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 May 1, 2008 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, New Perspectives of White Deer Run 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 May 27, 2008.
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Plan of Correction
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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
Based on a review of 13 patient records, the facility failed to maintain confidentiality of patient records in accordance with 42 CFR Part 2 and 28 Pa. Code in two records, specifically patient records # 4 and 6. In patient record # 4, the full name of another patient was included in the record content. Patient record # 6 contained two consents to release information to the same agency, both consents were signed on the same date but each identified different, contradictory information that could be released.
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Plan of Correction
Nursing Leader will review confidentiality regulations with entire nursing staff at next nursing staff meeting on 6-4-08.
In addition, Nursing Leader will review at a minimum 10% of all patient records over the next 3 months for compliance. |
715.14(a) LICENSURE Urine testing
(a) A narcotic treatment program shall complete an initial drug-screening urinalysis for each prospective patient and a random urinalysis at least monthly thereafter.
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Observations
Based on a review of 13 patient records, the facility failed to obtain a complete urine drug screen analysis from a CLIA and Department of Health approved laboratory, as required by this Chapter, prior to the administration of Suboxone, a narcotic agent, in all 13 records reviewed.
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Plan of Correction
The Lead Nurse, or her designee, will audit 100% of the buprenorphine patient records for 30 days beginning July 14, 2008 to ensure that the results of the urine drug screen test are obtained and reviewed by the physician prior to administering buprenorphine. Thereafter, random monthly chart audits will be conducted by the Lead Nurse or her designee to ensure ongoing compliance. New Perspectives will comply withh the requirements of this standard until such time as the Division notifies all narcotic treatment programs of alternative options for compliance. |
715..23(b)(1) LICENSURE Patient records
(b) Each patient file shall include the following information:
(1) A complete personal history.
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Observations
Based on a review of 13 patient records, the facility failed to document a complete personal history in 5 records, specifically #1, 5, 6, 9, and 11. The personal histories contained brief or one-word answers with no clarification to the documented patient responses.
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Plan of Correction
Nursing Leader will review the personal history section with the entire nursing staff at the next nursing staff meeting on 6-4-08.
Nursing Leader will also review 100% of the records for compliance for the next 3 months. |