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 June 1-3, 2009 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 7, 2009.
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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 facility failed to maintain patient confidentiality in six of eight records reviewed.
The findings include:
Eight patient records were reviewed on June 1-2, 2009. Six patient records were reviewed for confidentiality. The consents to release information to the patient's funding source exceeded 4 PA Code 255.5 by allowing progress notes, discharge plans and summaries, lab results, treatment plans and psychosocial evaluations to be released in patient records # 1, 3, 5, 6, 7 and 8.
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Plan of Correction
1. Eagleville Hospital continues to educate 3rd party payors, managed care organizations and others, as appropriate, on PA Regulation 4 Pa. Code 255.5 (b) and limits of disclosure. This is ongoing. Eagleville Hospital's program and department directors are responsible for achieving and maintaining compliance with this standard.
2. Eagleville Hospital staff will be re-educated on PA Regulation 4 Pa. Code 255.5 (b) and limits of disclosure. The quality manager will develop an online educational training to be completed by staff by August 3, 2009. All staff who are responsible for releasing confidential information will complete this training by August 21, 2009.
3. The release of information consents will be reviewed and revised as appropriate to ensure PA Regulation 4 Pa. Code 255.5 (b) and limits of disclosure are met. This item will be completed by August 21, 2009.
4. Medical records will be monitored by the director of medical records.
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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.
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Observations
Based on a review of patient records and discussion with the medical director, the facility failed to complete an initial drug-screening urinalysis prior to admitting and dosing three of six patients.
The findings include:
Eight patient records were reviewed on June 1-2, 2009. Six patient records were reviewed for initial dosing schedules and initial completed urine drug screens. Three of six patient records reviewed were dosed prior to the initial urine drug screen being completed. Patient # 1 was admitted on March 11, 2009 and received initial dose on March 12, 2009. The first documented urine drug screen was dated April 3, 2009. The physician ordered 20 milligrams methadone to be administered on admission. Patient # 6 was admitted and dosed on January 15, 2009. The initial tool used was an instant test which is currently not approved for use on admission by the Department. Patient # 8 was admitted and dosed on February 6, 2009, also with the use of the instant testing tool.
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Plan of Correction
1. Assessment of the medical records identified that methadone was administered prior to receiving urine drug screen results for patients presenting with signs and symptoms of acute withdrawal. Assessment of the records was completed June 5, 2009.
2. A urine sample will be taken upon admission to the unit from all patients presenting for opiate detox. The physicians will review the results from the urinalysis and will document the acute signs and symptoms of withdrawal prior to dosing methadone. This item has been completed and is ongoing.
3. Methadone will not be administered prior to receiving the urine drug screen results. Physicians will utilize other medications in place of methadone to treat patient's symptoms of withdrawal until the urine drug screen results are received. Physicians have received verbal notification of this requirement and will receive notification in writing by July 31, 2009.
4. Physicians were educated on documentation of acute signs and symptoms of withdrawal on July 7, 2009. Physicians will continue to be educated, including on appropriate procedures for dosing methadone and the use of other medications in place of methadone to treat patient's withdrawal symptoms. This education will be completed by July 31, 2009 and will be documented.
5. The electronic health record will be revised to update the opiate detox admission order set and to include additional criteria for physicians to document the signs and symptoms of acute withdrawal. Due to upgrades in the electronic record currently being completed, this item will be completed by September 20, 2009.
6. The Director of Physician Services will review data collected from medical records through medical record reviews to ensure that all requirements are being fulfilled. Medical record reviews will be implemented August 3, 2009.
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715.23(b)(15) LICENSURE Patient records
(b) Each patient file shall include the following information:
(15) Psychosocial evaluations of the patient.
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Observations
Based on a review of patient records the facility failed to include a psychosocial that contained an evaluation of the obtained historical data in five of six records reviewed.
The findings include:
Eight patient records were reviewed on June 1-2, 2009. Six patient records were reviewed for psychosocial evaluations. Five of the six records contained a repeat of the historical data obtained and patient reported information. These records were # 1, 2, 3, 4 and 8.
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Plan of Correction
1. The Director of Clinical Services will re-educate staff on how to evaluate the historical data obtained from patients during our assessment process. This education will be documented.
2. The Director of Clinical Services will monitor medical records through monthly reviews to ensure that this requirement is being fulfilled.
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715.23(b)(23) LICENSURE Patient records
(b) Each patient file shall include the following information:
(23) Discharge summary.
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Observations
Based on a review of patient records, the facility failed to complete a discharge summary in one of three patient records, and another one was completed late.
The findings include:
Eight patient records were reviewed on June 1-2, 2009. Three patient
records required a discharge summary. Patient # 4 was discharged on
March 18, 2009 and the discharge summary was completed May 17, 2009. Patient # 8 was discharged on March 25, 2009 and there was no discharge summary completed as of the June 2, 2009.
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Plan of Correction
1. Discharge summary completion data is currently evaluated on a semi-annual basis. Evaluation of monitoring results has identified a specific program and staff who are not completing discharge summaries per policy. Monitoring by the director of co-occurring disorders of discharge summary completion for this program and staff will be increased to weekly as of July 31, 2009 for a period of two months and then will be monitored monthly for a period of 3 months.
2. The Director of the Co-Occurring Programs will provide additional supervision and education by August 7, 2009 to those counselors who failed to complete discharge summaries as required per policy. Supervision and education provided to counselors will be documented.
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