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 November 12 and 13, 2009 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 December 13, 2009.
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Plan of Correction
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715.9(c) LICENSURE Intake
(c) If a patient was previously discharged from treatment at another narcotic treatment program, the admitting narcotic treatment program, with patient consent, shall contact the previous facility for the treatment history.
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Observations
Based on the review of patient records, the narcotic treatment program failed to contact the previous narcotic treatment program for the treatment history in one of four patient records.
The findings include:
Nine patient records were reviewed on November 12 and 13, 2009. Four records were reviewed that identified previous narcotic treatment history. Documentation that the facility attempted to obtain the patient's consent to contact the previous facility for the treatment history was missing in one of four patient records. Patient record # 8 did not contain documentation that, with patient consent, the previous facility was contacted for the treatment history.
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Plan of Correction
as of 12/7/09, the admissions director will retrain staff that attemtping to obtain prior treatment records is a requirement for any person indicating that they participated in prior NTP. They will request consent and document such request was made and it will become part of the clinical record.
Admissions director will complete chart audits on all incoming NTP patients to assure this process has been followed. |
715.10(c) LICENSURE Pregnant patients
(c) Counseling records and other appropriate patients records shall reflect the nature of prenatal support provided by the narcotic treatment program.
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Observations
Based on the review of patient records the narcotic treatment program failed to document that pregnant patients' records reflect the nature of prenatal support provided by the narcotic treatment program in two out of four records.
The findings include:
Nine patient records were reviewed on November 12 and 13, 2009. Four pregnant patient records were reviewed for prenatal support provided by the program. Two patient records, # 4 and #6 did not contain documentation on the treatment plan that identified the nature of the prenatal support provided by the narcotic treatment program.
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Plan of Correction
As of 12/7/09
Clinical director will meet with counselor primarily responsible for workingw tih the pregnant females and reorient during supervision the need to document prenatal servicdes in the treatment planning process. During Supervision and chart audits, the clinical director will monitor documentation of initial aftercare plans, support services already in place as well as those needed prior to discharge. Will work close with medical in documenting clinic, OBGYN, community resources, and parent-child programs. |
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 the review of patient records and interviews with staff, the narcotic treatment program failed to document that an initial drug-screening urinalysis was conducted for each prospective patient prior to dosing in two out of nine patient records.
The findings include:
Nine patient records were reviewed on November 12 and 13, 2009. Nine patient records were reviewed for an initial drug screening urinalysis. Two patient records #1 and #2 did not contain documentation of an initial drug-screening urinalysis prior to dosing. This information was confirmed by staff during the on-site review of the documentation.
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Plan of Correction
As of 12/7/09, the Director of Nursing identified an area on the MAR for documentation of the drug screening urinalysis. This area immediately precedes documentation of the first dose to be given to assure no first dose is given without the drug screenign urinalysis documentation being present. Per Shift audit processes will occur by the charge nurses to assure this process is followed.
Director of Nursing will review audit findings to assure ongoign compliance. |
715.15(b) LICENSURE Medication dosage
(b) The narcotic treatment physician shall determine the proper dosage level for a patient, except as otherwise provided in this section. If the narcotic treatment physician determining the initial dose is not the narcotic treatment physician who conducted the patient examination, the narcotic treatment physician shall consult with the narcotic treatment physician who performed the examination before determining the patient 's initial dose and schedule.
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Observations
Based on the review of patient records and staff interview, the narcotic treatment program failed to document a consult with the narcotic treatment physician and the physician assistant (PAc) preforming the patient examination before determining the patient's initial dose and schedule in nine out of nine patient records.
The findings include:
Nine patient records were reviewed on November 12 and 13, 2009. Nine patient records were reviewed for documentation of consultations. Based on the review of nine patient records, the facility failed to provide documentation verifying that the physician who determined the dose had consulted with the PAc who had performed the patient examination. Specifically, this was noted in nine of nine patient records reviewed, # 1, 2, 3, 4, 5, 6, 7, 8, and 9. Interviews with staff confirmed that the PAc does complete the patient examination; there was no documentation of a physician to PAc consultation in any of the patient records.
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Plan of Correction
This Executive Director, in consultation with NTP staff edited current "face to face" form to include an item indicating that a consultation was had if a different NTP did the H & P than the NTP that did the face to face.
This form will be implemented as of 12/8/09.
Random chart audits done by daily nursing shifts and reviewed by Director of Nursing will assure proper form is being used and the consult is being documented appropriately. |
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 staff interviews, the narcotic treatment program failed to document in the patient record the verbal medication order or the physician sign off of the order in one out of nine patient records.
The findings include:
Nine patient records were reviewed on November 12 and 13, 2009. One patient record, #1, required documentation of a verbal order issued on March 3, 2009 and documented in the nursing progress notes. There is no documentation in the patient record of the physician order or the physician signing off on the verbal medication order.
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Plan of Correction
Director of Nursing will implement a standardized verbal order documentation process to be in place by 12/14/09.
Daily per shift, chart audit process completed by charge nurses to assure compliance with procedure.
Director of Nursing will review audit results to assure ongoing compliance. |
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, the narcotic treatment program failed to document the results of the mantoux test in one out of nine patient records.
The findings include:
Nine patient records were reviewed on November 12 and 13, 2009. One of nine patient records, record #3, did not contain documentation of a mantoux test being completed.
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Plan of Correction
As of 12/7/09, all staff reoriented to teh proper Mantoux test procedure and associated documentation.
Daily, per shift, chart audits done by charge nurses to assure compliance with procedure.
REview of audit process done by Director of Nursing to assure ongoing compliance. |
715.23(d)(1) LICENSURE Patient records
(d) A narcotic treatment program shall prepare a treatment plan that outlines realistic short and long-term treatment goals which are mutually acceptable to the patient and the narcotic treatment program.
(1) The treatment plan shall identify the behavioral tasks a patient shall perform to complete each short-term goal.
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Observations
Based on the review of patient records, the narcotic treatment program failed to document support services in treatment plans in five of nine patient records.
The findings include:
Nine patient records were reviewed on November 12 and 13, 2009. Treatment plans were required in nine patient records. The narcotic treatment program did not document support services in the treatment plan in patient records # 3, 5, 6, 8 and 9.
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Plan of Correction
During Supervision the clinical director will review with staff treatment care plans, the need to document support services and also to document this as part of initial after care planning. During weekly chart audits, support services documentation will be monitored. Such reviews will be documented in supervision notes and chart audits as applicable.
This will begin as of 12/7/09 |