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 January 20, 2011 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, UHS Recovery Foundation, Inc. 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 February 20, 2011.
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Plan of Correction
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Observations
Based on a review of patient records and a discussion with the project/facility director, the medical director and head nurse, the facility failed to ensure that verbal medication orders are put in writing and signed within 24 hours thereafter by the prescribing physician, as required by regulation in three of six patient records.
The findings include:
Six detoxification patient records were reviewed on January 20, 2011. All verbal medication orders are required to be signed within 24 hours by the prescribing physician. Patient records # 1, 3 and 5 contained documentation of a verbal medication order that was not signed by the prescribing physician within 24 hours.
Patient # 1 was admitted on January 16, 2011. Verbal orders contained in the patient record dated January 17, 2011 did not have a physician signature.
Patient # 3 was admitted on January 10, 2011. A verbal order dated January 10, 2011 was not signed by the prescribing physician. It was signed by a certified registered nurse practitioner on January 11, 2011.
Patient # 5 was admitted on October 7, 2010 and discharged on October 12, 2010 against medical advice. Verbal orders dated October 7, 2010 at 7:10 PM did not have a physician signature.
The above information was confirmed by the project/facility director, medical director and head nurse during discussions throughout the licensing inspection.
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Plan of Correction
Physician verbal orders received by licensed nursing staff will be faxed via secure fax to physician who authored the order for approval and signature. Physician will fax, via secure fax, signed order back to nursing within twenty-four hours of the original order. Signed verbal order will be placed in order section of medical record stapled on top of original order. New procedure will be implemented on 3/15/11. All nursing staff will be trained by Director of Nursing on revised procedure by 3/11/2011. Director of Nursing will review 24-hour chart checks and perform random audits for compliance. Results will be reported monthly to PI Committee. |