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 methadone and buprenorphine, in the treatment of narcotic addiction. This inspection was conducted on August 10-11, 2011 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, White Deer Run, 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)(1) 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:
(1) Verify that the individual has reached 18 years of age.
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Observations
Based on the review of patient records and discussion with facility staff, the facility failed to ensure all patients reached at least 18 prior to administration of a narcotic agent.The findings include:Eleven patient records were reviewed August 10-11, 2011. Eleven patient records required documentation of verification the patient had reached at least 18 years of age. Patient # 7 was admitted July 20, 2011. Documentation reviewed in the record showed the patient was 17 years of age at the time of admission. A urine drug screen was completed July 21, 2011. The patient was administered Suboxone, a narcotic agent used in the treatment of opiate addiction, on July 21, 2011. The narcotic agent was discontinued on July 26, 2011.
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Plan of Correction
White Deer Run Allenwood will no longer administer Suboxone to any patient under the age of 18. |
715.23(b)(11) LICENSURE Patient records
(b) Each patient file shall include the following information:
(11) Counselor notes regarding patient progress and status.
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Observations
Based on the review of patient records, the facility failed to document clinical notes regarding patient progress and status in four of nine patient records.The findings include:Eleven patient records were reviewed August 10-11, 2011. Progress notes were reviewed in nine of those patient records.Patient records # 1 and 2 contained clinical notes utilizing the DAP (data, assessment and plan) format. The "A" (assessment) failed to provide a clinical assessment of the patient's progress, but rather was more observational data.Patient records # 6 and 9 contained notes written by the counselors, but the content was medical information and nothing about the clinical and therapeutic progress of the patients. The nursing and medical staff are the staff to be writing the medical notes on the patient's signs and symptoms of the detoxification process. Patient record # 8 contained group notes that failed to include an individual comment for the individuals in the group. In addition, the facility's admission unit is using a pre-printed admission note; this was observed in all records reviewed.
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Plan of Correction
Clinical staff will be trained on the proper use of a DAP note. Detox Unit Clinical Supervisor will instruct Detox Clinical Staff on documenting patient's level of engagement and motivation versus medical notes. Training will be provided by the Detox Unit Clinical Supervisor by September 19th. Ongoing random chart reviews, 15 charts per week, will be conducted for 2 months to ensure compliance.
Structured Activity Notes (SAN) reflect patient's participation in psycho-educational activities. Small Group Notes are individualized.
The actual first admission note is completed by Nursing staff at the time of the Nursing Assessment.
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715.29(5) LICENSURE Exceptions
A narcotic treatment program is permitted, at the time of application or any time thereafter, to request an exception from a specific regulation.
(5) If the exception relates to a specific patient, the narcotic treatment program shall maintain documentation of the exception in the patient 's record.
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Observations
Based on the review of patient records and discussion with facility staff, the facility failed to wait for the response of the Department to an exception request regarding the adminsitration of a narcotic agent to a patient under the age of 18 years in one of one patient records. The findings include:Eleven patient records were reviewed August 10-11, 2011. One patient record required a Department approved exception prior to the administration of a narcotic agent. Patient # 7 was admitted July 20, 2011. Documentation reviewed in the record identified that the patient was 17 years of age at the time of admission. A urine drug screen was completed July 21, 2011. The patient was administered Suboxone, a narcotic agent used in the treatment of opiate addiction, on July 21, 2011. In order to be treated with Suboxone, the patient must be at least eighteen years of age. The facility submitted an exception request on July 22, 2011, requesting approval to provide Suboxone to the seventeen year old patient The Department denied the exception request on July 25, 2011 because of limited information and, according to documentation in the patient record, requested additional information from the facility pertaining to the patient's history and current drug history. The facility re-submitted the exception request on July 26, 2011 without adding more information and, again, the exception was denied. Facility records indicated the patient was dosed July 21 - July 26, 2011.
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Plan of Correction
If White Deer Run Allenwood files an exception to DOH for any reason, we will wait for a response from DOH before taking action. |