Observations
Based on a review of patient records, the facility's physician failed to document in the patient's record the basis for the determination of current dependency and evidence of a one year history of addiction in seven of seven patient records.
The findings include:
Eight client records were reviewed on March 8, 2013. Eight patients were prescribed Suboxone. Seven patient records were reviewed for documentation that the physician made a face-to-face determination of whether the individual was currently physiologically dependent upon a narcotic drug and had been physiologically dependent for at least one year prior to admission for maintenance treatment and the basis for this determination. The physician failed to document in the patient's record the basis for determination of current dependency and evidence of a one year history of addiction in patient records # 1, 2, 3, 4, 5, 6 and 7.
Patient # 1 was admitted into treatment on November 1, 2012. The physician conducted a face-to-face visit with patient # 1 on November 1, 2012. The physician prescribed 8 mg/2 mg Suboxone BID on November 1, 2012. The physician failed to document whether patient # 1 was currently physiologically dependent upon a narcotic drug and had been physiologically dependent for at least one year prior to admission for maintenance treatment and the basis for the determination.
Patient # 2 was admitted into treatment on January 4, 2013. The physician conducted a face-to-face visit with patient # 2 on January 4, 2013. The physician prescribed 8 mg/2 mg Suboxone BID on January 4, 2013. The physician failed to document whether patient # 2 was currently physiologically dependent upon a narcotic drug and had been physiologically dependent for at least one year prior to admission for maintenance treatment and the basis for the determination.
Patient # 3 was admitted into treatment on December 17, 2012. The physician conducted a face-to-face visit with patient # 3 on December 17, 2012. The physician prescribed 8 mg/2 mg Suboxone BID on December 17, 2012. The physician failed to document whether patient # 3 was currently physiologically dependent upon a narcotic drug and had been physiologically dependent for at least one year prior to admission for maintenance treatment and the basis for the determination.
Patient # 4 was admitted into treatment on November 20, 2012. The physician conducted a face-to-face visit with patient # 4 on November 20, 2012. The physician prescribed 8 mg/2 mg Suboxone BID on November 20, 2012. The physician failed to document whether patient # 4 was currently physiologically dependent upon a narcotic drug and had been physiologically dependent for at least one year prior to admission for maintenance treatment and the basis for the determination.
Patient # 5 was admitted into treatment on December 19, 2012. The physician conducted a face-to-face visit with patient # 5 on December 19, 2012. The physician prescribed 8 mg/2 mg Suboxone BID on December 19, 2012. The physician failed to document whether patient # 5 was currently physiologically dependent upon a narcotic drug and had been physiologically dependent for at least one year prior to admission for maintenance treatment and the basis for the determination.
Patient # 6 was admitted into treatment on January 17, 2013. The physician conducted a face-to-face visit with patient # 6 on January 17, 2013. The physician prescribed 8 mg/2 mg Suboxone BID on January 17, 2013. The physician failed to document whether patient # 6 was currently physiologically dependent upon a narcotic drug and had been physiologically dependent for at least one year prior to admission for maintenance treatment and the basis for the determination.
Patient # 7 was admitted into treatment on November 7, 2012. The physician conducted a face-to-face visit with patient # 7 on November 7, 2012. The physician prescribed 8 mg/2 mg Suboxone BID on November 7, 2012. The physician failed to document whether patient # 7 was currently physiologically dependent upon a narcotic drug and had been physiologically dependent for at least one year prior to admission for maintenance treatment and the basis for the determination.
The clinical supervisor was interviewed in March 8, 2013 and confirmed the findings.
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Plan of Correction
Effective immediately the treating physician will make a face to face determination of opioid dependency of one year. The finding will be documented on a single page in the chart.
Medical Director and/or Clinical Director will inform each physician of the change and review charts quarterly to assure compliance. |