INITIAL COMMENTS
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This report is a result of an on-site plan of correction follow up inspection conducted on June 19, 2007 by staff from the Division of Drug and Alcohol Program Licensure. The following deficiencies were identified during this inspection and a plan of correction is due on July 27, 2007.
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Plan of Correction
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705.3 LICENSURE Living rooms and lounges.
705.3. Living rooms and lounges.
The residential facility shall contain at least one living room or lounge for the free and informal use of clients, their families and invited guests. The facility shall maintain furnishings in a state of good repair.
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Observations
The facility failed to provide for clean and sanitary living rooms and lounges. The carpets were worn, dirty and bug infested and the radiators were dusty and rusted. Residents complained that they were getting bug bites from the carpet and sinus infections from the dusty and rusted radiators.
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Plan of Correction
Nursing station, two Detox bedrooms and all hallways were tiled in the Spring. All remaining carpets are slated for deep cleaning 8/7/07. Housekeeper terminated c. 6/10/07 and had not done spring cleaning of radiators which are being done currently by new housekeeping staff. A short infestation of flying ants was dealt with by exterminator 6/8, 6/15 and 6/25/07 with no reoccurrence. Compliance of all cleaning will be monitored by the Program Director weekly beginning 8/1/07. |
705.4 (2) LICENSURE Counseling areas.
705.4. Counseling areas.
The residential facility shall:
(2) Maintain counseling areas with furnishings which are in good repair.
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Observations
The facility failed to provide for clean and sanitary counseling areas with furnishings that are in good repair. The carpets are stained and in poor condition and the radiators were dusty and rusted. Residents complained that they were getting bug bites from the carpet and sinus infections from the dusty and rusted radiators.
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Plan of Correction
All counseling areas (offices and group rooms) are scheduled for deep carpet cleaning 8/7/07. A short infestation of flying ants was dealt with by exterminator 6/8, 6/15 and 6/25/07 with no reoccurrence. Compliance of all cleaning will be monitored by the Program Director weekly beginning 8/1/07. |
715.9(a)(1) LICENSURE Intake
(a) Prior to administration of an agent, a narcotic treatment program shall screen each individual to determine eligibility for admission. The narcotic treatment program shall:
(1) Verify that the individual has reached 18 years of age.
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Observations
The facility failed to document that the clients represented by client records #1 and 2 were at least 18 years of age.
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Plan of Correction
Assessment and Nursing staff will not under any circumstances admit any opiate detox client for buprenorphine Detox without verified identification of age. If the client so accepts, he/she will be admitted under a non-buprenorphine protocol for Detox. When the physician approves a client for buprenorphine administration, their presented picture ID will be initialed by the first administering nurse. A memo will be circulated to Admissions and Assessor so stating by 8/15/07. Compliance will be monitored by the Assistant Director of Nursing by daily chart monitoring. |
715.9(a)(2) LICENSURE Intake
(a) Prior to administration of an agent, a narcotic treatment program shall screen each individual to determine eligibility for admission. The narcotic treatment program shall:
(2) Verify the individual 's identity, including name, address, date of birth, emergency contact and other identifying data.
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Observations
The facility failed to document verification of the individual's identity, including name, address, date of birth, emergency contact and other identifying data for the clients represented by client records # 1 and 2.
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Plan of Correction
Assessment and Nursing staff will not under any circumstances admit any opiate detox client for buprenorphine Detox without verified identification of name, address, date of birth, emergency contact and/or other identifying data. Emergency contact information will be added to our facility photo ID with a signed Consent in the chart. Compliance will be monitored by the Assistant Director of Nursing by daily chart monitoring. |
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
The facility failed to provide for a complete consent to release information document for the client represented by client record #2. The release form failed to indicate who the recipient of the information would be.
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Plan of Correction
Assessment staff will be trained by the Assessment Supervisor and Nursing staff will re-trained by the Assistant Director of Nursing on completion in full of all Release forms.
Compliance will be monitored by the Assistant Director of Nursing by daily chart monitoring.
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715.13(a) LICENSURE Patient identification
(a) A narcotic treatment program shall use a system for patient identification for the purpose of verifying the correct identity of a patient prior to administration of an agent.
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Observations
The facility failed to include a name and birth date with the identification photograph in client record # 2.
