INITIAL COMMENTS
|
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 14, 2014 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, White Deer Run Inc. - Lancaster was found not to be in compliance with the applicable chapters of 4 PA Code and 28 PA Code which pertain to the facility.
|
Plan of Correction
|
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.
|
Observations
Based on a review of patient records, the facility failed to show documentation that the physician made a face-to-face contact with the patients prior to being dosed in nine of twelve patient records.
The findings include:
Twelve patient records were reviewed on October 14, 2014. All patient records were reviewed for documentation showing that the physician made a face-to-face determination of whether the patient is currently physiologically dependent on a narcotic drug and have been dependent for a least 1 year prior to admission. The facility failed to document this face-to-face contact in patient records, #1, 2, 3, 4, 5, 6, 7, 9 and 10.
Patient #1 was admitted on October 10, 2014 and dosed on October 11, 2014.
Patient #2 was admitted on October 11, 2014 and dosed on October 12, 2014.
Patient #3 was admitted on October 9, 2014 and dosed on October 10, 2014.
Patient #4 was admitted on October 9, 2014 and dosed on October 10, 2014.
Patient #5 was admitted on September 14, 2014 and dosed on September 14, 2014.
Patient #6 was admitted on September 5, 2014 and dosed on September 6, 2014.
Patient #7 was admitted on April 8, 2014 and dosed on April 9, 2014.
Patient #9 was admitted on October 10, 2014 and at this present time was not dosed due to sickness.
Patient #10 was admitted on April 2, 2014 and dosed on April 3, 2014.
These findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
Pysician and or Nurse Practiioner will ensure the Opioid Dependency Criteria Checklist is completed when they meet with the client and prior to the client being dosed. This will be implemented immediately. Campus Director will review 10 charts per month for the next 3 months and then randomly after. |
715.11 LICENSURE Confidentiality of patient records
A narcotic treatment program shall physically secure and maintain the confidentiality of all patient records in accordance with 42 CFR 2.22 (relating to notice to patients of Federal confidentiality requirements) and § 709.28 (relating to confidentiality).
|
Observations
Based on a review of patient records, the facility failed to obtain informed and voluntary consents in four of twelve records reviewed.
The findings include:
Twelve patient records were reviewed on October 14, 2014. Eleven of the twelve were reviewed for informed and voluntary consent forms. The facility failed to document informed and voluntary consents in four patient records, specifically records, #1, 2, 5 and 9.
Client record #1 contained a consent to release information form dated 10/10/14 to a local pharmacy that exceeded 4 PA Code 255.5 by allowing the facility to release the following information: Treatment plan & treatment plan updates, case consultations, multidisciplinary discharge summary, psychosocial diagnostic summary, psychological tests, psychological evaluations, psychosocial evaluations, continuing care plan, legal status, medical history & physical exam, nursing assessment, PPD results, mandatory testing results and brief description of progress & prognosis. The purpose for the release was documented as back up pharmacy. Additionally, a consent to release information form dated 10/10/14 to the funding source failed to have documented the patient's signature and date.
Client record #2 contained a consent to release information form dated 10/11/14 to a local pharmacy that exceeded 4 PA Code 255.5 by allowing the facility to release the following information: Treatment plan & treatment plan updates, case consultations, multidisciplinary discharge summary, psychosocial diagnostic summary, psychological tests, psychological evaluations, psychosocial evaluations, continuing care plan, legal status, medical history & physical exam, nursing assessment, PPD results, mandatory testing results and brief description of progress & prognosis. Additionally, the purpose for the release was not documented on the consent form.
Client #5 contained a consent to release information form dated 9/14/14 for the patient's emergency contact that failed to have the date the patient signed the consent form.
Client #9 contained a consent to release information form dated 10/10/14 for the patient's funding source which failed to document the purpose of the release.
These findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
Nurse Manager and Campus Director will schedule a training for all staff to review Confidentiality as it pertains to Consents to Release information. The training will be completed by November 20, 2014 in the all staff meeting. Nurse Manager will review 10 charts per month for the following 3 months and then randomly after that to verify consents are being completed correctly. |