INITIAL COMMENTS
|
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 October 17-18, 2012 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.
|
Plan of Correction
|
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.
|
Observations
Based on the review of patient records, the facility failed to document verification that the individual has reached 18 years of age in two of nine patient records.
The findings include:
Nine patient records were reviewed October 17-18, 2012. All patient records were reviewed for documentation of verification that the individual has reached 18 years of age. Prior to administration of an agent, a narcotic treatment program shall screen each individual to determine eligibility for admission.
Patient #1 was admitted on August 9, 2012 and was discharged on August 29, 2012. The initial dose of Methadone was given to the patient on August 10, 2012. The facility failed to document verification that the individual had reached 18 years of age prior to administration of Methadone.
Patient #7 was admitted on October 9, 2012. The initial dose of Methadone was given to the patient on October 10, 2012. The facility failed to document verification that the individual had reached 18 years of age prior to administration of Methadone.
|
Plan of Correction
Admissions staff will ensure all incoming clients are aware they must possess a valid photo ID that identifies their age (i.e. Driver's License, State Photo ID Card) in order to participate in the narcotic treatment program.
Intake staff will collect the identification card upon intake and make copies for the client's chart.
If identification card is not available, intake staff will utilize the People Search website program to identify the person's age through use of social security number and other identifying information. A copy of the verification will be printed for the chart.
Until medical staff has received the documented verification of age, no client will be administered an agent.
The Charge Nurse will complete daily medical chart audits on all methadone clients to ensure compliance with verification of age and identity prior to receiving administration of an agent.
Age/identify verification will be added to the Pre-Methadone checklist, completed for all methadone clients prior to administration.
|
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.
|
Observations
Based on the review of patient records, the facility failed to verify the identity of the patient prior to the administration of an agent in one of nine patient records.
The findings include:
Nine patient records were reviewed on October 17-18, 2012. All patient records were reviewed for patient identity information. Patient records # 7 did not contain any verification of patient's identity.
Patient # 7 was admitted October 9, 2012. The initial dose of Methadone was give on October 10,2 012. The facility failed to identify the identity of the patient prior to the administration of Methadone.
|
Plan of Correction
Admissions staff will ensure all incoming clients are aware they must possess a valid photo ID that identifies their age (i.e. Driver's License, State Photo ID Card) in order to participate in the narcotic treatment program.
Intake staff will collect the identification card upon intake and make copies for the client's chart.
If identification card is not available, intake staff will utilize the People Search website to identify the person's age through use of social security number and other identifying information. A copy of the verification will be printed for the chart.
Until medical staff has received the documented verification of age, no client will be administered an agent.
The Charge Nurse will complete daily medical chart audits on all methadone clients to ensure compliance with verification of age and identity prior to receiving administration of an agent.
Age/identify verification will be added to the Pre-Methadone checklist, completed for all methadone clients prior to administration. |
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 the review of patient records, the facility failed to obtain an informed and voluntary consent for the disclosure of the information contained in three of eight patient records.
The findings include:
Nine patient records were reviewed on October 17-18, 2012. Informed consents to disclose information were reviewed in eight patient records. The facility failed to ensure that an informed and voluntary consent to release information was in three patient records reviewed, # 3, 4, and 8.
A review of patient record # 3 revealed the staff checked for authorization on an electronic verification system for a funding on August 28, 2012 without prior consent to release from the patient.
A review of patient record # 4 revealed the staff checked for authorization on an electronic verification system for a funding on August 24, 2012 without prior consent to release from the patient.
A review of patient record # 8 revealed the staff checked for authorization on an electronic verification system for a funding on October 11, 2012 without prior consent to release from the patient.
|
Plan of Correction
When the initial assessment is conducted off-site, consent to check for authoirzation of funding will be completed with the assessor/assessing agency.
The written consent completed by the off-site assessor/assessing agency will be sent to White Deer Run Allenwood Admission's Department and will be included in the written chart for such patient.
