INITIAL COMMENTS
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This report is a result of an on-site inspection conducted for the approval to use a narcotic agents, specifically methadone and buprenorphine, in the treatment of narcotic addiction. This inspection was conducted on February 7 and 8, 2008 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, White Deer Run, Inc. 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 March 3, 2008.
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Plan of Correction
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715.9(a)(1) 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:
(1) Verify that the individual has reached 18 years of age.
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Observations
Based on review of 11 random patient records, the facility failed to provide documentation verifying the individual's identity to include proof of name, date of birth and address in five of eleven records, specifically patient records #1, 2, 5, 6 and 8.
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Plan of Correction
At the beginning of the intake process, the Intake technician will request verification of the individual's identity and other demographic information. This verification may include a driver's license, social security card, passport, PA citizen identify card, or any other form of identification that is provided by a governmental agency.
After obtaining this form of identification, a photocopy will be made and placed in the patient's record.
Facility will enroll in web based program: USA People Search which will allow us to run an unlimited number of people searches for name, addresses, birth dates and phone numbers. It will verify that name and birthdates match information being provided by the patient.
This service will be used for those patients who show up in need of care but do not provide adequate ID as requested. Facility will continue to exhaust all possibilities of obtaining adequate ID and document such. When no ID can be provided, the patient will be asked to sign a consent for us access the above mentioned web site to verify their information. Print out from the website will be placed in chart to serve as ID for age and identity.
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715.9(a)(3) 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:
(3) Obtain a drug use history and current drug use status of the individual.
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Observations
Based on a random review of 11 patient records, the facility failed to provide drug and alcohol histories that documented current dependency and progression of patient usage; specifically, patient records #3 and #5 contained drug and alcohol histories that identified patient usage as "past" or "no recent use" and gave no detail that addressed age of use, amount used or other significant information that would lead to the identification of drug dependency.
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Plan of Correction
Effective 2/5/07, the Nursing Manager began reviewing and will continue to review 100% of drug and alcohol histories the morning after admission. The deficient history is corrected by the Nurse Manager (or Charge Nurse) meeting with the patient, updating the form and placing the corrected history into the patient's medical chart prior to the patient meeting with the Doctor. On any history in which there is a deficiency with respect to current dependency, progression of usage, patterns and route of use and last date of use the Nursing Manager has and will continue to meet with nurses completing histories that are deficient and provide supervision and direction on how to complete histories correctly. |
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
The facility failed to follow its policy and procedure which required that each patient be provided privacy while at the dispensing window; specifically, patients in-line to be medicated, stood in close proximity to the dispensing window, which compromised both the dosing patient's privacy and were a distraction to the nurse who administered the dose.
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Plan of Correction
Signs will be posted by 3/15/08 above both medication windows directing patients in line to provide privacy to those patients receiving medications. Nurses will notify patients that no dosing will occur until this direction is followed. The Nursing Manager or Charge Nurse on each shift will observe patient compliance and intervene as needed to assist the medication nurses in assuring compliance with this standard. |