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 November 8, 2012 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 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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715.6(b)(1-9) LICENSURE Physician Staffing
(b) A narcotic treatment program may employ narcotic treatment physicians to assist the medical director. A narcotic treatment physician 's responsibilities include:
(1) Performing a medical history and physical exam.
(2) Determining diagnosis and determining narcotic dependence.
(3) Reviewing treatment plans.
(4) Determining dosage and all changes in doses.
(5) Ordering take-home privileges.
(6) Discussing cases with the treatment team.
(7) Issuing verbal orders pertaining to patient care.
(8) Assessing coexisting medical and psychiatric disorders.
(9) Treating or making appropriate referrals for treatment of these disorders.
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Observations
Based on a review of the narcotic treatment physicians updated job description, and an interview with the nurse supervisor, the facility failed to include all of the physician's responsibilities.
The findings include:
The facility updated the narcotic treatment physicians job description in September 2012. The updated description did not include; (2) Determining diagnosis and determining narcotic dependence, (3) Reviewing treatment plans, (4) Determining dosage and all changes in doses, (6) Discussing cases with the treatment team, (7) Issuing verbal orders pertaining to patient care, (8) Assessing coexisting medical and psychiatric disorders, (9) Treating or making appropriate referrals for treatment of these disorders.
The findings were reviewed with the facility director and the nurse supervisor and were not disputed.
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Plan of Correction
The Director of Nursing will redo the physician's job description to include the areas listed below: (2) Determining diagnosis and determining narcotic dependence, (3) Reviewing treatment plans, (4) Determining dosage and all changes in doses, (6) Discussing cases with the treatment team, (7) Issuing verbal orders pertaining to patient care, (8) Assessing coexisting medical and psychiatric disorders, (9) Treating or making appropriate referrals for treatment of these disorders.
Each year, when the policies are reviewed, the Director of Nursing and the Executive Director will ensure that all of these areas are included in the job description. These changes will be completed prior to 12/31/12. |
715.17(c)(3)(i-v) LICENSURE Medication control
(c) A narcotic treatment program shall develop and implement written policies and procedures regarding the medications used by patients which shall include, at a minimum:
(3) Inspection of storage areas. A narcotic treatment program shall inspect all drug storage areas and the dispensing station at least quarterly to ensure that the areas are maintained in compliance with Federal, State and local laws and regulations. A narcotic treatment program shall develop and implement written policies and procedures regarding who performs the inspections, how often, and in what manner the inspections are to be documented. The policies and procedures shall include the following:
(i) Disinfectants and drugs for external use shall be stored separately from oral and injectable drugs.
(ii) Drugs requiring special conditions for storage to insure stability shall be properly stored.
(iii) Outdated and contaminated drugs shall be removed and destroyed according to Federal and State regulations.
(iv) Administration of controlled substances shall be documented.
(v) Controlled substances and other abusable drugs shall be stored in accordance with Federal and State regulations.
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Observations
Based on a review of the facility policy and procedures, the documentation of the inspections, and discussions with the nurse supervisor, the facility failed to provide complete procedures and documentation.
The findings include:
The facility updated this policy and procedure in November 2012. The updated procedures failed to include who performs the inspections, how often, and in what manner the inspections are to be documented.
The facility was completing the inspection of storage areas on a monthly basis. The inspections were reviewed from November 2011 to October 2012. Of the twelve months reviewed, three inspections (January 2012, February 2012, July 2012) were not completed within the month, and one inspection (June 2012) did not have a dated signature.
The findings were reviewed with the facility director and the nurse supervisor.
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Plan of Correction
The Director of Nursing will update the inspection policy to include who performs the inspections, how often, and in what manner the inspections are to be documented. The Director of Nursing will also do checks monthly to ensure that the inspections are occurring each month and report that information quarterly to the quality improvement committee. The Director of Nursing will verify that the form is completed each month and that each inspection has a dated signature. This will be completed by 12/31/12. |
715.17(c)(5) LICENSURE Medication control
(c) A narcotic treatment program shall develop and implement written policies and procedures regarding the medications used by patients which shall include, at a minimum:
(5) Security of all substances. A narcotic treatment program shall develop and implement written policies and procedures to minimize the likelihood of loss, theft or misuse of an agent or another controlled substance as well as a plan of action if a loss, theft or misuse does occur. In the event of loss, theft or misuse, the Federal and State statutes and regulations regarding reporting shall be followed.
