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 20, 2010 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, White Deer Run-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. The following deficiencies were identified during this inspection and a plan of correction is due on November 10, 2010.
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Plan of Correction
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715.23(b)(13) LICENSURE Patient records
(b) Each patient file shall include the following information:
(13) Patient record of services.
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Observations
Based on a review of patient records and a discussion with administrative staff, the facility failed to document a complete record of service in four out of five records, as required.
The findings include:
Five patient records were reviewed on October 20, 2010. Five patient records were reviewed for a record of service. Per regulation, each patient record shall include a complete record of service. The facility failed to document a complete record of service in patient records # 1, 3, 4, and 5.
Patient # 1 was admitted into treatment on October 16, 2010. There was no documentation of a group note in the record of service for October 19, 2010.
Patient #3 was admitted into treatment on August 25, 2010 There was no documentation of group notes in the record of service for August 26 and August 27, 2010.
Patient #4 was admitted into treatment on May 21, 2010. There was no documentation of a group note in the record of service for May 24, 2010.
Patient #5 was admitted into treatment on July 14, 2010. There was no documentation in the record of service of group notes on July 16 and July 17, 29110.
An interview was conducted with administrative staff and it was confirmed that the record of service did not contain the group note documentation.
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Plan of Correction
A record of service will be completed for each patient. A process has been developed at other WDR locations to document the record of service for Detox patients who attend group sessions. The Regional Nursing Coordinator has obtained a copy of this format and will be responsible for implementation of this process in Lancaster. As Detox patients generally only attend a small number of group sessions a record of service form will be completed and entered into the client chart by the counselor conducting the group. Nursing will review the chart when the client is discharged from Detox. The Nursing Coordinator will conduct random, on-going chart reviews to ensure the record of service has been competed. The form and implementation of the process will occur by 11/30/2010. |
715.23(e) LICENSURE Patient records
(e) Patient file records, information and documentation shall be legible, accurate, complete, written in English and maintained on standardized forms or electronically.
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Observations
Based on a review of patient records and a discussion with administrative staff, the facility failed to provide patient records that were legible in two of five records reviewed.
The findings include:
Five patient records were reviewed on October 20, 2010. Five patient records contained physician notes. In two of five records the physician notes were not legible. In patient record # 1 the physician's orders were not legible as the physician's handwriting could not be read. In patient record # 4 the content of the physician's physical exam was not legible as the physician's handwriting could not be read.
This was discussed with administrative staff on October 20, 2010 and it was confirmed that the physician's handwriting was not legible.
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Plan of Correction
The patient medical charts were complete however the handwritten orders by the one medical professional were not legible. In order to correct the issue concerning legibility we will implement the following:
1. The Regional Administrator and Regional Nursing Coordinator will be responsible to revise and replace the current physicians order form; medication administration form; and progress notes with forms that incorporate "check boxes" to simplify and clarify the doctor's orders in order to minimize and eliminate the potential for errors. 2. Develop a means for transcription of Doctors verbal orders. Currently we are evaluating the process used at other WDR locations to see if we can contract with an existing vendor for transcription services. We are also evaluating the use of a medical "voice recognition software package" which would allow the doctor to record his orders on a digital voice recorder which can then be downloaded by the nursing staff into the computer and allow a written transcript to be printed for inclusion into the client chart. We anticipate completing an evaluation of transcription options by 11/30/2010 and implementation of either the use of a transcription service or the purchase of a transcription software package by 12/15/2010.
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