INITIAL COMMENTS
|
This report is a result of an on-site inspection conducted for the approval to use a narcotic agent, specifically buprenorphine, in the treatment of narcotic addiction. This inspection was conducted on June 28, 2010 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, New perspectives At White Deer Run 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 August 1, 1010.
|
Plan of Correction
|
715.23(b)(13) LICENSURE Patient records
(b) Each patient file shall include the following information:
(13) Patient record of services.
|
Observations
Based on the review of patient records, the facility failed to maintain a complete patient record of services in four of five patient records.
The findings include:
Five patient records were reviewed June 28, 2010. Five patient records required documentation on the record of services. Four patient records, # 1, 2, 3 and 4 failed to maintain records of service that included all contacts identified in the progress notes,such as entries for group therapy sessions.
|
Plan of Correction
Training will be conducted by the nursing coordinator regarding the implementation of a non-clinical record of service worksheet provided by nursing for detox patients which will be given to each patient daily in the morning and returned at the end of the day to the nursing department. Night shift will place all of the information from the worksheet on the record of service in the patient record. The nursing coordinator, or designee will collect data sheets daily to ensure that record of service contains updated and accurate information. The training and process will be implemented no later than August 16, 2010 and will be the responsibility of the Nursing Coordinator for ongoing compliance.
|
715.23(b)(15) LICENSURE Patient records
(b) Each patient file shall include the following information:
(15) Psychosocial evaluations of the patient.
|
Observations
Based on the review of patient records, the facility failed to complete a clinical assessment and composite picture in the psychosocial evaluation of the patient in five of five patient records reviewed.
The findings include:
Five patient records were reviewed for completion of a psychosocial evaluation. The psychosocial evaluations failed to include a composite picture of the patient in patient records # 1, 2, 3, 4 and 5. Instead, the documentation focused on the patient's drug history without any clinical evaluation of the information.
|
Plan of Correction
The evaluative summary will include a composite picture of their dependency to include medical, physical, emotional, social and behavioral consequences. The nurse evaluating will write in his/her own words an objective view of these factors. An admission note will be written to include a comprehensive assessment/evaluation of the patient as well. Nursing staff will be given instruction by the nursing coordinator and campus director no later than August 23, 2010. The nursing coordinator will continue to evaluate daily and will be responsible for ongoing compliance. |
715.23(b)(23) LICENSURE Patient records
(b) Each patient file shall include the following information:
(23) Discharge summary.
|
Observations
Based on a review of patient records, the facility failed to document all of the required information in four of five patient records.
The findings include:
Five patient records were reviewed June 28, 2010. Five patient records were reviewed for complete discharge summaries.
Patient records # 2, 3, 4 and 5 did not document a response to the treatment process, but a general statement focused on the discharge reason or attendance of the patient.
Patient records # 1, 2, 3, 4 and 5 did not document all services offered to the patient during the course of their treatment.
|
Plan of Correction
Multidisciplinary summaries will be made more specific to the patient and their treatment. This will include and not be limited to their medical treatment and all services offered to them. The nursing coordinator will provide instruction on summary writing to all current nursing staff as well as review of each summary with chart audits and will be responsible for ongoing compliance. Instruction/reinstruction will take place no later than August 23, 2010. |
715.24(4)(iv) LICENSURE Narcotic detoxification
If a narcotic treatment program provides narcotic detoxification services, the narcotic treatment program shall develop and implement narcotic detoxification policies and procedures which include the following:
(4) Minimum requirements for short-term narcotic detoxification treatment are as follows:
(iv) No narcotic treatment program may provide short-term narcotic detoxification treatment to an individual until at least 7 days after the conclusion of any previous short-term narcotic detoxification treatment.
|
Observations
Based on the review of patient records and discussion with facility staff, the facility failed to ensure at least seven days between one short term detoxification treatment and another in one of one patient records reviewed.
The findings include:
Five patient records were reviewed June 28, 2010. One patient record was a re-admission. The patient was admitted June 4, 2010. The patient was discharged previously on June 1, 2010 against medical advice.
|
Plan of Correction
Protocol will be followed for all bupe detox re-admissions effective immediately. Dosing with suboxone will not be provided if the patient is readmitted prior to 7 days. The former/recent patient seeking readmit will be provided this information. Verification of the potential readmission will be made through the nursing coordinator and/or medical director. The Nursing Coordinator and Campus Director will be responsible for ongoing compliance. |