INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection and buprenorphine monitoring inspection conducted on December 1-2, 2014 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Gateway Rehabilitation Center 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:
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Plan of Correction
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705.10 (d) (1) LICENSURE Fire safety.
705.10. Fire safety.
(d) Fire drills. The residential facility shall:
(1) Conduct unannounced fire drills at least once a month.
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Observations
Based on a review of fire drill logs, the facility failed to conduct a fire drill during sleeping hours at least once every six months.
The findings include:
A review of the fire drill logs was conducted on December 2, 2014. The time period reviewed was January - December 2014. Documentation of a fire drill conducted during sleeping hours is required once every six months. The facility did not document any fire drills during sleeping hours in the time period reviewed.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Upon review of the process for fire drills it was determined that there was an error in procedure. Security and counselors on the shift during sleeping hours are responsible for conducting and documenting fire drills during that shift. Security and Counselors were educated on 12/2 that sleeping hours occurs from 11p-7a and fire drills conducted to satisfy the requirement of once every 6 months need to occur during that time, the error in procedure was resolved.
Security supervisor and Director of Main Campus are responsible to ensure that fire drills occur every month, with fire frills conducted during sleeping hours at least once every 6 months, and are documented appropriately. |
709.32(b) LICENSURE Medication Control
709.32. Medication control.
(b) Verbal medication orders may be accepted but shall be put in writing and signed within 24 hours thereafter by the prescribing physician.
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Observations
Based on a review of client records, the facility failed to document that verbal orders for medication were authenticated in writing by a physician or other medical professional authorized by State and Federal law within 24 hours for the detoxification level of care in two of six client records.
The findings include:
Six detoxification client records were reviewed on December 1-2, 2014. Verbal orders, in the detoxification level of care, are required to be authenticated within 24 hours by a physician or other authorized medical professional. Patient records # 5 and 6 contained verbal orders that were not authenticated within 24 hours.
Patient #5 was admitted on November 27, 2014. Verbal orders for opiate detox and phenobarbital were issued on November 27 and a phenobarbital taper for opiate detox and phenobarbital were issued on November 27 and a phenobarbital taper was ordered on November 28. None of these orders were authenticated by a physican or other medical professional by the end of the inspection, December 2, 2014.
Patient #6 was admitted on November 22 2014 and discharged November 29, 2014. Verbal orders for opiate detox and phenobarbital were issued on November 22. Neither of these orders were authenticated by a physican or other medical professional by the end of the inspection, December 2, 2014.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
All nurses will be re-educated on the Medication Control Standard. This training
shall include the following and will be completed by 1/5/15:
a. Required authentication of all verbal orders in writing by a physician within 24 hours.
b. The 11p-7am nursing staff will be assigned the task of preparing all medical records that contain verbal orders written within the prior 24 hours. These medical records will be made available to the physician for review and authentication by signature.
c. Compliance will be monitored by the nursing department
d. The Medical Director has reviewed this process and requirement with all physicians
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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, the facility failed to document verification that the individual has reached 18 years of age in two of five patient records.
The findings include:
Five patient records were reviewed on December 1-2, 2014. All five patient records were required to include documentation of verification that the individual has reached 18 years of age. Patient records #1 and 2 did not include documentation of the verification that the individual has reached 18 years of age.
Patient #1 was admitted on July 7, 2014 and was discharged on July 10, 2014. There was no identification or verification of age documented in patient record #1.
Patient #2 was admitted on September 21, 2014 and was discharged on September 24, 2014. There was no identification or verification of age documented in patient record #2.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Upon review of the intake process, it was determined there was an error in the process...the following plan of correction addresses the errror.
Prior to the administration of Buprenorphine all patients will be screened for the individual's identity, including name, address, date of birth, emergency contact and other identifying data.
The plan of correction will include:
All individuals will be screened initially by the admission department. The admission department will obtain valid identification which may include a current Driver's License or State Issued Identification.
If the individual fails to produce a valid form of identification the Nursing Department will be notified in writing.
