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 January 3, 2012 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, UHS Recovery Foundation, Inc. was found not to be in compliance with the applicable chapters of 4 PA Code and 28 PA Code which pertain to the facility. The following deficiencies were identified during this inspection.
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Plan of Correction
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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 the review of patient records, the facility failed to document the attempt or completion of patient follow up contact in three of four patient records reviewed.
The findings include:
Seven patient records were reviewed January 3, 2012. Four patient records required documentation of an attempt or completion of a follow up contact. The facility failed to document follow-up in patient records # 2, 3, and 4.
Patient # 2 was admitted August 23, 2011. The patient was discharged as having completed treatment on September 11, 2011. The follow up contact was required to have been attempted within seven days of the referral appointment. The patient had an appointment on September 13, 2011. There was no documented follow up in this patient record at the time of the inspection.
Patient # 3 was admitted October 11, 2011 and discharged on October 27, 2011. The follow up contact was required to have been attempted within seven days of the referral appointment. There was no documented follow up in this patient record at the time of the inspection.
Patient # 4 was admitted July 4, 2011 and was discharged as having completed treatment on August 1, 2011. The follow up contact was required to have been attempted within seven days of the referral appointment. There was no documented follow up in this patient recordtat the time of the inspection.
The CEO confirmed this finding.
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Plan of Correction
All clinical staff have been trained on the importance of confirming each client's follow-up appointment within seven days of discharge. Director of Clinical Services held an inservice training on January 10, 2012 for this purpose. Follow-up calls will be made and documented by case managers within seven days of discharge. Compliance will be monitored during monthly closed chart audits conducted by the Clinical Coordinator and reported at Performance Improvement meeting each month. |
709.32(b) LICENSURE Medication Control
709.32. Medication control.
(b) Verbal medication orders may be accepted but shall be put in writing and signed within 24 hours thereafter by the prescribing physician.
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Observations
Based on the review of patient records, the facility failed to ensure the physician or certified registered nurse practitioner signed the verbal order within 24 hours as required by the regulations in one of one records reviewed.
The findings include:
Seven patient records were reviewed January 3, 2012. One record contained documentation of a physician and a certified registered nurse practitioners verbal order. While the physician did sign these verbal order in patient record # 2, the date was not legible and one could not determine if the order was signed within 24 hours. Also, in the same record the certified registered nurse practitioner gave a verbal order on 9/1/2011. The verbal order was not signed off until 9/6/2011. This exceeded the allotted 24 hours for authentication for a verbal order.
The Director of Nursing confirmed this finding. This is a repeat citation from the January 20, 2011 buprenorphine monitoring inspection.
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Plan of Correction
Nurse receiving verbal order will fax via secure fax all verbal orders/ telephone verbal orders to the author of the verbal order. The physician who gave the verbal order will electronically sign the order and secure fax back to nursing within 24 hours.
The signed returned copy will be placed on top of the original order, stapled together and placed in the chart in the physician order section by the receiving nurse. All nursing staff and physicians will be trained by DON in new procedure and procedure will be implemented by 3/1/12. This process will be monitored by Director of Nursing and will be audited via 24 hour chart checks for compliance. Results will be reported at monthly Performance Improvement meeting.
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