Observations
Based on a review of patient records, the narcotic treatment physician failed to document whether an individual has been physiologically dependent for at least 1 year prior to admission for maintenance treatment and evidence of a 1 year history of addiction in one of one patient records.
The findings include:
Ten client records were reviewed on November 19, 2015. One patient was prescribed Suboxone. This patient record was reviewed for documentation that the physician made a face-to-face determination of whether the individual was currently physiologically dependent upon a narcotic drug and had been physiologically dependent for at least one year prior to admission for maintenance treatment. The narcotic treatment physician failed to document whether an individual has been physiologically dependent for at least 1 year prior to admission for maintenance treatment and evidence of a 1 year history of addiction in patient record # 10.
Patient # 10 was admitted into treatment on July 10, 2015. The narcotic treatment physician conducted a face-to-face examination of patient # 10 on July 11, 2015 and prescribed Suboxone. The narcotic treatment physician failed to document whether patient # 10 had been physiologically dependent for at least 1 year prior to admission for maintenance treatment and evidence of a 1 year history of addiction.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
1 1/2 weeks before Gateway Squirrel Hill's licensing date, another Gateway outpatient facility acquired this same citation. Immediately the Outpatient Director and the Medical Records Director developed the following procedure and a progress note form for Gateway physicians to use when evaluating a patient for treatment with Suboxone:
1) If a patient is induced with Suboxone by a Gateway staff physician, that physician will complete a specific progress note, called "Physician Progress Note Initial Suboxone Evaluation". This progress note format guides the physician to complete documentation on a variety of important and required clinical information, and includes the statement, "Based on my face to face evaluation, it is my best judgment as a physician, that this patient shows evidence of current physiologic addiction to heroin or other opiate drugs and has a history of at least one year addiction as documented above (in the progress note)."
Completing this specific documentation form will ensure a thorough physician evaluation for each Suboxone patient and will ensure documentation that the patient had been involved with, at least one year of opiate addiction. This evaluation and included statement will be signed and dated by the physician.
The Manager of the facility or her designee will review each patient record, for those who have been prescribed buprenorphine, to ensure that the ?Physician Progress Note Initial Suboxone Evaluation? was appropriately completed and signed by the evaluating physician. This review will occur within one work day of the completion of the evaluation.
This procedure and progress note form was implemented on 11/18/2015
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