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 residential detoxification from opioid dependence. This inspection was conducted on January 22 and 23, 2008 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Gaudenaia Common Ground was found not to be in compliance with the applicable chapters of 28 PA Code which pertain to the facility. Deficiencies were identified during this inspection and plan of correction is due on February 18, 2008.
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Plan of Correction
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715.9(a)(2) 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:
(2) Verify the individual 's identity, including name, address, date of birth, emergency contact and other identifying data.
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Observations
Based on a random review of 11 patient records, the facility failed to provide documentation verifying the individual's identity, to include proof of name, date of birth and address in four of eleven records, specifically patient records #2, 4, 9 and 10.
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Plan of Correction
The Nurse Manager will inservice all nurses, intake specialist, and other staff regarding the need for documentation verifying the identity of persons's served, including name, address, and date of birth. Inservice shall be completed by 2/14/08. Nurse Manager shall also monitor compliance for 3 months and report outcome on her monthly Performance Improvement report to be reviewed in the monthly regional PI committee meeting. |
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).
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Observations
A random review of eleven patient records revealed that patient # 1's record contained more than one patient name. Specifically, a line was drawn through another patient's name and information on the intake form which was then reused in the process of patient # 1's admission; both patient names and information were clearly readable. Further, patient # 8 signed a consent to release information that failed to document whether the patient was offered a copy of stated consent.
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Plan of Correction
The Nurse Manager will inservice all staff on the proper procedures for completion of all forms to assure compliance with confidentiality regulations. Inservice shall include but not be limited to, restricting one patient name to each form, indicating whether the client was offered/accepted a copy of consents to release information, and completing all form components in their entirety. This inservice shall be completed by 2/14/08. Specific staff idntified during the monitoring visit have already been re-trained. Nurse Manager will monitor comliance for 3 months and report status on her monthly Performance Improvement report to be reviewed in the regional PI committee meeting. |
715.23(b)(2) LICENSURE Patient records
(b) Each patient file shall include the following information
(2) A complete drug and alcohol history.
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Observations
A random review of eleven patient records revealed eleven records failed to document the progression of drug and alcohol use in the patient histories.
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Plan of Correction
Nurse Manager will conduct inservice for nurses and any relevant counslors regarding documentation of progression of D&A use in the client histories. Inservice shall be completed by 2/14/2008. Nurse Manager will monitor compliance for 3 months and will report in her monthly Performance Improvement report to be reviewed at the regional monthly PI committee meeting. |