INITIAL COMMENTS
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This report is a result of an onsite inspection pertaining to incident reports received by the Department. The inspection was conducted on August 8, 2012 by staff from the the Division of Drug and Alcohol Program Licensure. Based on the findings of the onsite follow-up inspection, White Deer Run, Inc. 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.
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Plan of Correction
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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 the review of patient records, the facility failed to demonstrate that the narcotic treatment physician documented the initial dose and schedule following the completion of the physical examination in one of five records. Additionally, the narcotic treatment physician failed to document his justification for ordering the administration of methadone when the patient did not have a positive urine drug screen for opiates in two of five records. The findings include:Five patient records were reviewed August 8, 2012. Patient record # 4 contained documentation that the narcotic treatment physician determined the dose and schedule for the patient prior to the completion of history and physical examination. The methadone order sheet was completed by the narcotic treatment physician on April 19, 2012 at 9:58 a.m. This documentation included a dosing order for methadone that was determined prior to the completion of the history and physical examination. The history and physical examination was completed on April 19, 2012 at 11:59 am. Patient # 5 was admitted to the program on March 7, 2012. Documentation in the patient record revealed that the patient received her first dose of 15 mg of methadone on March 8, 2012 at 1:30 pm. The urine drug screen results indicated that the patient had a negative drug screen for opiates and methadone. There was no documentation in the patient record that specified a rationale for dosing the patient without a positive drug screen for opiates. Patient # 1 was admitted to the program on January 6, 2011. Documentation in the record revealed the patient received his first dose of 15 mg of methadone on January 7, 2011 at 12:00 p.m. The urine drug screen results indicated that the patient had a negative drug screen for both opiates and methadone. There was no documentation in the patient record that specified a rationale for dosing the patient without a positive drug screen for opiates.
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Plan of Correction
The Director of Nursing and Regional Administrator reviewed with physicians on August 31, 2012 the requirements of Policy 715.24 Narcotic Detoxification which states: Methodone will not be administered until the Narcotic Treatment Physician (NTP) has completed an comprehensive physical examination of the client, and review of the UDS. The examination will specific history of opioid/opiate drug use and whether the client is physically dependent on opioid/opiates drugs. This will be evidenced by timely and legible documentation in the client's record by the NTP.
Effective August 31, 2012 upon receipt of the electronic UDS results, a copy will be printed; nursing staff will review, date, time, and initial the results. The nurse will review results with the NTP. The narcotic treatment physician will sign, date and time the lab results prior to the ordering of the initial dosing. The nurse will be responsible for ensuring the results are filed in the client's record.
Nursing Staff were trained on the above process August 31, 2012. Ongoing random audits will occur to ensure compliance.
Clients who UDS results show negative for opiates yet present with active withdrawal symptoms as evidenced during the physical examinations, COWS scoring, and clients history will be treated on an individualized basis. If the NTP deems a patient appropriate for Methadone, based on the above indicators the narcotic treatment physician will document these findings in the client's record supporting the administration of Methodone.
Ongoing, weekly random audits of 15 charts will be conducted by the Nurse Manager, and/or designee to ensure compliance with M115.
The Methodone Initial Dosing Chart Audit (MIDCA) Form will be implemented and utilized by September 10, 2012. The MIDCA will track the results of information obtained audits including audit date, number, patient name, , UDS submission date, results, review with NTP, COWS scores, order, administration, legibility, and findings. Results of the weekly random chart audits will be sent to the Director of Nursing and Regional Administrator for review.
When an audit indicates a deficiency of less than 100% compliance per week, a meeting with the Physician and Nurse Manager, or designee will occur within 72 hours to review the deficiency and correct as needed.
These indicators will be included in the tracking process allowing WDR Allenwood to identify patterns, individuals, and to take appropriate disciplinary actions as needed.
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715.23(e) LICENSURE Patient records
(e) Patient file records, information and documentation shall be legible, accurate, complete, written in English and maintained on standardized forms or electronically.
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Observations
Based on the review of patient records, the facility failed to ensure that the documentation in the record was legible.The findings include:Based on the review of patient records, the facility failed to ensure that the documentation included in the patient record was legible in all records reviewed. Five patient records were reviewed on August 8, 2012. All records included documentation by the narcotic treatment physician that was not legible. Facility staff was asked to translate the information in the patient record. This finding was confirmed by the Director of Nursing.
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Plan of Correction
The Director of Nursing and Regional Administrator met with the NTPs on August 31, 2012 to review the standards related to legibility of documentation of chart entries, and ongoing compliance.
Accuracy and legibility of documentation is included as part of the ongoing weekly random chart Audits as per the Methodone Initial Dosing Audit (MIDCA) Policy and form.
When an audit indicates a deficiency of less than 100% compliance per week, a meeting with the Physician and Nurse Manager, or designee will occur within 72 hours to review the deficiency and correct as needed.
These indicators will be included in the tracking process allowing WDR Allenwood to identify patterns, individuals, and to take appropriate disciplinary actions
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715.26(a) LICENSURE Security
(a) A narcotic treatment program shall meet the security standards for the distribution and storage of controlled substances as required by Federal regulations, including 21 CFR 1301.72 and 1301.74 (relating to physical security controls; and other security controls) and State statutes and regulations.
