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 November 14, 2012 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, White Deer Run of Lancaster, was found not to be in compliance with the applicable chapters of 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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715.9(a)(4) LICENSURE Intake
(a) Prior to administration of an agent, a narcotic treatment program shall screen each individual to determine eligibility for admission. The narcotic treatment program shall:
(4) Have a narcotic treatment physician make a face-to-face determination of whether an individual is currently physiologically dependent upon a narcotic drug and has been physiologically dependent for at least 1 year prior to admission for maintenance treatment. The narcotic treatment physician shall document in the patient 's record the basis for the determination of current dependency and evidence of a 1 year history of addiction.
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Observations
Based on a review of patient records, the narcotic treatment program failed to have a narcotic treatment physician make a face-to face determination and document in the patient's record the basis for determining an individual's physiological dependence upon a narcotic drug in one of seven patient records.
The findings were:
Seven patient records were reviewed for documentation that the narcotic treatment physician conducted a face-to-face determination of the patient's physiological dependence upon a narcotic drug. The narcotic treatment physician (NTP) failed to document this for patient # 5.
Patient # 5 was admitted on July 4, 2012. The narcotic treatment physician (NTP) completed the patient's history and physical on July 5, 2012. The NTP's penmanship was not legible on the history and physical examination. The narcotic treatment physician also failed to complete the "Opiate Dependency Criteria" form for patient # 5. There was no way to determine if the NTP determined the patient was physiologically dependent upon a narcotic drug.
This finding was not disputed by the Director of Nursing.
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Plan of Correction
There are two different areas in this observation that need to be addressed.
The first area is the Opiate Dependency Criteria form was not found to be completed in one of the patient's records. The nurse on duty will red flag all documents that need to be reviewed and/or filled out by the physician and then prior to the physician leaving for the day, the nurse will review the paperwork for completeness. The Opiate Dependency Criteria form will also be added to the Suboxone Checklist in our patient's record, again to reassure that it is not overlooked. This will be added to our checklist form and all areas of compliance will be reviewed with the nursing department by the nursing supervisor and will go into effect on 12/11/2012.
The second issue is the penmanship not being legible. The nursing supervisor will purchase a signature stamp as well as a date and time stamp for each physician to use when completing paperwork. This will be completed by 12/31/2012.
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715.23(b)(2) LICENSURE Patient records
(b) Each patient file shall include the following information
(2) A complete drug and alcohol history.
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Observations
Based on a review of patient records, the facility failed to document the lengths and patterns related to the client's progression of drug and alcohol use in four of seven records reviewed.
The findings were:
Seven patient records were reviewed on November 14, 2012. Seven records were reviewed for documentation of drug and a alcohol history that included lengths and patterns related to the patient's progression of use. The facility failed to document the lengths and patterns related to the patient's progression of use in patient records # 2, 3, 4, and 5.
This finding was discussed with the director of nursing and was not disputed.
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Plan of Correction
To ensure the collection of proper drug and alcohol histories, Nursing Supervisor will conduct an in-service training on 12/10/2012 for the entire nursing department. The in-service training will include reviewing capturing the data of lengths and patterns related to patient's progression.
Nursing supervisor will monitor collection of data during weekly chart audits. |