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Plan of Correction
All client identification will note name and birth date, as well as other identifying data.
Compliance will be monitored by the Assistant Director of Nursing by daily chart monitoring beginning 8/1/07.
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715.13(b) LICENSURE Patient identification
(b) A narcotic treatment program shall maintain onsite a photograph of each patient which includes the patient 's name and birth date. The narcotic treatment program shall update the photograph every 3 years.
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Observations
The facility failed to document identification photographs for the clients represented by client records # 1 and 3.
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Plan of Correction
All client identification will note name and birth date, as well as other identifying data.
Compliance will be monitored by the Assistant Director of Nursing by daily chart monitoring effective 8/1/07.
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715.17(c)(1)(i-vi)) LICENSURE Medication control
(c) A narcotic treatment program shall develop and implement written policies and procedures regarding the medications used by patients which shall include, at a minimum:
(1) Administration of medication.
(i) A narcotic treatment physician shall determine the patient 's initial and subsequent dose and schedule. The physician shall communicate the initial and subsequent dose and schedule to the person responsible for the administration of medication. Each medication order and dosage change shall be written and signed by the narcotic treatment physician.
(ii) An agent shall be administered or dispensed only by a practitioner licensed under the appropriate Federal and State laws to dispense agents to patients.
(iii) Only authorized staff and patients who are receiving medication shall be permitted in the dispensing area.
(iv) There shall be only one patient permitted at a dispensing station at any given time.
(v) Each patient shall be observed when ingesting the agent.
(vi) Administering and dispensing shall be conducted in a manner that protects the patient from disruption or annoyance from other individuals.
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Observations
The facility failed to document the time of day the medication order was written and signed by the narcotic treatment physician in client records #2 and 4 which resulted in the inability to determine if the medication order was written prior to the administration of the medication. The facility failed to follow written medication orders by administering Subutex to clients represented by client records #1 and 2 when the opiate withdrawal scale scores were less than 13, but failing to administer Subutex to the client represented by client record # 4 who had an opiate withdrawal scale score of 17. The facility failed to document the date, time and actual scores from the opiate withdrawal scale for the clients represented by client records # 1, 2, 3 and 4.
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Plan of Correction
Nurses will assist physicians to ensure they note time of orders. While we were unable to verify any opiate withdrawal scores of 17 that went unmedicated, all nurses will be retrained in the use of the opiate withdrawal scale and the required completeness of that form including policy that buprenorphine is only administered if the scale show 13 or above. Compliance will be monitored by the Assistant Director of Nursing by daily chart monitoring beginning 8/1/07. |
715.17(c)(4)(i-viii) LICENSURE Medication control
(c) A narcotic treatment program shall develop and implement written policies and procedures regarding the medications used by patients which shall include, at a minimum:
(4) Method for control and accountability of drugs. A narcotic treatment program shall develop and implement written policies and procedures regarding who is authorized to remove drugs from the storage area and the method for accounting for all stored drugs. An agent or other drug prescribed or administered shall be documented on an individual medication record or sheet in a manner sufficient to maintain an accurate accounting of medication at all times and shall include:
(i) The name of the medication.
(ii) The date prescribed.
(iii) The dosage.
(iv) The frequency.
(v) The route of administration.
(vi) The date and time administered.
(vii) The name of the person administering the medication.
(viii) The take-home schedule, if applicable.
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Observations
The facility failed to ensure that all entries on the medication administration records were legible in client records #1 and 2.
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Plan of Correction
Nurses will be retrained by the Assistant Director of Nursing by 8/1/07 in proper procedures for penmanship and legibility as well as how to correct errors on the MAR. Compliance will be monitored by the Assistant Director of Nursing by daily chart monitoring. |
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
The facility failed to ensure that the psychosocial evaluations documented in client records #1, 2, 3 and 4 included evaluative clinical impressions and in fact the documents consisted primarily of historical data that was not evaluative.
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Plan of Correction
Approximately 2/10/07 the nurses were educated on proper psychosocial evaluations. New instructions were added c. 6/10/07. The Program Director and/or Clinical Supervisor will meet with and train all nursing staff weekly for a month beginning 7/31/07 to assist them in writing evaluative summaries. Compliance will be monitored by the Assistant Director of Nursing by daily chart monitoring, with the assistance of the Clinical Supervisor and Program Director. |