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, in the treatment of narcotic addiction. This inspection was conducted on July 23, 24 and 25, 2008 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 28 PA Code which pertain to the facility. Deficiencies were identified during this inspection and a plan of correction is due on August 19, 2008.
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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 a review of 13 patient records and staff interviews, all 13 records were reviewed for compliance with physician documentation of current and a one year history of opioid dependency. The facility failed to provide documentation by the physician of the required components. Documentation reviewed during monitoring visit revealed only the physician signature and the date of the assessment and determination, not the content.
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Plan of Correction
1. The Senior Applications Analyst will modify the History and Physical in the computerized medical record system to prompt the physician to enter the determination made by the physician of current dependency.
2. The Director of Physician Services will notify all physicians of the change in the computerized medical record system. Individual training will be provided by him as necessary.
3. The Medical Records Director will monitor medical records through monthly reviews to ensure that the determination of current dependency is being consistently documented.
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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 13 patient records, 12 were reviewed for compliance with urinalysis testing. The facility failed to obtain a complete urine drug screen (including the result of the drug screen) prior to the administration of a narcotic agent, in 12 of 12 patients records, #1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11 and 12.
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Plan of Correction
1. Initial drug-screening urinalysis will be completed for each prospective patient prior to the patient receiving their first dose of methadone or Bupronorphine.
2. When a prospective patient is being referred to Eagleville from a Methadone Clinic or other healthcare facility the Intake and Assessment Director will attempt to obtain the patient's recent (within past 3 weeks) drug-screening urinalysis if available. This urinalysis will be reviewed by the physician prior to the patient receiving his first dose of methadone or Bupronorphine.
3. The Medical Records Director will monitor medical records through monthly reviews to ensure that this requirement is being fulfilled.
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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 13 patient records, 12 were reviewed for initial dose requirements. The facility failed to provide documentation verifying that the physician who determined the dose had consulted with the physician's assistant who had performed the patient examination. Specifically, this was noted in 3 of 13 patient records reviewed, # 3, 6 and 8.
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Plan of Correction
1. The Quality Manager will revise policy #5200.402, History and Physical, to include the requirement for the physician who is ordering the first dose of Methadone or Bupronorphine to consult with the physician or physician extender who completed the History and Physical prior to ordering the first dose of Methadone or Bupronorphine.
2. The Director of Physician Services will notify all physicians of the change in policy.
3. The Medical Records Director will monitor medical records through monthly reviews to ensure that this requirement is being fulfilled.
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715.23(b)(24) LICENSURE Patient records
(b) Each patient file shall include the following information:
(24) Follow-up information regarding the patient.
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Observations
Based on a review of 13 patient records,10 were reviewed for patient follow-up. The facility failed to provide documentation of follow-up services for 8 of 10 patients, #2, 3, 5, 6, 7, 8, 9 and 11.
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Plan of Correction
1. The Director of Clinical Services will conduct a staff training on completion of follow-up which will be provided to all applicable staff to ensure follow-up is completed and documented as required.
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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