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 buprenorphine, in the treatment of narcotic addiction. This inspection was conducted on September 16, 2013 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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715.15(b) LICENSURE Medication dosage
(b) The narcotic treatment physician shall determine the proper dosage level for a patient, except as otherwise provided in this section. If the narcotic treatment physician determining the initial dose is not the narcotic treatment physician who conducted the patient examination, the narcotic treatment physician shall consult with the narcotic treatment physician who performed the examination before determining the patient 's initial dose and schedule.
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Observations
Based on a review patient records, the facility failed to document the consultation between the narcotic treatment physician determining the initial dose and the narcotic treatment physician performing the physical examination in one of two patient records.
Findings
Nine patient records were reviewed September 16, 2013. Two patient records contained documentation of one physician conducting the physical exam and another determining the patient's initial dose and schedule.
Patient # 5 was admitted June 16, 2013. Documentation in the patient record revealed that two physicians entered documentation in the patient record that pertained to the patient assessment regarding the administration of buprenorphine. Documentation by physician #1 on June 17, 2013 provided a face to face exam and an assessment that resulted in an indication that the patient would benefit by buprenorphine treatment. Physician # 2 completed a physical examination on June 18, 2013. There was no record of a consultation between the two physicians regarding buprenorphine treatment ordered for patient #5. The patient record did reveal that patient # 5 received buprenorphine treatment.
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Plan of Correction
Medical Director will, on comploetion of physical examination, consult with, and document consultation with any other involved physician or CRNP, as to any medications he prescribes, and the reason for that prescription. Program Director and Supervisor will monitor through monthly chart/QI reviews. |
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 the physician dated the signature after submitting a verbal order in one of six patient records.
The findings include:
Nine patient records were reviewed September 16, 2013. Six patient records contained documentation of a physician's verbal orders. A review of patient record # 1 revealed that the physician issued verbal orders on September 10 and 11, 2013. The verbal orders were never signed by the physician.
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Plan of Correction
Program Director and Supervisor reviewed policy with medical personnel; directed that verbal orders will be documented in chart and signed by issuance of the orders. Night nurse on duty will review all charts for compliance; Program Director and Supervisor will monitor throuch monthly chart and QI reviews. |