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 buprenorphine, in the treatment of narcotic addiction. This inspection was conducted on March 25-26, 2014 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Conewago - Pottsville was found not to be in compliance with the applicable chapters of 4 PA Code and 28 PA Code which pertain to the facility.
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Plan of Correction
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715.23(b)(6) LICENSURE Patient records
(b) Each patient file shall include the following information:
(6) Results of laboratory tests or other special examinations given by the narcotic treatment program.
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Observations
Based on the review of patient records and discussion with facility staff, the facility failed to complete all required laboratory tests as part of the admission process in six of eight patient records reviewed. The findings include:Ten patient records were reviewed March 25-26, 2014. Eight patient records were reviewed for completed laboratory tests as part of the admission process, including a tuberculosis test, Purified Protein Derivative (PPD).Patient records # 1, 2, 3, 4, 6, and 8 did not include documentation of tuberculin tests having been administered as part of the admission process. All were admitted between October 2013 and March 2014. Administrative staff reported a shortage by the supplier they contract with for the PPD product Aplisol Staff also reported that there were times the product was available, but in a larger amount then they could use before the potency expired, so they did not obtain it, but instead, relied on a screening questionnaire.
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Plan of Correction
On March 31, 2014 Conewago Pottsville was informed that the TB testing serum was now available and has secured that serum for use in its facility. All clients are now receiving the appropriate testing.
The director of nursing will monitor the supply of serum and notify the director in the event of any supply disruption. The project director will immediately request a waiver from the Department should any testing supply shortage interfere with this process in the future.
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709.33(b) LICENSURE Notification of Termination
709.33. Notification of termination.
(b) The client shall have an opportunity to request reconsideration of a decision terminating treatment.
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Observations
Based on the review of patient records, the facility failed to ensure the patient had an opportunity to request a reconsideration of a decision to terminate treatment in two of two patient records reviewed. The findings include:Ten patient records were reviewed March 25-26, 2014. Two patient records required written notification of a decision to terminate treatment along with a reconsideration of the decision to terminate. Patient # 5 was discharged June 30, 2013 as an involuntary termination. While there was a termination letter documented within the patient's electronic medical record, there was no documentation the patient ever received this notice along with an opportunity to request reconsideration.Patient # 10 was discharged June 9, 2013 as an involuntary termination. While there was a termination letter documented within the patient's electronic medical record, there was no documentation the patient ever received this notice along with an opportunity to request reconsideration.
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Plan of Correction
The Project Director will revise the Notification of Termination Form on 4/14/14 to include the statement "Client was offered a copy of the termination report, check boxes for accepted or refused, and a comment section for staff to document the outcome".
The Facility Director will retrain all clinical staff on the form revisions and implement its use on 4/16/14. Facility Director will monitor on a weekly basis through regular client chart reviews to ensure ongoing compliance. |