Medical Records will identify any invalid consent or breach of confidentiality during their audit of all closed charts. Medical Records staff will alert Regional Director, Clinical Director, and QI Coordinator of any situations of invalid consents or lack of consents. |
715.21(1)(i-iv) LICENSURE Patient termination
A narcotic treatment program shall develop and implement policies and procedures regarding involuntary terminations. Involuntary terminations shall be initiated only when all other efforts to retain the patient in the program have failed.
(1) A narcotic treatment program may involuntarily terminate a patient from the narcotic treatment program if it deems that the termination would be in the best interests of the health or safety of the patient and others, or the program finds any of the following conditions to exist:
(i) The patient has committed or threatened to commit acts of physical violence in or around the narcotic treatment program premises.
(ii) The patient possessed a controlled substance without a prescription or sold or distributed a controlled substance, in or around the narcotic treatment program premises.
(iii) The patient has been absent from the narcotic treatment program for 3 consecutive days or longer without cause.
(iv) The patient has failed to follow treatment plan objectives.
|
Observations
Based on the review of patient records, the facility failed to restrict the reasons for involuntary termination to those reasons allowed by regulation in one of one patient record.
The findings include:
Nine patient records were reviewed October 17-18, 2012. One patient record was reviewed for involuntary, or therapeutic, discharge. The facility failed to document all efforts to retain the patient in the program prior to initiating an involuntary termination. Patient record # 4 contained documentation of the patient being discharged for reasons other than those listed by regulation.
Patient # 4 was admitted to treatment on August 24, 2012 and involuntarily discharged on August 27, 2012. The patient was involuntarily terminated for allegedly stealing from a facility vehicle. This is not one of the reasons that a patient can be involuntarily terminated according to this regulation.
|
Plan of Correction
Clinical and Medical staff will participate in team meetings with Clinical Director and Nursing Director to review the involuntary termination policy for clients in the narcotic treatment program.
During the meetings, the policy will be distributed which outlines what constitutes the ability to involuntarily discharge someone from treatment.
Patients involved in problematic behaviors that could lead to an involuntary discharge will go through the following process:
1-The problem behaviors will be incorporated into their treatment plan and process.
2-The unit supervisor will meet with the clinical director to review case.
3-The clinical director will review case with regional administrator to discuss plan of action and to receive recommendations.
4-An Administrative Review Team will be assembled to meet with the client to discuss the behaviors and potential next steps of action.
In situations where an act or threat of violence has occurred, contact will be made to the clinical director, medical staff, and the regional administrator. In such situations, the client may be involuntarily discharged without participating in the above mentioned steps.
Prior to any involuntary discharge from treatment, the regional administrator will need to approve such discharge.
Nursing will also be made aware of all involuntary discharges in order to review any medical concerns.
|
715.23(b)(23) LICENSURE Patient records
(b) Each patient file shall include the following information:
(23) Discharge summary.
|
Observations
Based on the review of patient records, the narcotic treatment program failed to document complete discharge summaries in two of five patient records.
The findings include:
Nine patient records were reviewed on October 17-18, 2012. Discharge summaries were required in five patient records. The narcotic treatment program did not document discharge summaries in patient records #1 and 2.
Patient # 1 was admitted on August 9, 2012 and discharged on August 29, 2 012. The discharge summary was due by September 4, 2012. The facility failed to document a discharge summary as of the date of the inspection.
Patient # 2 was admitted on August 12, 2012 and discharged on August 31, 2012. The discharge summary was due by September 7, 2012. The facility failed to document a discharge summary as of the date of the inspection.
This finding was confirmed by facility staff and was not disputed.
|
Plan of Correction
Clinical Director will review with Unit Supervisors the findings of the lack of timeliness in completing discharge summaries.
Unit Supervisors will meet with their perspective staff to re-educate them on the necessity of completing discharge summaries for all clients within seven days of discharge. This will be done in writing and through verbal communication.
Medical Records staff will check each chart for a completed discharge summary. Any deficient discharge summaries will be sent on a list to all clinical staff, unit supervisors, clinical director, and regional administrator.
Unit Supervisors will complete chart audits with the focus being on completed discharge summaries. Each unit supervisor will complete a minimum of 3 audits per month for a six month time period (minimum of 21 charts per month total).
|