INITIAL COMMENTS
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This report is a result of an onsite follow-up inspection pertaining to the plans of correction for the September 7, 2011 Suboxone monitoring inspection. The follow-up inspection was conducted on May 31,2012 by staff from the the Division of Drug and Alcohol Program Licensure. Based on the findings of the onsite follow-up inspection,Gaudenzia Common Ground was found not to be in compliance with the applicable chapters of 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, the facility failed to ensure that the physician dated and signed a verbal order in one of three patient records reviewed.
The findings include:
Six patient records were reviewed May 31, 2012. Three records contained documentation of a physician's verbal orders. A verbal order documented in patient record
# 3 indicated a verbal order was issued by the doctor on December 28, 2011. The verbal order was signed by the physician, however, he did not date his signature. There was no way to determine if it was signed off within the required 24 hours.
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Plan of Correction
The site visit findings and licensing regulations were reviewed with the nurses and physician.
When verbal orders are taken by a nurse and documented in the client record, the prescriber will sign the order within 24 hours and date said signature as verification of timeliness.
Chart audits will be performed monthly by nursing staff and the Program Director and monitored inconjunction with the Performance Improvement process to ensure continued conformance.
Target Resolution Date: 6/13/12 |
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 in three of six patient records.
The findings include:
Six patient records were reviewed on May 31, 2012. Medication Administration Records were reviewed in all records. The facility failed to document when a patient refused to take a medication or was not provided their medication in three of six patient records.
Patient # 5 had orders written on 2/13/2012 to receive Multivitamin 1 PO Daily. The patient did not take the medication on February 21, 2012. The facility failed to document why the patient failed to take the medication.
Patient # 6 had orders written on 5/8/2012 to receive Multivitamin 1 PO Daily. The patient did not take the medication on May 12, 2012. The facility failed to document why the patient failed to take the medication.
Patient # 7 had an order written on 5/30/2012 to receive Keflex 500 mg PO QID for 10 days. The patient did not receive any medication as of the date of the inspection. According to the Medication Administration Record (MAR), the patient should have had a dose at 5:30 p.m. and 9:30 p.m. on 5/30/2012 and then a dose on 5/31/2012 in the a.m. After further discussion about the blank MAR with the nurse, it was explained that the order was written at 5:00 p.m. on 5/30/2012. The nurse explained that the medication order was faxed to the pharmacy that evening and the facility had not received the medication from the pharmacy. However, there was no documentation on the MAR that indicated why the patient had not received their medications as of the time of the inspection. An interview with the nurse on May 30, 2012, at 8:50 a.m. confirmed that there was nothing documented on the MARS explaining why the patient had not received any of their medication.
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Plan of Correction
The site visit findings and licensing regulations were reviewed with nursing staff and the physician.
All clients will be encouraged to take medications as prescribed. In the event that a client refuses a medication or does not receive a medication dose for any reason, it shall be documented on the medication administration record. As per policy documentation shall include circling the date/time a dose was due and adding an explanation of why the medication was not taken under the comments section of the form.
The physician will also clarify his orders to reflect initiation of medication administration upon receipt of the actual medication from the pharmacy.
The nurses and program director will monitor ongoing conformance via monthly chart audits and the performance improvement process.
Target Resolution Date: 6/13/12
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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, the facility failed to complete all required laboratory tests as part of the admission process in one of six patient records reviewed.
The findings include:
Seven patient records were reviewed May 31, 2012. Six patient records were reviewed for completed laboratory tests as part of the admission process, specifically a tuberculosis Mantoux test (PPD).
Patient record # 1 had documentation of tuberculin Mantoux test having been administered on May 27, 2012 as part of the admission process. The test results should be read within 72 hours of administration. As of the date of the inspection, May 31, 2012, the test did not have the results read and documented in the patient record. It was over the 72 hours time period to read the results.
The nurse confirmed this finding and was not disputed.
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Plan of Correction
The site visit findings and licensing regulations were reviewed with the nursing staff and physician.
Nurses will read PPD Mantoux test results within 48 to 72 hours of administration and promptly document results in the client record. Tests to be read will be included in the medication administration record book for daily review and completion within the allotted time frames.
Nurses will review the PPD tests tracking system each night and monthly chart audits will be completed by nursing personnel and the program director to assure continued conformance.
Target Resolution Date: 6/13/12
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