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 for detoxification in a residential treatment facility, in the treatment of narcotic addiction. This inspection was conducted on October 2, 2007 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Twin Lakes Center, Inc. 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 and a plan of correction is due on November 16, 2007. .
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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 a review of patient records on October 2, 2007, the facility failed to document the patient's age in patient records #1 and #3.
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Plan of Correction
Age verification will be required on all buprenorphine candidates prior to administering the first dosage. A driver's license will be the identifier of choice, if this is not available, a request will be made for the individual to bring their birth certificate with them. If this is not available, they will need to provide some form of ID that confirms their date of birth.
All opiate addicts and /or their referral sources will receive this request at the time their admission date is confirmed, prior to their actual arrival at the facility.
Also, there will be a checklist added to the chart that confirms certain thing have been checked prior to first dosing. This will include age and identification verification, as well as a signed informed consent for buprenorphine.
The Director of nursing will do a random chart audit of buprenorphine detox patients and report on the findings, quarterly in PI meetings. These chart audits will begin 11/21/07.
A memo educating detox staff on this policy will be distributed 11/19/07.
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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 the facility failed to document the verification of the client's identity in two of four patient records, specifically patient records # 1 and 3.
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Plan of Correction
Identification will be required for all patients prior to administering buprenorphine. A driver's license will be the identifier of choice, however if this is not available the patient will be required to show 2 forms of identification. This may include a social security card, or mail ( utility bills, a pay check, etc) being received at their current address, with their name on it within the last 30 days.
All opiate addicts and /or their referral sources will receive this request at the time their admission date is confirmed, prior to their actual arrival at the facility.
Also, there will be a checklist added to the chart that confirms certain thing have been checked prior to first dosing. This will include age and identification verification, as well as a signed informed consent for buprenorphine.
The Director of nursing will do a random chart audit of buprenorphine detox patients and report on the findings, quarterly in PI meetings. These chart audits will begin 11/21/07.
A memo educating detox staff on this policy will be distributed 11/19/07.
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715.12(1-5) LICENSURE Informed patient consent
A narcotic treatment program shall obtain an informed, voluntary, written consent before an agent may be administered to the patient for either maintenance or detoxification treatment. The following shall appear on the patient consent form:
(1) That methadone and LAAM are narcotic drugs which can be harmful if taken without medical supervision.
(2) That methadone and LAAM are addictive medications and may, like other drugs used in medical practices, produce adverse results.
(3) That alternative methods of treatment exist.
(4) That the possible risks and complications of treatment have been explained to the patient.
(5) That methadone is transmitted to the unborn child and will cause physical dependence.
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Observations
Based on patient record reviews it was determined that the facility failed to document a consent to Buprenorphine treatment in patient record # 3.
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Plan of Correction
All buprenorphine detox patients will sign a consent to treatment with buprenorphine prior to their first dosing.
There will be a checklist added to the chart that confirms certain thing have been checked prior to first dosing. This will include age and identification verification, as well as a signed informed consent for buprenorphine.
The Director of nursing will do a random chart audit of buprenorphine detox patients and report on the findings, quarterly in PI meetings. These chart audits will begin 11/21/07.
A memo educating detox staff on this policy will be distributed 11/19/07.
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715.23(b)(6) LICENSURE Patient records
(b) Each patient file shall include the following information:
(6) Results of laboratory tests or other special examinations given by the narcotic treatment program.
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Observations
Based on patient record reviews it was determined that the facility failed to document the blood work in two of four patient records, specifically patient records #2 and 4.
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Plan of Correction
If labwork is ordered by the physician, the results will be recorded in the MAR, which becomes part of the patient chart. The Director of nursing will do a random chart audit of buprenorphine detox patients and report on the findings, quarterly in PI meetings. These chart audits will begin 11/21/07.
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