INITIAL COMMENTS
|
This report is a result of an on-site licensure renewal inspection and methadone monitoring inspection conducted on October 30, 2018 by staff from the Department of Drug and Alcohol Programs, Bureau of Quality Assurance for Prevention and Treatment, Division of Accountability and Program Improvement. Based on the findings of the on-site inspection, UPMC McKeesport Hospital 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
|
715.9(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.
|
Observations
The facility failed to verify the individual 's identity, including name, address, date of birth and other identifying data in three of three client records reviewed on October 30, 2018.
Client records # 1, 2 and 3 did not document the identity of the client was verified prior to being given the initial dose.
These findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
UPMC McKeesport will verify the identities of individual's seeking Methadone treatment.
1.
The Evaluating Clinician as part of the initial Emergency Room assessment will be responsible for verification of identification obtained via Photo ID that is to include their name, address, date of birth or other identifying data(social security#.
Accepting IDs for NTPs include:
(a)State or Federal photo identification cards or clear and legible copy(expired acceptable,
(b)Photo ID issued by another NTP- (clear and legible copy.
(c)Passports
(d) Unaltered check cashing photo identification cards
(e) Student photo ID card for dosing (containing the date of birth).
2. The Program manager will be responsible for monitoring compliance with the verification of patient identification process.
3.Compliance with this process will be monitored by the Program Manager via weekly chart audits. |
715.10(f) LICENSURE Pregnant patients
(f) The narcotic treatment program shall ensure that each female patient is fully informed of the possible risk to her or her unborn child from continued use of illicit drugs and from use of, or withdrawal from a narcotic drug administered or dispensed by the program in comprehensive maintenance or detoxification treatment.
|
Observations
The facility failed to ensure that each female patient was fully informed of the possible risk to her or her unborn child in two of two patient records reviewed on October 30, 2018.
Patient records # 1 and 3 did not document that the females were informed of the risks.
These findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
UPMC McKeesport will obtain from all female patients written consent for Buprenorphine and Suboxone treatment.
1.This consent will include the risk and dangers associated with the use and treatment of Buprenorphine and Suboxone to them and their unborn child.
2.The consents are to be obtained following confirmation of their admittance to 3 Crawford by the Evaluating Clinicians.
3.The validation of consent will be monitored by the Program Manager through weekly chart audits.
|
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.
|
Observations
The facility failed to obtain an informed written patient consent, which included the required information, prior to the the administration of Buprenorphine for patient records # 1, 2 and 3 reviewed on October 30, 2018.
These findings were reviewed with facility staff during the licensing inspection.
|
Plan of Correction
UPMC McKeesport will obtain from all patients written consent for all patients seeking Buprenorphine treatment.
1. The consent will be obtained following confirmation of their admittance to 3 Crawford by the Evaluating Clinicians.
2.The validation of consent will be monitored by the Program Manager through weekly chart audits.
|