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 December 18, 2014 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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715.11 LICENSURE Confidentiality of patient records
A narcotic treatment program shall physically secure and maintain the confidentiality of all patient records in accordance with 42 CFR 2.22 (relating to notice to patients of Federal confidentiality requirements) and § 709.28 (relating to confidentiality).
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Observations
Based on a review of the client records, the facility failed to document consents to release information which include the name of the person or agency to whom the information was to be released and/or failed to offer the client a copy of the signed consent in two of five patient records reviewed.
The findings include:
Five patient records were reviewed for consent forms on December 18, 2014. The consents to release information forms did not document all required information in two out of five patient records, specifically records # 2 and 3.
The findings include:
Patient # 2 was admitted into detox on December 14, 2014. Twelve consent forms had been signed by the patient on December 14, 2014, none of which specified that the patient was offered a copy of this consent. Additionally, four of the signed consents did not specify to whom the consent would be releasing information to or what information was being released.
Patient # 3 was admitted into detox on December 14, 2014. Five consent forms had been signed by the patient on December 14, 2014, none of which specified who the consent would be releasing information to or what information was being released.
These findings were reviewed with facility staff during the inspection process.
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Plan of Correction
Recently hired nursing staff will be directed IMMEDIATELY that:
1) No release EVER be signed by any client which does not FIRST indicate to whom, specifically, information is to be released, from whom it is to be received, and the specific nature of whatever information is to be exchanged.
2) EVERY release signed by the client specify that a copy of the release in question was offered to the client signing it.
Nurses with experience at Common Ground responsible for training, and oversight of the work of recent hires, will be required not to accept any release not including the above indicated information.
Written,corrective action will result from any failure to abide by the above indicated requirements, for which failure there will be zero tolerance. |
715.17(c)(6)(i-iv) 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:
(6) Inventories. A narcotic treatment program shall conduct monthly inventories of agents and other controlled substances stored. Each inventory record shall include:
(i) The date the inventory was conducted.
(ii) The time of day it was conducted.
(iii) The name and amount of each product on hand at the time of the inventory.
(iv) The name of the individual conducting the inventory.
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Observations
Based on the inspection of the nurses station and an interview with facility staff, the facility failed to document a monthly inventory of agents and other controlled substances.
The findings include:
An inspection of the nurses station/medication room was conducted on December 18, 2014. During the inspection, documentation of the facility's medication inventory was requested. However, it was not furnished. Furthermore, during an interview with the head nurse on duty, it was advised that the facility did not conduct an inventory and was unfamiliar with any such practice.
These findings were reviewed with facility staff during the inspection process.
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Plan of Correction
Going forward, and beginning immediately, on the first of each month, a written inventory of all controlled substances will be taken. This inventory will be kept in the front of the Narcotics Record Book, located in the medical office of the facility. |
715.23(b)(11) LICENSURE Patient records
(b) Each patient file shall include the following information:
(11) Counselor notes regarding patient progress and status.
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Observations
Based on the review of patient records, the facility failed to document progress notes regarding patient progress and status.
The findings include:
Five detox patient records were reviewed for documentation of progress notes on December 18, 2014. The facility failed to document the client's progress and/or status in three out of five detox patient records reviewed, specifically client records # 2, 3, and 5.
The findings include:
Patient # 2 was admitted into detox treatment on December 14, 2014 and was still active during the time of inspection. The record of services and progress notes only reflected one entry for patient #2, dated December 14, 2014. Additionally, the medication administration record reflects the client refused the last three doses of Suboxone on December 16, 17, and 18th and there was no progress note to state the clients status following the refusal of the medication.
Patient # 3 was admitted into detox treatment on December 14, 2014 and was still active during the time of inspection. The record of services and progress notes reflected only one entry for patient #3, dated December 14, 2014.
Patient # 5 was admitted into detox treatment on September 10, 2014 and discharged from detox on September 17, 2014. There were no progress notes to indicate the progress or status of patient #5 during detoxification treatment.
These findings were reviewed with facility staff during the inspection process.
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Plan of Correction
In addition to the Clinical Opiate Withdrawal Scale which is currently completed daily for opiate detox cliends, beginning IMMEDIATELY, a not-less-than-daily progress note will be entered for each opiate detox patient in his/her chart by medical staff, indicating that client's status on the day in question. |