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 Suboxone in the treatment of narcotic addiction. This inspection was conducted on September 7, 2011 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Gaudenzia Common Ground 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.
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Plan of Correction
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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 discussion with facility director, the facility failed to ensure that the physician dated and the signed a verbal order in one of three patient records reviewed.
The findings include:
Seven patient records were reviewed September 7, 2011. Three records contained documentation of a physician's verbal orders. A verbal order documented in patient record
# 5 indicated a verbal order was issued by the doctor on 6/19/2011. The verbal order was not signed by the physician as of the date of the inspection.
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Plan of Correction
The Program Director assured that all nurses and physician reviewed the regulations, policy/procedures, and the plan of correction related to a physician dating and signing verbal orders.
Anytime verbal orders are received by a nurse, the receiving nurse shall document the orders accordingly, flag the client record, and place it in the physician's signature bin.
On a nightly basis, the third shift nurse will review the physician's orders in each client record to insure that all verbal and written orders are appropriately signed by the physician. The nurse shall document the nightly review on the physician's orders sheet. Should a signature be missing, the next shift's nurse will assure that the physician is contacted to obtain his signature within 24 hours of the written order.
The physician shall be responsible for completing all required chart documentation and signature each visit. The nurse on duty shall assure that client records are available for the physician.
The Program Director, Nurse Supervisor, and Administrative Coordinator will assume responsibility for monitoring ongoing conformance via chart audit and review in the Quality Improvement process.
Targeted Resolution Date: 9/30/11
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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
Based on the review of patient records, the facility failed to document when a patient failed to report to take a prescribed medication or refused to take a prescribed medication.
The findings include:
Seven patient records were reviewed on September 7, 2011. Medication Administration Records were reviewed in all records. The facility failed to document when a patient refused to take a medication in one of seven patient records.
Patient # 6 was admitted on May 21, 2011. The patient had orders written on 5/21/2011 to receive 25 mg of Vistaril PO QHS. The patient did not take the medications on May 22, 23, and 24. The facility failed to document why the patient failed to take the medication.
On May 22, 2011 patient # 6 had an order to receive 600 mg of Neurotin PO QID. The patient did not take the medication on 5/24/2011 at 5:00 p.m. or at 9:30 p.m. The facility failed to document why the patient failed to take the medication.
On May 22, 2011 patient # 6 had an order to receive 1 mg of Ativan PO TID for two days. The patient did not take their dose at 9:30 p.m. on 5/24/2011. The facility failed to document why the patient failed to take the medication.
Patient # 6 was also prescribed a three day Suboxone taper. The client only took one dose of Suboxone on May 23, 2011 at 6:00 p.m. The client did not take the prescribed dose on 5/24/2011 and 5/25/2011. The facility failed to document why the patient failed to take the medication.
The facility director confirmed this finding.
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Plan of Correction
The Program Director assured that all nurses reviewed the regulations, policy and procedures, and plan of correction around documentation on the medication administration record (MAR) of any client refusal to take or failure to receive a medication as ordered.
When a client refuses to take or failes to receive a medication, the medication administration nurse on duty shall document such on the MAR by circling their initials in the designated administration area and writing an explanation in the comments section for why the medication was not taken.
The third shift nurse shall review each client MAR on a nightly basis for completion and shall document any deficiencies on the shift report so that correction can be made promptly by the responsible nurse.
Ongoing conformance shall be monitored by the Program Director, Nurse Supervisor, and Administrative Coordinator via chart audit and the monthly quality improvement process.
Targeted Resolution Date: 9/30/11 |
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 facility failed to complete all required laboratory tests as part of the admission process in one of seven patient records reviewed.
The findings include:
Seven patient records were reviewed September 7, 2011. All patient records were reviewed for completed laboratory tests as part of the admission process, specifically a tuberculosis Mantoux test (PPD).
Patient record # 7 did not have documentation of tuberculin Mantoux test having been administered as part of the admission process.
The facility director confirmed this finding.
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Plan of Correction
The Program Director assured that all nurses reviewed the regulations, policy, procedure, and plan of correction related to the provision of laboratory testing including tuberculosis Mantoux test (PPD) and the documentation of results in client records.
All nurses shall assume responsibility for administering a PPD within 48 hours of admission of each client and documenting results accordingly.
Client permission for PPD testing shall be obtained by the admitting nurse and TB testing forms shall be placed on the clipboard with the vital signs sheet to assure visual attention. The client's name shall also be added to the TB log sheet and included in the shift report as a to do task.
The third shift nurse shall review nightly the status of TB tests, results, and related documentation in the client record. Any incomplete tests shall be administered and/or results read before the end of the next shift and shall be noted in the shift report.
The Program Director, Nurse Supervisor, and Administrative Coordinator will monitor ongoing conformance via chart audit and monthly quality improvement process.
Targeted Resolution Date: 9/30/11 |