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 methadone and buprenorphine, in the treatment of narcotic addiction. This inspection was conducted on July 12, 2011 through July 14, 2011 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, BGI of Brandywine, Inc. 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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715.15(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 the review of patient records and an interview with the facility director, the facility failed to document that a consultation took place between the physician who determined the initial dose and the the Physician Assistant who completed the physical examination in nine of fourteen records.
The findings include:
Fifteen patient records were reviewed July 12, 2011 through July 14, 2011. Fourteen records were reviewed for documentation that a consultation took place between the narcotic treatment physician and the Physician's Assistant ( PA-C) prior to the physician's determination of the patient's initial dose and schedule. Nine of fourteen records had documented consultations, however, the physical examination was not completed prior to the completion of the face to face with the physician. The facility has a form that is specifically used to document the findings of the physician's face to face assessment of the patient as well as document that a consult took place between the physician who determines the initial dose and the physician or physician's assistant who performed the physical examination. A review of the documention revealed that, while the physician completed the face to face assessment and determined the patient's initial dose, the patient's physical examination had not yet been completed in records # 1, 7, 8, 9, 11, 12, 13, 14, and 15.
Patient # 1 was admitted 6/4/2011. The doctor documented a face to face with the patient on 6/5/2011, but failed to indicate that the narcotic treatment physician consulted with the PA-C who completed the history and physical examination on the patient. The patient received a physical examination by the PA-C on 6/6/2011 at 10:40 a.m. The patient received their first dose of 20 mg methadone at 14:30 p.m. on 6/5/2011.
Patient #7 was admitted on 7/8/2011. The PA-C completed the history and physical examination on the patient on 7/11/2011 at 13:00 p.m. The doctor countersigned the history and physical examination; however, the doctor failed to document the date and time he countersigned this document. The face to face was documented by the doctor on 7/9/2011. The doctor checked off on the face to face form that a consultation took place with the narcotic treatment physician who completed the history and physical examination. However, the history and physical examination were not completed at the time this document was completed. The patient received their first dose of 20 mg of methadone at 16:30 p.m. on 7/9/2011.
Patient # 8 was admitted on 7/1/2011. The PA-C completed the history and physical examination on the patient on 7/3/2011 at 11:35 a.m. The physician countersigned the history and physical examination on 7/5/2011 at 08:00 a.m. The face to face was documented by the physician on 7/2/2011 at 13:42 p.m. The physician indicated on the face to face form that a consultation took place with the narcotic treatment physician who completed the history and physical examination. However, the history and physical examination were not completed at the time this document was completed. physician wrote the order for 190 mg of methadone to start on 7/2/2011 at 13:42 p.m.
Patient # 9 was admitted on 7/5/2011. The PA-C completed the history and physical examination on the patient on 7/6/2011 at 14:15 p.m. The physician countersigned the history and physical examination on 7/7/2011 at 11:50 a.m. The face to face was documented by the doctor on 7/6/2011 at 11:50 a.m. The doctor checked off on the face to face form that a consultation took place with the narcotic treatment physician who completed the history and physical examination. However, the history and physical examination were not completed at the time the face to face took place. The doctor wrote the order for 110 mg of methadone on 7/6/2011 at 11:50 a.m. prior to the physical examination being completed.
Patient # 11 was admitted on 6/1/2011. The PA-C completed the history and physical examination on the patient on 6/2/2011 at 14:00 p.m.. The doctor countersigned the history and physical examination on 6/3/2011 at 09:00 a.m. The face to face was documented by the doctor on 6/2/2011 at 09:40 a.m. The physician indicated on the face to face form that a consultation took place with the narcotic treatment physician who completed the history and physical examination. However, the history and physical examination were not completed at the time the face to face took place. The physician wrote the order for the induction of methadone on 6/2/2011 at 09:45 a.m. The patient received their first dose of 20 mg of methadone at 14:10 p.m. on 6/2/2011.