The Nursing Department will make every effort to attempt to obtain valid patient identification.
All nurses will be trained to scan valid forms of identification during off hours. This training will be completed by 1/5/15.
Admission staff will be trained regarding new process that includes notification of nursing when patient fails to produce valid identification. This training will be completed by 1/5/15.
If Nursing is unable to obtain valid patient identification the physician will be notified in writing and the patient will be made aware of restrictions to their treatment and offered alternatives to care.
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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 verification of the individual's identity, including name, address and date of birth in two of five patient records.
The findings include:
Five patient records were reviewed on December 1-2, 2014. All five patient records were required to include verification of the individual's identity, including name, address and date of birth. Patient records #1 and 2 did not include documentation of the verification of the individual's identity, including name, address and date of birth.
Patient #1 was admitted on July 7, 2014 and was discharged on July 10, 2014. There was no identification or verification of the individual's identity, including name, address and date of birth documented in patient record #1.
Patient #2 was admitted on September 21, 2014 and was discharged on September 24, 2014. There was no identification or verification of the individual's identity, including name, address and date of birth documented in patient record #2.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Upon review of the intake process, it was determined there was an error in the process...the following plan of correction addresses the errror.
Prior to the administration of Buprenorphine all patients will be screened for the individual's identity, including name, address, date of birth, emergency contact and other identifying data.
The plan of correction will include:
All individuals will be screened initially by the admission department. The admission department will obtain valid identification which may include a current Driver's License or State Issued Identification.
If the individual fails to produce a valid form of identification the Nursing Department will be notified in writing.
The Nursing Department will make every effort to attempt to obtain valid patient identification.
All nurses will be trained to scan valid forms of identification during off hours. This training will be completed by 1/5/15.
Admission staff will be trained regarding new process that includes notification of nursing when patient fails to produce valid identification. This training will be completed by 1/5/15.
If Nursing is unable to obtain valid patient identification the physician will be notified in writing and the patient will be made aware of restrictions to their treatment and offered alternatives to care.
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715.14(a) LICENSURE Urine testing
(a) A narcotic treatment program shall complete an initial drug-screening urinalysis for each prospective patient and a random urinalysis at least monthly thereafter.
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Observations
Based on review of the patient records, the facility failed to obtain a complete drug screen urinalysis prior to the administration of Suboxone, a narcotic agent, in five of five patient records. A complete drug screen includes receiving the results from the CLIA and Department of Health approved laboratory.
The findings include:
Five patient records were reviewed on December 1-2, 2014. All five patient records were required to include a complete drug screen urinalysis prior to the administration of Suboxone, a narcotic agent. A complete urine drug screen includes receiving the results from the CLIA and Department of Health approved laboratory. The facility failed to obtain a complete drug screen urinalysis prior to the administration of Suboxone, a narcotic agent, in five of the five patient records.
Patient #1 was admitted on July 7, 2014 and discharged July 10, 2014. The initial dose of Suboxone was given on July 8, 2014; however, the urinalysis results were received on July 9, 2014.
Patient #2 was admitted on September 21, 2014 and discharged September 24, 2014. The initial dose of Suboxone was given on September 22, 2014; however, the urinalysis results were received on September 23, 2014.
Patient #3 was admitted on July 21, 2014 and discharged July 24, 2014. The initial dose of Suboxone was given on July 22, 2014; however, the urinalysis results were received on July 23, 2014.
Patient #4 was admitted on November 29, 2014. The initial dose of Suboxone was given on November 30, 2014; however, the urinalysis results were received on December 2, 2014.
Patient #5 was admitted on November 22, 2014 and discharged November 29, 2014. The initial dose of Suboxone was given on November 23, 2014; however, the urinalysis results were received on November 28, 2014.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
upon reviewing the procedure, it was determined that drug screen urinalysis reports are not consistently reported timely from the Lab prior to administration of suboxone.
standing orders were changed to reflect that initiation of suboxone will not occur until urine drug screen results have been reviewed and opiate dependence has been verified.
the director of nursing is responsible for monitoring compliance |