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Observations
Based on a review of the facility policy and procedures, and discussions with the nurse supervisor, the facility failed to provide complete procedures.
The findings include:
The facility updated this policy and procedure in November 2012. The updated procedures failed to include procedures to minimize the likelihood of loss, theft or misuse of an agent or another controlled substance as well as a plan of action if a loss, theft or misuse does occur. In the event of loss, theft or misuse, the Federal and State statutes and regulations regarding reporting shall be followed.
The findings were reviewed with the facility director and the nurse supervisor.
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Plan of Correction
The Director of Nursing will review the policy on medications to address the issues of loss, theft or misuse of an agent or another controlled substance. The Director of Nursing will add the above information to the policy and will add that in the event of loss, theft or misuse, the Federal and State statutes and regulations regarding reporting will be followed. Each year when this policy is reviewed the Executive Director and the Director of Nursing will ensure that this information is included. This will be updated by 12/31/12. |
715.21 LICENSURE Patient termination
A narcotic treatment program shall develop and implement policies and procedures regarding involuntary terminations. Involuntary terminations shall be initiated only when all other efforts to retain the patient in the program have failed.
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Observations
Based on a review of the facility policy and procedures, and discussions with the nurse supervisor, the facility failed to provide complete procedures.
The findings include:
The facility updated this policy and procedure in September 2012. The updated procedures failed to include reasons that a facility may involuntary discharge patients. The procedure is missing (ii) patient possessed a controlled substance, (iii) absent from the narcotic treatment program, and (iv) the patient has failed to follow the treatment plan objectives.
The findings were reviewed with the facility director and the nurse supervisor.
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Plan of Correction
The Director of Nursing will add information regarding involuntary discharge information to our current discharge policy. It will include that involuntary discharge can occur from a patient possessing a controlled substance, being absent from the narcotic treatment program, and the patient has failed to follow the treatment plan objectives.
The Executive Director and the Director of Nursing will ensure that when the policy is reviewed each year that the policy will include the above information. This will be completed by 12/31/12. |
715.28(a)(1-10) LICENSURE Unusual incidents
(a) A narcotic treatment program shall develop and implement policies and procedures to respond to the following unusual incidents:
(1) Physical assault by a patient.
(2) Inappropriate behavior by a patient causing disruption to the narcotic treatment program.
(3) Selling of drugs on the premises.
(4) Complaints of patient abuse (physical, verbal, sexual and emotional).
(5) Death or serious injury due to trauma, suicide, medication error or unusual circumstances.
(6) Significant disruption of services due to disaster such as fire, storm, flood or other occurrence.
(7) Incident with potential for negative community reaction or which the facility director believes may lead to community concern.
(8) Theft, burglary, break-in or similar incident at the facility.
(9) Drug related hospitalization of a patient.
(10) Other unusual incidents the narcotic treatment program believes should be documented.
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Observations
Based on a review of the facility policy and procedures, and discussions with the nurse supervisor, the facility failed to provide complete policies and procedures.
The findings include:
The facility updated this policy and procedure in November 2012. The updated procedures failed to include: (2) Inappropriate behavior by a patient causing disruption to the narcotic treatment program, (3) Selling of drugs on the premises, (4) Complaints of patient abuse (physical, verbal, sexual and emotional), (5) Death or serious injury due to trauma, suicide, medication error or unusual circumstances, (6) Significant disruption of services due to disaster such as fire, storm, flood or other occurrence, (7) Incident with potential for negative community reaction or which the facility director believes may lead to community concern, (8) Theft, burglary, break-in or similar incident at the facility,
(9) Drug related hospitalization of a patient, (10) Other unusual incidents the narcotic treatment program believes should be documented.
The findings were reviewed with the facility director and the nurse supervisor.
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Plan of Correction
The Director of Nursing will add the areas below to the unusual incident policy, including Inappropriate behavior by a patient causing disruption to the narcotic treatment program, Selling of drugs on the premises, Complaints of patient abuse (physical, verbal, sexual and emotional), Death or serious injury due to trauma, suicide, medication error or unusual circumstances, Significant disruption of services due to disaster such as fire, storm, flood or other occurrence, Incident with potential for negative community reaction or which the facility director believes may lead to community concern, Theft, burglary, break-in or similar incident at the facility, Drug related hospitalization of a patient, any other unusual incidents that Twin Lakes Center believes should be documented. Each year when this policy is reviewed, the Executive Director and the Director of Nursing will ensure that this information is included in the policy. This will be completed by 12/31/12.
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