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Observations
Based on a review of patient records, the facility failed to provide secure storage for all controlled substances within the facility.The findings include: Five patient records were reviewed on August 8, 2012. Two patient records revealed that the patients had medications in their possession that were not secured by the facility. Patient # 1 was admitted to the program on January 6, 2011 and was found unresponsive in his room on January 11, 2011. The client was pronounced dead at the facility on January 11, 2011 at 0202 hours by the coroner. The corner's report indicated the cause of death was suicide due to an adverse effect (overdose) of medications. Patient # 4 was admitted to the program on April 18, 2012 and was discharged on April 24, 2012. Documentation in the patient record revealed the patient was transported to the hospital on April 21, 2012 due to a possible overdose. Prior to the patient's hospital admission, facility staff responded medically to the needs of the patient and provided her with three doses of Narcan prior to the arrival of paramedics. Documentation in the patient's record indicated the patient admitted to ingesting medications (specifically benzodiazepines) that she brought into treatment in the pocket of a jacket she was wearing at the time of admission. The disclosure made by the patient confirmed that the patient had medication that had not been provided to her by facility staff.
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Plan of Correction
Client Search Guidelines revised/enhanced and implemented.
Clients admitting to WDR Allenwood sign the Consent for Treatment and Patient Orientation Form which includes consent for body search and search of personal belongings at the time of admission. Clients agree by signing such documents they understand throughout treatment staff may deem it necessary to inspect person, possessions, room search. It is imperative staff communicates such and they ensure the client understands the agreement. Clients shall always be afforded privacy during a body search.
Any suspicion behavior should be immediately communicated to the nursing staff. The nursing staff will determine if further evaluation and/or examination are needed including up to cavity search (only with consent of client). A UDS will be required. In the event a client refuses the case shall be referred to the Regional Administrator to determine next steps including up to Administrative Discharge.
All staff escorting, assisting with and/or performing searches and nursing staff will be been trained on the new client search guidelines by 09/21/2012.
Client Search Observation Checklist developed and implemented. The competency based tool allows supervisors to directly obverse/monitor staff performing searches.
Based on direct observation, any staff requiring additional training or supervision shall receive such training prior to assisting in additional searches and up to employee improvement sessions.
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709.53(a)(10) LICENSURE Discharge Summary
709.53. Client records.
(a) There shall be a complete client record on an individual which includes information relative to the client's involvement with the project. This shall include, but not be limited to, the following:
(10) Discharge summary.
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Observations
Based on the review of patient records, the facility failed to document a discharge summary that included a summary of events that took place during the patient's treatment stay in three of five patient records.The findings include: Five patient records were reviewed on August 8, 2012. All records required a discharge summary. Patient # 1 was admitted on January 6, 2011 and discharged on January 11, 2011. The discharge summary included in the patient record failed to indicate the reason the patient sought treatment nor did the summary summarize this patient's treatment stay. The patient suffered a medical emergency while in treatment and died at the facility. The discharge summary failed to include the details of the death in the documentation and, although the patient was deceased, the treatment recommendations specified that the patient continue at the same level of care.Patient # 2 was admitted on April 20, 2012 and discharged on April 22, 2012. The discharge summary failed to include an individualized reason for treatment. The reason for admission was generic and the same statement was documented in two other client records that were reviewed (patient records 3 & 4). The reason for admission documented on the discharge summary was, "Client was admitted to detox and was motivated to make changes." Patient # 3 was admitted on April 23, 2012 and discharged on April 25, 2012. Patient # 4 was admitted on April 18, 2012 and discharged on April 24, 2012. The discharge summaries in both records failed to include an individualized reason for treatment. The reasons for admission were identical in both records and the reason for admission stated, "Client was admitted to detox and was motivated to make changes in (her) life, however, at this time was not medically appropriate to complete and participate in treatment at this time." The discharge summaries for patients # 3 and 4 contained identical information and typographical errors in the following areas: Reason for admission, history of present illness, services offered while in treatment, individual services offered while in treatment, course and progress during treatment/ level of attainment, and prognosis. The last name documented on both discharge summaries was the same and the last name of the patient identified on the form was not correct for either patient. The discharge summary in both of the patient records was not individualized or specific to the patient's treatment and failed to document the events that led to each patient's discharge from the facility. The findings were reviewed with the Director of Nursing and were not disputed.
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Plan of Correction
The Clinical Directors will meet with all clinical staff by September 10, 2012 to ensure discharge summaries are individualized and specific to the patient's treatment, and include events leading up to the patient's discharge.
Within 7 days post discharge, the Unit Supervisor will review discharge summaries for compliance. Upon completion of the review the Unit Supervisors will sign off on all discharge summaries.
Unit Supervisors will review with the Clinical Directors any non-compliant charts and will conduct ongoing supervision, and if needed employee improvement sessions with those Counselors that may require additional training.
Residential D & A Chart Audit form has been revised to include the above criteria and those outlined in Policy 709.53 Multi-Disciplinary Discharge Summary.
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