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 October 9, 2013 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Pyramid Healthcare, 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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715.9(a)(4) 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:
(4) Have a narcotic treatment physician make a face-to-face determination of whether an individual is currently physiologically dependent upon a narcotic drug and has been physiologically dependent for at least 1 year prior to admission for maintenance treatment. The narcotic treatment physician shall document in the patient 's record the basis for the determination of current dependency and evidence of a 1 year history of addiction.
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Observations
Based on the review of clinical documentation, the facility failed to document the basis for determining current opiate dependency prior to medicating the patient in one of five patient records.
The findings include:
Five patient records were reviewed on October 7-9, 2013. The five patient records were required to include the physician's documentation of the basis for determining current opiate dependency prior to medicating the patient. The facility failed to document the basis for determining current opiate dependency prior to medicating patient #1.
Patient # 1 was admitted on October 5, 2013 and was given an initial dose on October 6, 2013. The physician's documentation of current opiate dependency was not completed until October 8, 2013.
An interview with the Facility Director, Director of Nursing and Nurse Supervisor was completed on October 9, 2013 and the aforementioned information was confirmed.
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Plan of Correction
The date on the physician documentation of addiction was not clear. It appears as though the physician dated the document as 10/08/2013 then wrote a 6 over the 8 instead of drawing a line through the error and rewriting the correct date. DON met with physician on 10/22/13 to review the proper procedure for correcting errors in the medical record. The physician documentation of addiction will be completed prior to the administration of Subutex. This was reviewed with physician on 11/26/13. In addition, a stamper will be used to ensure the date is legible. The date stamper was put into effect on 11/4/13. The nurse supervisor will monitor and ensure compliance. |
715.14(a) LICENSURE Urine testing
(a) A narcotic treatment program shall complete an initial drug-screening urinalysis for each prospective patient and a random urinalysis at least monthly thereafter.
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Observations
Based on review of patient records, the facility failed to complete an initial drug-screening urinalysis prior to the administration of Subutex, a narcotic agent, in one of five patient records.
The findings include:
Five patient records were reviewed on October 7-9, 2013. The facility was required to complete an initial drug-screening urinalysis for the five patients prior to the administration of Subutex, a narcotic agent. The facility failed to document an initial drug-screening urinalysis prior to the administration of Subutex in patient record # 1.
Patient #1 was admitted on October 5, 2013 and the initial dose of Subutex was given on October 6, 2013 at 9:00 A.M. The facility failed to complete an initial drug-screening urinalysis prior to the administration of Subutex to patient # 1 as the urine screen results were not reported by the laboratory until October 8, 2013.
An interview with the Nurse Supervisor took place on October 9, 2013 at which time it was confirmed that there were no urinalysis results documented in the patient record prior to October 8, 2013.
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Plan of Correction
Nursing will be retrained to complete an initial drug screen prior to the administration of Subutex with a copy of the results to be placed on the medical chart. This was completed by 11/4/13. The nurse supervisor will monitor and ensure compliance. |
715.23(b)(4) LICENSURE Patient records
(b) Each patient file shall include the following information:
(4) The results of an initial intake physical examination.
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Observations
Based on an interview with the Facility Director, Director of Nursing and Nurse Supervisor, the facility failed to document individualized physical examinations in 5 of 5 patient records.
The findings include:
Physical examination forms contained in five patient records were reviewed on October 7-9, 2013. The vital signs documented on the physical examination forms contained in patient records # 1, 2, 3, 4 and 5 were identical and did not appear to be individualized. The vital signs documented for all five patients were: temperature of 97; respirations of 18; blood pressure of 130/80; and pulse of 75.
The findings of the patient record review were discussed and confirmed during an interview that was conducted with the Facility Director, Director of Nursing and Nurse Supervisor on October 9, 2013.
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Plan of Correction
The nursing staff will provide the physician with vital signs on each individual client during each physical examination completed. DON informed physician of reinforcement of procedure with nursing staff. Nursing staff will be trained and procedure will be in effect by 11/4/13. The nurse supervisor will monitor and ensure compliance. |