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 residential detoxification from opioid dependence. This inspection was conducted on June 1, 2009 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Gaudenzia Erie Inc. Crossroads, was found not to be in compliance with the applicable chapters of 28 PA Code which pertain to the facility. Deficiencies were identified during this inspection and plan of correction is due on June 28, 2009.
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Plan of Correction
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715.13(b) LICENSURE Patient identification
(b) A narcotic treatment program shall maintain onsite a photograph of each patient which includes the patient 's name and birth date. The narcotic treatment program shall update the photograph every 3 years.
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Observations
Based on a review of patient records, the facility failed to document a photograph of the patient which includes the patients name and birth date in one of four records.
Findings include:
Four records were reviewed on June 1, 2009. Patient photographs which included the patients name and birth date were required in four patient records. The photograph was not documented in record # 3.
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Plan of Correction
All records will have a patient photograph with name and date of birth, effective immediately. The Nurse Manager and Program Director will montitor this during the monthly PI/QI process. |
715.17(c)(1)(i-vi)) 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:
(1) Administration of medication.
(i) A narcotic treatment physician shall determine the patient 's initial and subsequent dose and schedule. The physician shall communicate the initial and subsequent dose and schedule to the person responsible for the administration of medication. Each medication order and dosage change shall be written and signed by the narcotic treatment physician.
(ii) An agent shall be administered or dispensed only by a practitioner licensed under the appropriate Federal and State laws to dispense agents to patients.
(iii) Only authorized staff and patients who are receiving medication shall be permitted in the dispensing area.
(iv) There shall be only one patient permitted at a dispensing station at any given time.
(v) Each patient shall be observed when ingesting the agent.
(vi) Administering and dispensing shall be conducted in a manner that protects the patient from disruption or annoyance from other individuals.
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Observations
Based on a review of patient records, the facility failed to document physician determination of the patient's initial and subsequent medication dose in four of four records.
Findings include:
Four records were reviewed on June 1, 2009. The physician's determination of the patients initial and subsequent medication dose were required in four patient records. This was not documented in records #1, 2, 3, and 4. The facility had standing medication orders, which included the use of buprenorphine, for opiate detoxification. The patient records failed to document the physician's determination of the medication doses for patients # 1, 2, 3, and 4.
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Plan of Correction
All patient records will have written documentation of the physician's determination of the medication doses. This is effective immediately. The Nurse Manager re-trained the nurses and will monitor the files monthly during the PI/QI process. |
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 a review of patient records, the facility failed to document the time the medication dose was administered in one of four records.
Findings include:
Four records were reviewed on June 1, 2009. The medication administration record, including the time of the medication dose, was required in four patient records. The time the dose was administered was not documented on the medication administration record for the dates 3-6-09 and 3-7-09 in record #2.
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Plan of Correction
Each patient file will contain documentation of dates and times of medication administration, effective immediately. The Nurse Manager re-trained the nurses on this and will monitor the files during the monthly PI/QI process. |
715.22(a) LICENSURE Patient grievance procedures
(a) A narcotic treatment program shall develop and utilize a patient grievance procedure.
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Observations
Based on a review of the facility policy and procedure manual, the facility failed to include the time frames for completing the grievance procedure.
Findings include:
The facility policy and procedure manual was reviewed on June 1, 2009. The updated grievance procedure from August 2008 does not include the time frames for completing the steps of the grievance procedure.
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Plan of Correction
The Grievance Policy was amended on 8/18/09 adding specific time frames for completing the steps of a grievance. |
715.23(b)(23) LICENSURE Patient records
(b) Each patient file shall include the following information:
(23) Discharge summary.
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Observations
Based on a review of patient records, the facility failed to document the discharge summary within one week in two of three records, and failed to document the patients progress while in treatment in one of three records.
Findings include:
Four records were reviewed on June 1, 2009. The discharge summary was required in three patient records. Record #2 does not include the progress in progress section, and was not completed within one week of discharge. The client, record #2, was discharged on 3-8-09, and the discharge summary was completed 5-14-09. Record #4 does not have a discharge summary completed within one week of discharge. The client, record #4, was discharged on 3-7-09, and the discharge summary was completed 5-14-09.
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Plan of Correction
All discharge summaries will be completed within 7 days of patient discharge. The Program Supervisors reviewed this policy with the counselors during weekly supervision. The Program Supervisors and Program Director will monitor the files and time frames of the discharge summaries during the monthly PI/QI process. |