INITIAL COMMENTS
|
This report is a result of an onsite follow-up inspection pertaining to the plans of correction for the May 10 through May 12, 2011 methadone monitoring inspection. The follow-up inspection was conducted on August 31, 2011 by staff from the the Division of Drug and Alcohol Program Licensure. Based on the findings of the onsite follow-up inspection, Coatesville Treatment Center 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.
|
Plan of Correction
|
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 the review of patient records and discussion with administrative staff, the facility failed to ensure a random monthly drug-screening urinalysis was completed in three of nine patient records.
The findings include:
Ten patient records were reviewed August 31, 2011. Nine patient records were reviewed specifically for monthly random drug-screening urinalysis. Three of the nine patient records did not record at least one monthly drug screen during the months reviewed. Monthly drug screens were reviewed from June 2011 to August 2011.
Patient # 1 was admitted May 11, 2011. A drug-screening urinalysis was not conducted for the months of June 2011, July 2011 and August 2011. An interview with the facility director confirmed that this patient is currently coming to the facility to be dosed from the prison and facility had not provide monthly urinalysis testing on patients that are incarcerated.
Patient # 3 was admitted April 21, 2011. A drug-screening urinalysis was not conducted for the month of June 2011.
Patient # 7 was admitted May 24, 2011. A drug-screening urinalysis was not conducted for the month of June 2011.
|
Plan of Correction
Since 9/1/2011, the DON has ensured that all pregnant prison patients have been given a urine drug screen here at our facility. All pregnant prison patients coming to our facility will be given a urine drug screen in the staff bathroom where confidentiality can be secured from other patients in the dispensing area.
Starting 10/3/2011, Director of Nursing will utilize new reports from our new patient system that indicates urine drug screens that have not been administered. The report will be run prior to the last week of the month to ensure that every patient has been given a urine drug screen.
|
715.17(b) LICENSURE Medication control
(b) A narcotic treatment program shall develop policies and procedures regarding verbal medication orders, including the issuing and receiving of orders, identifying circumstances when orders are appropriate and documenting orders, in accordance with applicable Federal and State statutes and regulations.
|
Observations
Based on a review of patient records and discussion with the facility director, the facility failed to ensure the physician signed verbal orders as required.
The findings include:
Ten patient records were reviewed August 31, 2011. Two patient records reviewed contained documentation of the physician issuing a verbal order. Two of the two patient records had verbal orders issued by the physician that were not signed within the required 24 hours.
Patient # 4 was admitted on June 22, 2011. The physician issued a verbal order on August 6, 2011. The patient was to receive a dose of 80 mg of methadone. Patient returned after three day incarceration and was on a 5 mg taper per protocol. A call was made to the physician to increase the dose to 80 mg. Last dose was 65 mg on August 5, 2011. The nurse wrote the verbal order on August 6, 2011. The physician signed the order on August 9, 2011.
Patient # 9 was admitted on July 5, 2011. The physician issued a verbal order on July 17, 2011 for the patient to receive a dose of 55 mg. Patient was complaining of cramping, restless legs and insomnia. The nurse wrote the verbal order on July 17, 2011. The physician signed the order on July 19, 2011.
The facility director confirmed this finding. She stated they are continuing to work on a solutions for this issue and are looking to get the physician a computer with a signature pad to be able to sign off on the verbal orders when he is not at the clinic.
|
Plan of Correction
Regional Director will be placing an order through the IT Department for the physician to have his own company laptop. This laptop will enable him to submit electronic orders. As the order has been placed, the equipment should be received by 10/28/2011.
Until the laptop is received, a printer/scanner was purchased on 9/28/2011 in order for the Medical Director to print verbal orders that will be emailed to him be the Nursing Staff. Once signed, he will scan them back to the Nursing Staff. The DON will ensure that all verbal orders are signed by the Medical Director within 24 hours. She will be copied on all verbal orders. |
715.20(1) 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.
(1) The transferring narcotic treatment program shall transfer patient files which include admission date, medical and psychosocial summaries, dosage level, urinalysis reports or summary, exception requests, and current status of the patient, and shall contain the written consent of the patient.
|
Observations
Based on the review of patient records, the facility failed to ensure all of the required patient records are transferred in one of four patient records.
The findings include:
Ten patient records were reviewed August 31, 2011. Four patient records were transferred to another narcotic treatment program. One patient records did not transfer the required documentation.
Patient # 8 was admitted February 21, 2007. A consent was signed by the patient in June 2011 to transfer to another narcotic treatment program. The patient was admitted to another narcotic treatment program on June 23, 2011 There was no documentation in the client record that indicated the required files were transferred to the receiving treatment program.
The facility director confirmed this finding.
|
Plan of Correction
Clinical Supervisors will conduct a training with all Clinical Staff to ensure that they utilize the fax form that was created specifically for transfers, which has check boxes that indicates exactly what was sent to the transferring facility. They will be informed that this sheet must be kept in the chart at all times along with the fax confirmation page as it serves as an indicator that the paperwork was sent. At the time of discharge, Clinical Supervisors will audit all transfer charts to ensure that the faxed cover sheets have been maintained in the charts. |