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 July 8, 2010 by staff from the Division 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 August 4, 2010.
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Plan of Correction
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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 patient records and staff interviews, the narcotic treatment program 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 three of six patient records.
Findings:
Six patient records were reviewed on July 8, 2010; all were required to provide documentation of a face-to-face determination of current dependency by the physician. A review of documentation in patient records # 2 and 4 revealed that staff other than the physician had made the determination of current dependency. Further review of patient record # 2 indicated that patient # 2 had been dosed prior to the determination of current dependency. Patient record # 3 failed to document that a face-to face determination had taken place.
Staff interviews addressed the finding from the record reviews. Staff concurred that the face-to-face determinations were completed by staff other than the physician.
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Plan of Correction
The Program Director and Nursing personnel shall assure that no client receives suboxone dosing without first being seen face-to face by the narcotic treatment physician determining the client's physiological dependence upon a narcotic drug.
The same staff shall assure that documentation is maintained in the client record in accordance with policy.
The Program Director reviewed the related licensing standards and protocols with the nursing staff.
The Program Director and/or designated Nurse shall monitor ongoing conformance and report via the monthly continuous quality improvement process.
Target Resolution Date: 8/3/10 |
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 patient records, the facility failed to ensure that the narcotic treatment physician determined the proper dosage level for a patient in one of six patient records.
The findings include:
Six patient records were reviewed on July 8, 2010; all were required to have documentation of dose determinations by the physician. In patient record # 4, staff, other than the physician, made the determination to dose patient #4.
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Plan of Correction
The Program Director and all Nurse personnel shall ensure that the narcotic treatment physician determines the proper buprenorphine dosage level for all clients and that such is clearly documented in the client record.
The Program Director reviewed relevant licensing standards and protocols with the Nurse staff.
The Program Director and/or designated Nurse shall monitor ongoing conformance and report monthly via the continuous quality improvement meeting process.
Targeted resolution Date: 8/3/10 |
715.17(b) LICENSURE Medication control
(b) A narcotic treatment program shall develop policies and procedures regarding verbal medication orders, including the issuing and receiving of orders, identifying circumstances when orders are appropriate and documenting orders, in accordance with applicable Federal and State statutes and regulations.
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Observations
Based on the review of patient records and staff interview, the facility failed to ensure the physician signed a verbal order within 24 hours of issue within 24 hours of issue. The findings include:
Seventeen patient records were reviewed July 8, 2010. Two records contained documentation of a physician's verbal orders. In patient record # 4, the physician issued a verbal order on March 29, 2010; the physician did not sign the order until April 7, 2010.
Staff were interviewed and were able to concur the verbal order in patient record # 4 was not signed within 24 hours of issue.
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Plan of Correction
The Program Director and all Nurse personnel shall ensure that the physician signs a verbal order within 24 hours of issue.
Client records shall be reviewed nightly with respect to physician orders and required documentation.
The Program Director reviewed related licensing standards and protocols with Nurse staff.
The Program Director and/or designated Nurse shall monitor ongoing conformance and report monthly via the continuous quality improvement meeting process. |
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 a review of patient records and a staff interview, the facility failed to complete psychosocial evaluations within the facility policy in two of six patient records.
The findings include:
Six patient records were reviewed on July 8, 2010; all were reviewed for psychosocial evaluation content. In interviews with facility staff it was agreed the the evaluations are to be completed within 24 hours of admission to the facility. Patient # 3 was admitted into treatment on November 29, 2009; the psychosocial evaluation was completed on December 2, 2009. Patient # 4 was admitted into treatment on March 28, 2010; the psychosocial evaluation was completed on March 30, 2010.
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Plan of Correction
The Program Director and all Nurse personnel will ensure that all client psychosocials will be completed within the time frames outlined in program policy.
The Program Director reviewed relevant licensing standards and program protocols with Nurse staff.
The Program Director and/or designated Nurse will monitor for ongoing conformance and report monthly via the continuous quality improvement meeting process.
Target Resolution Date: 8/8/7/10 |