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 January 19, 2010 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, White Deer Run of 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 February 13, 2010.
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Plan of Correction
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715.23(b)(6) LICENSURE Patient records
(b) Each patient file shall include the following information:
(6) Results of laboratory tests or other special examinations given by the narcotic treatment program.
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Observations
Based on the review of patient records and the policy and procedure manual, the facility failed to complete all required laboratory tests as part of the admission process in three of four patient records reviewed.
The findings include:
The policy and procedure manual was reviewed on January 19, 2010. The policy for completing the admission laboratory tests includes reading the tuberculosis Mantoux test (PPD) in 48 hours and then at 72 hours.
Four patient records were reviewed January 19, 2010. Four patient records were reviewed for completed laboratory tests as part of the admission process, specifically a tuberculosis Mantoux test (PPD).
Patient # 1 had the PPD administered on 1-12-2010 @ 16:00. The patient discharged on 1-15-2010 without having the PPD read.
Patient # 3 had the PPD administered on 12-29-2009 @ 22:30. The PPD test results were read on 01-02-2010 @ 06:30, more than 72 hours later.
Patient # 4 had the PPD administered on 11-23-2009 @ 16:00. The PPD test results were read on 11-27-2009 @ 08:00, more than 72 hours later.
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Plan of Correction
The Regional Nurse Manager has scheduled a meeting with all facility nurses on Feb. 11, 2010 to review policy and procedures with all nursing staff. All nurses will be re-trained at this time with regard to proper administration and documentation of PPD tests. Additionally, the Nurse Manager will conduct on-going reviews of client charts to inspect them for accuracy and monitor that PPD tests are being given correctly and that documentation is in compliance with the regulation. |
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 the review of patient records, the facility failed to maintain a complete patient record of services in four of four patient records reviewed .
The findings include:
Four patient records were reviewed on January 19, 2010. Four patient records required documented record of services.
Patient records # 1, 2, 3 and 4 contained progress notes of provided services without an entry on the facility's record of services form.
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Plan of Correction
The Regional Administrator and Regional Clinical Director are currently interviewing applicants for an additional counselor position who will work with detox as well as rehab patients. This is a new position created on Jan 1, 2010. This counselor will be responsible for documenting the clinical services provided to detox clients including the completion of the record of service form. We anticipate hiring and completion of orientation by March 1st. The Clinical Director will conduct on-going chart reviews to ensure the record of service is documented. |
715.23(b)(15) LICENSURE Patient records
(b) Each patient file shall include the following information:
(15) Psychosocial evaluations of the patient.
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Observations
Based on the review of patient records, the facility failed to ensure the psychosocial evaluations included a clinical assessment of the historical data collected in three of four patient records.
The findings include:
Four patient records were reviewed on January 19, 2010. Four records required a psychosocial evaluation to be completed. Patient records # 2, 3 and 4 did not have a composite picture assessing the historical data that was collected, but rather repeated a segment of the drug and alcohol history and the assessment for treatment.
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Plan of Correction
The Regional Nursing Manager and Regional Clinical Director will conduct training with all of the facility nursing staff on Feb. 11, 2010 to ensure the psychosocial assessments contain a more accurate composite picture of the historical data gathered on the patient. Additionally the Regional Administrator and Regional Nursing Manager will be conducting nursing department meetings on a quarterly basis to continue the focus on quality improvement of the overall client documentation. Client charts will also be reviewed on an on-going basis and the Nurse Manager will be meeting regularly one-on-one with staff nurses to provide direction around quality improvement and to ensure charts are in compliance with the standard. |
715.23(b)(23) LICENSURE Patient records
(b) Each patient file shall include the following information:
(23) Discharge summary.
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Observations
Based on the review of patient records and discussion with the director, the facility failed to document a discharge summary in two of three patient records.
The findings include:
Four patient records were reviewed on January 19, 2010. Three patient records required a discharge summary or transfer note.
Patient # 2 was transferred into the rehabilitation program of the facility. There was no discharge summary completed or a transition note showing the transition from one level to the next. The director also reviewed the patient record and conceded it was not completed.
Patient # 4 left against facility advise on November 28, 2009. A discharge summary was not documented in the patient record.
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Plan of Correction
The Regional Nursing Manager will conduct a re-training on Feb. 11, 2010 and will ensure that all facility nurses are informed as to the requirements for discharge summaries and/or transfer notes related to detox clients. The Regional Clinical Director will also meet with Counseling staff prior to Feb. 15th and review policy and procedure with them to ensure they are completing discharge summaries in a timely manner ? the reviewed chart which was missing the discharge summary was a rehab client and therefore the responsibility of the counselor. The Regional Administrator will also meet with the medical secretary prior to Feb. 15th to review policy related to internal chart audits and to ensure her understanding of the timelines for completion of documentation. |