010 for a minimum period of two months and then will be monitored monthly.
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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 the review of patient records, the facility failed to ensure the patient signed the informed consent prior to the administration of a narcotic agent in two of six patient records.
The findings include:
Fourteen patient records were reviewed on June 22-23, 2010. Informed consent documentation was reviewed in nine patient records.
Patient record # 2 contained documentation the patient was admitted May 25, 2010 and received the first dose on May 26, 2010. The patient signed the consent containing the required information on June 17, 2010.
Patient record # 6 contained documentation that the patient was admitted December 4, 2009 and received the first dose on December 5, 2009. There was no documentation that the patient signed the consent containing the required information.
Patient # 13 was admitted May 20, 2010. The patient was admitted for a buprenorphine detoxification and received the first dose on May 21, 2010. There was a blank consent for methadone in the patient record.
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Plan of Correction
1. The Director of Nursing will educate nursing staff on the need to complete the Informed Consent for Use of Methadone/Buprenorphine for Detoxification or Methadone Maintenance with patients upon admission to the unit. This education will be completed by July 30, 2010 and will be documented.
2. The Director of Nursing will implement a new Nursing Admission Checklist to ensure all necessary consents are signed and dated by the patient and placed in the patient's medical record. This checklist will be implemented by July 30, 2010.
3. The Chief Compliance Officer will monitor medical records on a weekly basis as of August 1, 2010 for a minimum period of two months to ensure the Informed Consent for Use of Methadone/Buprenorphine for Detoxification or Methadone Maintenance is in the medical record.
4. The Director of Medical Records will monitor medical records through monthly reviews to ensure that the Informed Consent for Use of Methadone/Buprenorphine for Detoxification or Methadone Maintenance is being completed and placed in the medical record. Medical record reviews will be implemented beginning with August admissions.
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715.20(4) LICENSURE Patient transfers
A narcotic treatment program shall develop written transfer policies and procedures which shall require that the narcotic treatment program transfer a patient to another narcotic treatment program for continued maintenance, detoxification or another treatment activity within 7 days of the request of the patient.
(4) The receiving narcotic treatment program shall document in writing that it notified the transferring narcotic treatment program of the admission of the patient and the date of the initial dose given to the patient by the receiving narcotic treatment program.
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Observations
Based on the review of patient records, the facility failed to document that it notified the referring facility of the admission and initial dosing of the patient in three of four patient records.
The findings include:
Fourteen patient records were reviewed June 22-23, 2010. Four patient records were reviewed for documentation of notification to the referring facility of the admission and dosing of the referred patient. Patient records # 2, 6 and 11 were referred by another narcotic treatment program and there was no documentation of the referral source's notification of the patient's admission and initial dosing.
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Plan of Correction
1. The Quality Manager will review and revise policy #4000.300, Methadone Maintenance, to ensure it includes that the therapist will notify the referring facility within seven days of the patient's admission and initial dosing and that the therapist will document this notification in the patient's medical record.
2. The Director of Clinical Services will educate staff that they are to notify the referring facility of the patient's admission and initial dosing within seven days of the patient's admission to Eagleville. Staff will also be educated that they are to document this notification in the patient's medical record. This education will be documented.
3. The Chief Compliance Officer will monitor medical records on a weekly basis as of August 1, 2010 for a minimum period of two months to ensure that the referring facility was informed of the patient's admission and initial dosing.
4. The Director of Medical Records will monitor medical records through monthly reviews to ensure that the referring facility was informed of the patient's admission and initial dosing within seven days. Medical record reviews will be implemented beginning with August admissions.
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715.28(c)(1-5) LICENSURE Unusual incidents
(c) A narcotic treatment program shall file a written Unusual Incident Report with the Department within 48 hours following an unusual incident including the following:
(1) Complaints of patient abuse (physical, verbal, sexual and emotional).
(2) Death or serious injury due to trauma, suicide, medication error or unusual circumstances.
(3) Significant disruption of services due to a disaster such as a fire, storm, flood or other occurrence.
(4) Incidents with potential for negative community reaction or which the facility director believes may lead to community concern.
(5) Drug related hospitalization of a patient.
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Observations
Based on a review of administrative documentation provided during the inspection and staff interviews, the facility failed to submit documentation of unusual incidents to the Department as required.
The findings include:
February 7, 2010 a female patient filed a grievance against a male staff alleging he was verbally/sexually abusive as substantiated through program investigation. This was not submitted to the Department as required.
March 16, 2010 a patient during the admission process was sent to the hospital emergency room for a suspected drug overdose via 911. The patient was admitted and treated for an overdose and sent back to facility on March 18, 2010. This was not submitted to the Department as required.
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Plan of Correction
1. Incident reports for unusual incidents are being submitted to the Department. Additional education and process changes will be completed to strengthen the response to this standard.
2. The Quality Manager will review and revise, as necessary, policy #4500.202, External Reporting, to ensure that it includes all types of unusual incidents defined in Chapter 715, standard #715.28. This policy will be revised by July 30, 2010.
3. The Quality Manager will review and revise, as necessary, the Hospital's External Reporting Matrix to ensure that it includes all types of unusual incidents defined in Chapter 715, standard #715.28. This matrix will be revised by July 30, 2010.
4. The Quality Manager will notify all staff of the unusual incidents that must be reported as defined in Chapter 715, standard #715.28. This notification will be sent by July 16, 2010 and will be documented.
5. Eagleville Hospital's internal electronic incident reporting system will be updated to include all incident categories defined in Chapter 715, standard #715.28. Due to upgrades currently being completed in the electronic incident reporting system, this item will be completed by August 30, 2010.
6. The Quality Manager will notify all staff of the changes in the electronic incident reporting system. Due to upgrades currently being completed in the electronic incident reporting system, this item will be completed by August 30, 2010. This notification will be documented.
7. The Quality Manager will submit all required Unusual Incident Reports to the Department as required. This item will be completed ongoing as unusual incidents are reported.
8. The Quality Management Officer will monitor incident reporting data through monthly reports to ensure that this requirement is being fulfilled. Monitoring will begin in September once all upgrades to the electronic system have been completed.
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