Patient # 12 was admitted on 6/15/2011. The PA-C completed the history and physical examination on the patient on 6/16/2011 at 11:30 a.m. The physician countersigned the history and physical examination on 6/17/2011 at 08:00 am. The face to face was documented by the doctor on 6/15/2011 at 06:50 a.m. The physician indicated on the face to face form that a consultation took place with the narcotic treatment physician who completed the history and physical examination. However the history and physical examination were not completed at the time the face to face took place. The patient received their first dose of 20 mg of methadone on 6/16/2011 at 15:00 p.m.
Patient # 13 was admitted on 2/1/2011. The PA-C completed the history and physical examination on the patient on 2/2/2011 at 14:00 p.m. The doctor countersigned the history and physical examination on 2/3/2011 at 08:30 a.m. The face to face was documented by the doctor on 2/2/2011 at 11:30 a.m. The physician indicated on the face to face form that a consultation took place with the narcotic treatment physician who completed the history and physical examination. However, the history and physical examination were not completed at the time the face to face took place. The patient received their first dose of 20 mg of methadone on 2/2/2011 at 14:40 p.m.
Patient # 14 was admitted on 3/7/2011. The PA-C completed the history and physical examination on the patient on 3/9/2011 at 14:50 p.m. The doctor countersigned the history and physical examination on 3/11/2011 at 21:35. The face to face was documented by the doctor on 3/8/2011 at 22:15 p.m. The doctor checked off on the face to face form that a consultation took place with the narcotic treatment physician who completed the history and physical examination. However, the history and physical examination were not completed at the time the face to face took place. The patient received their first dose of 95 mg of methadone on 3/8/2011 at 22:00 p.m.
Patient # 15 was admitted 5/17/2011. The PA-C completed the history and physical examination on the patient on 5/18/2011 at 14:45 p.m. The doctor countersigned the history and physical examination on 5/19/2011 at 09:40 a.m. The face to face was documented by the doctor on 5/18/2011 at 10:00 a.m. The doctor checked off on the face to face form that a consultation took place with the narcotic treatment physician who completed the history and physical examination. However, the history and physical examination were not completed at the time the face to face took place. The patient received their first dose of 55 mg of methadone on 5/18/2011 at 15:40 p.m.
An interview with the facility director confirmed these findings.
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Plan of Correction
Effective 10/31/2011, no first dose will be determined nor will any actual dosing of a patient occur until an H & P AND a face to face is done. If two different responsible staff conduct these functions, a consult between the two will occur and be appropriately documented in the patient record.
The Medical Director is responsible for assuring this occurs and the Director of Nursing is responsible for assuring ongoing compliance via random chart audits and the use of the NTP checklist that is used prior to dosing. |
715.20(4) LICENSURE Patient transfers
A narcotic treatment program shall develop written transfer policies and procedures which shall require that the narcotic treatment program transfer a patient to another narcotic treatment program for continued maintenance, detoxification or another treatment activity within 7 days of the request of the patient.
(4) The receiving narcotic treatment program shall document in writing that it notified the transferring narcotic treatment program of the admission of the patient and the date of the initial dose given to the patient by the receiving narcotic treatment program.
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Observations
Based on the review of patient records and an interview with the director of nursing, the facility failed to document that it notified the referring facility of the admission and initial dosing of the patient in 1 of 6 patient records.
The findings include:
Fifteen patient records were reviewed July 12, 2011 through July 14, 2011. Six patient records were reviewed for documentation of notification to the referring facility of the admission and dosing of the referred patient.
Patient record #15 was referred by another narcotic treatment program and there was no documentation of the referral being notified of the admission and initial dosing of the patients.
An interview with the director of nursing confirmed this finding.
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Plan of Correction
An in-service will be conducted by the Director of Nursing by 8/19/2011 to assure all involved staff are re-trained on the requirement related to Bowling Green notifying the referring facility of the admission and the initial dosing of the patient.
Compliance will be maintained by random chart audits done by the Nursing Designee. This process will be overseen by the Director of Nursing. |