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 methadone and buprenorphine, in the treatment of narcotic addiction. This inspection was conducted on August 25-26, 2010 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, BGI of Brandywine, 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 and a plan of correction is due on September 27, 2010.
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Plan of Correction
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715.6(e) LICENSURE Physician Staffing
(e) A physician assistant or certified registered nurse practitioner may perform functions of a narcotic treatment physician in a narcotic treatment program if authorized by Federal, State and local laws and regulations, and if these functions are delegated to the physician assistant or certified registered nurse practitioner by the medical director, and records are properly countersigned by the medical director or a narcotic treatment physician. One-third of all required narcotic treatment physician time shall be provided by a narcotic treatment physician. Time provided by a physician assistant or certified registered nurse practitioner may not exceed two-thirds of the required narcotic treatment physician time.
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Observations
Based on a review of patient records, the facility failed to ensure the medical director or a narcotic treatment physician properly counter-signed the functions completed by the physician assistant in eight of nine patient records.
The findings include:
Eleven patient records were reviewed August 25-26, 2010. Nine patient records contained history and physical exams completed by the physician assistant (PA-C). When a PA-C completes the patient's history and physical, the medical director or narcotic treatment physician is to counter-sign within 72 hours.
Patient # 1 was admitted July 10, 2010. The history and physical was completed July 12, 2010. The physician failed to date his signature, therefore there was no way to determine when he counter-signed.
Patient # 3 was admitted January 19, 2010. The history and physical was completed by the PA-C January 20, 2010. The medical director counter-signed January 28, 2010.
Patient # 6 was admitted June 15, 2010. The history and physical was completed by the PA-C June 16, 2010. There was no counter-signature by the medical director or another treatment physician.
Patient # 7 was admitted May 10, 2010. The history and physical was completed by the PA-C May 11, 2010. The medical director counter-signed June 24, 2010.
Patient # 8 was admitted June 15, 2010. The history and physical was completed by the PA-C June 17, 2010. The medical director counter-signed June 24, 2010.
Patient # 9 was admitted August 16, 2010. The history and physical was completed by the PA-C August 17, 2010. The medical director counter-signed August 24, 2010.
Patient # 10 was admitted August 3, 2010. The history and physical was completed by the PA-C August 4, 2010. The medical director counter-signed August 24, 2010.
Patient # 10 was admitted August 3, 2010. The history and physical was completed by the PA-C August 4, 2010. The medical director counter-signed August 24, 2010.
Patient # 11 was admitted August 11, 2010. The history and physical was completed by the PA-C August 12, 2010. The medical director counter-signed August 24, 2010.
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Plan of Correction
As of 9/10/2010, Physician Assistant is using a brightly colored post-it flag for all orders written that need signed within 72 hours by medical directgor or NTP. These are placed on the top row of our "chart check" rack for easy accessibility for signature.
There is an NTP 7 days per week. Each day one is assigned to signing off on these orders.
There is a daily chart check process done by a designated nurse to assure compliance, however, ultimate responsibility to assure these are done is by the medical director on a daily basis. |
715.17(b) LICENSURE Medication control
(b) A narcotic treatment program shall develop policies and procedures regarding verbal medication orders, including the issuing and receiving of orders, identifying circumstances when orders are appropriate and documenting orders, in accordance with applicable Federal and State statutes and regulations.
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Observations
Based on the review of patient records and administrative documentation, the facility failed to ensure the physician signed verbal orders in accordance with Federal and State statutes and regulations.
The findings include:
Eleven patient records were reviewed August 25-26, 2010. Patient record # 1 contained documentation of a telephone verbal order on July 10, 2010. There was no signature of the physician who issued the verbal order.
In addition, the facility contracted with an independent pharmacist to inspect the drug storage areas at least quarterly. These reports were reviewed August 26, 2010. The time frame reviewed was November 30, 2009 to July 31, 2010. The pharmacist documented the failure of the physician to sign the verbal orders within 24 hours as required on the following dates:
December 31, 2009 inspection noted a verbal order without the physician's signature on December 5, 2009.
January 31, 2010 inspection noted verbal orders written without physician signatures on January 4 and January 5, 2010.
March 31, 2010 inspection noted verbal orders written on March 8, 2010 without a physician signature.
May 31, 2010 inspection noted verbal orders written on May 4, 2010 without a physician's signature.
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Plan of Correction
The physician did not comply with the facility's verbal order policy which requires signature, date and time within twenty-four hours of a verbal order. Beginning 10/25/10, the Director of Nursing, or designee, will audit five charts weekly for four weeks to ensure ongoing compliance. |
715.20(4) LICENSURE Patient transfers
A narcotic treatment program shall develop written transfer policies and procedures which shall require that the narcotic treatment program transfer a patient to another narcotic treatment program for continued maintenance, detoxification or another treatment activity within 7 days of the request of the patient.
(4) The receiving narcotic treatment program shall document in writing that it notified the transferring narcotic treatment program of the admission of the patient and the date of the initial dose given to the patient by the receiving narcotic treatment program.
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Observations
Based on the review of patient records, the facility failed to document that it notified the referring facility of the admission and initial dosing of the patient in two of three patient records.
The findings include:
Eleven patient records were reviewed August 25-26, 2010. Three patient records were reviewed for documentation of notification to the referring facility of the admission and initial dosing of the referred patient. Patient records # 5 and 10 were referred by another narcotic treatment program and there was no documentation of the referral facility being notified of the admission and initial dosing of the patients.
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Plan of Correction
During the 2 weeks post-audit, the Director of Nursing did a cross check of all missing entries on the MAR's with who was the resonsible med nurse. Those staff responsible for such omissions were placed on an EIP (Employee Improvement Plan.)
This item, as of 9/20/2010, this item has been added to the daily "chart checks" done by a designated nursing staff person with results reported back to the Director of Nursing. Additionally, this item is checked weekly by our Quality Designee in the Nursing Department with results reported back to the Director of Nursing.
Any non-compliance with this issue will be handled utilizing the Progressive Discipline Process and will be the responsibility of the Director of Nursing. |