INITIAL COMMENTS
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This report is a result of a complaint investigation conducted on October 4, 2010 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the complaint investigation, the allegations made against New Directions Treatment Services were substantiated. A plan of correction must be submitted by November 1, 2010.
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Plan of Correction
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715.17(c)(1)(i-vi)) LICENSURE Medication control
(c) A narcotic treatment program shall develop and implement written policies and procedures regarding the medications used by patients which shall include, at a minimum:
(1) Administration of medication.
(i) A narcotic treatment physician shall determine the patient 's initial and subsequent dose and schedule. The physician shall communicate the initial and subsequent dose and schedule to the person responsible for the administration of medication. Each medication order and dosage change shall be written and signed by the narcotic treatment physician.
(ii) An agent shall be administered or dispensed only by a practitioner licensed under the appropriate Federal and State laws to dispense agents to patients.
(iii) Only authorized staff and patients who are receiving medication shall be permitted in the dispensing area.
(iv) There shall be only one patient permitted at a dispensing station at any given time.
(v) Each patient shall be observed when ingesting the agent.
(vi) Administering and dispensing shall be conducted in a manner that protects the patient from disruption or annoyance from other individuals.
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Observations
Based on observation and staff interviews, the facility did not restrict the dispensing area to only authorized staff and patients and failed to maintain a dispensing area that was free of disruption for the patients when they appeared to be medicated.. The findings include:On October 4, 2010, Department staff conducted an unannounced inspection of the facility dispensing area between 7:45 AM and 8:45 AM. During this time frame, three women with small children came to be dosed. The first woman, at 7:50 AM was in line to dose and the security monitor was observed whispering to her to not take the baby in the booth. She replied that she had been told she could not take her child in on Monday, Tuesday and Wednesday. She did have someone take the child when she went in to dose. At 8:13 and 8:30 AM two different patients took their respective babies into the dosing booth to be dosed. Another observation revealed that the administering and dispensing was disrupted when the dispensing staff had to stop to have patients sign paperwork. During the review of the facility's incident reports it was documented that on August 31 and September 8, 2010 there were dosing errors that specified they were a direct result of the disruptive activities that occurred in the dispensing area.
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Plan of Correction
We are implementing a policy whereby no one other than patients presenting for dosing, including infant children, are permitted in the dispensing area. At the same time we are preparing to request a waiver to exclude the application of this standard to infant children. We are also investigating various options regarding the limited provision of child care for patients while dosing and during counseling sessions and expect to implement within a few weeks.
Regarding "disruption" in the dosing area we have reminded our nursing staff regarding the importance of insuring that the act of dispensing medication cannot be compromised by patient behavior or other duties of their own. As the most regular point of contact for most patients with the program, it is impractical not to have nurses answer questions, convey messages and in some cases obtain signatures. Subsequent to this citation, we have reviewed these activities and redirected as much as possible to other staff and directed nurses to attend to any ancillary matters prior to initiating the dosing sequence. The nursing supervisor will insure that procedures are followed consistently.
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715.28(c)(1-5) LICENSURE Unusual incidents
(c) A narcotic treatment program shall file a written Unusual Incident Report with the Department within 48 hours following an unusual incident including the following:
(1) Complaints of patient abuse (physical, verbal, sexual and emotional).
(2) Death or serious injury due to trauma, suicide, medication error or unusual circumstances.
(3) Significant disruption of services due to a disaster such as a fire, storm, flood or other occurrence.
(4) Incidents with potential for negative community reaction or which the facility director believes may lead to community concern.
(5) Drug related hospitalization of a patient.
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Observations
Based on review of administrative documentation, the facility failed to submit documentation of unusual incidents to the Department as required. The findings include:The incident report folder was presented for review by the facility's executive director on October 4, 2010 at approximately 9:00 AM. The incident reports for 2010 were reviewed. On 8-25-2010, 8-27-1010, 8-28-2010 and 9-3-2010, individual patients were sent to hospital emergency rooms for possible drug-interaction related symptoms. On 8-27-10 and 9-3-10, it was the same patient who required emergency medical treatment. There was no documentation this was submitted to the Department as required.
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Plan of Correction
A policy and procedure is already in place instructing all personnel to report in writing any events fitting the description in this standard to the program director who is responsible for forwarding this information to the department by fax. Additionally, security personnel have been instructed to report in writing to the program director, executive director, managing director, nursing supervisor and clinical supervisor incident reports that respond to a variety of events broader than, but inclusive of all of the events described in this standard. Those five individuals review such reports for a variety of purposes including assessing whether or not they meet the criteria for reporting to the department. In such cases the program director is responsible for faxing this information to the department. |