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 February 26, 2009 by staff from the Division of of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Gaudenzia Common Ground was found not to be compliance with the applicable chapters of 28 PA Code which pertain to the facility. Deficiencies were identified during this inspection and a plan of correction is due on March 21, 2009.
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Plan of Correction
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715.9(a)(2) 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:
(2) Verify the individual 's identity, including name, address, date of birth, emergency contact and other identifying data.
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Observations
Based on a review of patient records and policy and procedure manual, the facility failed to provide verification of patient identification in three of eight records.
The findings include:
Eight patient records were reviewed on February 26, 2009. Verification of patient identity was required in eight patient records. In accordance with facility policy, the facility obtains a copy of photo identification at admission and maintains it in the patient record as their method of verifying patient identification. The facility failed to provide documentation to confirm patient identity in patient records # 3, 4 and 7 as the patient record did not contain a copy of the patient's photo identification.
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Plan of Correction
The Nurse Manager will inservice all nurses regarding responsibility for obtaining and maintaining in the record a copy of photo identification to verify each client's identity.
Nurses shall also document all efforts to obtain or verify client identification in cases when a client does not initially possess ID.
Nurse Manager will monitor through chart review and report progress in her monthy QI report.
Targetd date of resolution: 4/1/09. |
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 8 patient records, the facility 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 2 of 8 patient records.
The finding include:
Eight patient records were reviewed on February 26, 2009. Documentation that the physician performed a face-to face evaluation was required in eight patient records. Patient records # 2 and 5 contained documentation that revealed the physician's assistant completed the physical evaluation. There was no documentation that specifically identified that the physician conducted a face-to face prior to the admissions of these two patients. Patient record # 5 revealed documentation that indicated the physician's assistant had documented that she had discussed patient care with the physician and he was in agreement with her assessment. Additionally, documentation in the patient record # 5 identified a verbal (telephone) order had been given by the physician to initiate patient # 5's narcotic treatment.
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Plan of Correction
The program will assure that the narcotic treatment physician specifically documents the face to face determination of an individual's physilogical dependence upon a narcotic drug in each client record.
The Nurse Manager inserviced all nurses and met with the narcotic treatment physician to review the protocol.
The Nurse Manager will monitor through chart review and report progress in her monthly QI report.
Targetd Resolution Date: 4/1/09 |
715.14(a) LICENSURE Urine testing
(a) A narcotic treatment program shall complete an initial drug-screening urinalysis for each prospective patient and a random urinalysis at least monthly thereafter.
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Observations
Based on a review of patient records, the facility failed to document initial drug-screen urinalysis results in two of eight records.
Findings:
Eight patient records were reviewed on February 26, 2009; all eight records were required to document drug-screen urinalysis results prior to initial patient dosing. Patient records # 5 and 6 did not contain documentation of urinalysis results prior to the initial dosing of the patients.
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Plan of Correction
The facility will assure that all clients receive a urine drug screen analysis and that results are obtained and documented in the record prior to the initiation of dosing.
The Nurse Manager inserviced nurses regarding protocol and contacting the labs for results.
The Nurse Manager will monitor through client chart review and will report progress in her monthly QI report.
Projected date of resolution: 4/1/09 |
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 of eight patient records, the facility failed to provide physician documentation of a consult between the physician and the physician's assistant prior to the determination of the initial dose of the patient in two of two patient records.
Findings:
Eight patient records were reviewed on February 26, 2009. Patient records # 2 and 5 contained documentation that the physician's assistant had performed their physical evaluations. The facility failed to document the physician's consult with the physician's assistant who completed the patients' physical evaluations.
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Plan of Correction
When the physician assistant performs a client's physical examination, the narcotic treatment physician will clearly document in the client record, consultation with the physician assistant prior to the determination of the initial dosing of the client.
The Nurse Manager has inserviced nurses and has met with the narcotic treatment physician regarding protocol.
The Nurse Manager will monitor through client chart audit and report progress in her monthly QI report.
Projected resolution date: 4/1/09 |
715.23(b)(15) LICENSURE Patient records
(b) Each patient file shall include the following information:
(15) Psychosocial evaluations of the patient.
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Observations
Based on the review of patient records, the facility failed to document psychosocial evaluations in six of eight patient records.
The findings include:
Eight patient records were reviewed on February 27, 2009; psychosocial evaluations were required in these eight patient records. The narcotic treatment program did not document clinical impressions in psychosocial evaluations in patient records # 1, 2, 4, 5, 7 and 8.
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Plan of Correction
The program will continue to document psychosocial evaluations on all clients and maintain them in the client record. Each evaluation will include clinical impressions.
The Nurse Manager provided inservice training to facility nurses.
The Nurse Manager will monitor through client chart audit and report progress in her monthly QI report.
Projected date of resolution: 5/1/09. |