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 residential detoxification from opioid dependence. This inspection was conducted on October 24-25, 2012 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Pyramid Healthcare, 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.
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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 the review of clinical documentation, the facility physician failed to accurately document the basis for determining current opiate dependency in one of eight patient records.
The findings include:
Eight patient records were reviewed on October 25, 2012. All patient records were required to document the physician's documentation of the basis for determining current opiate dependency. The narcotic treatment physician's date next to his signature was not legible on the documentation of current opiate dependence in patient record # 7. There was no way to determine if the documentation was completed prior to the administration of a narcotic agent, specifically Subutex.
This finding was discussed with facility staff and was not disputed. This is a repeat citation from the monitoring inspection conducted on February 28, 2012 and the unannounced follow-up inspection on July 27, 2012.
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Plan of Correction
Date stamp currently utilized on physician orders. Will also include date stamp on determination of addiction. Will add this to the 3rd shift chart check. Nursing supervisor/program director will ensure completion by 12/17/12. |
715..23(b)(1) LICENSURE Patient records
(b) Each patient file shall include the following information:
(1) A complete personal history.
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Observations
Based on a review of the patient records, the facility failed to provide a personal history that included detail in the areas of family history, legal history, employment/vocational history, education history, military history, recreational history, prior treatment, client's perception of drug use, family drug abuse history and sexual history in seven of seven records.
The findings include:
Eight records were reviewed for compliance with the regulations. Seven records did not document personal histories that included all components of a personal history that are comprised of family drug abuse history, legal history, employment/vocational history, education history, military history, recreational history, prior treatment, client's perception of drug use, family drug abuse history, and sexual history. Specifically, patient records # 1,3, 4, 5, 6, 7 and 8.
Record # 1 - Patient was admitted on 10-20-2012. The personal history failed to include information in the area of family substance abuse history, client's perception of drug use, family history, recreation, and sexual history.
Record # 3 - Patient was admitted on 10-21-2012. The personal history failed to include information in the area of family substance abuse history, client's perception of drug use, family history, recreation, and sexual history.
Record # 4 - Patient was admitted on 10-20-2012. The personal history failed to include information in the area of family substance abuse history, client's perception of drug use, family history, recreation, and sexual history.
Record # 5 - Patient was admitted on 9-24-2012. The personal history failed to include information in the area of family substance abuse history, client's perception of drug use, family history, recreation, and sexual history.
Record # 6 - Patient was admitted on 10-16-2012. The personal history failed to include information in the area of family substance abuse history, client's perception of drug use, family history, recreation, and sexual history.
Record # 7 - Patient was admitted on 9-13-2012. The personal history failed to include information in the area of family substance abuse history, client's perception of drug use, family history, recreation, and sexual history.
Record # 8-Patient was admitted on 9-11-2012. The personal history failed to include information in the area of family substance abuse history, client's perception of drug use, family history, recreation, and sexual history.
This finding was discussed with the Director of Detox Services and was not disputed.
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Plan of Correction
A personal history will be provided by the client through newly implemented self assessment workbook. The nurse's will review with the client and sign, and will document the summary in the progress note. Nursing supervisor/ program director will ensure completion by 12/17/12. |
715.23(b)(2) LICENSURE Patient records
(b) Each patient file shall include the following information
(2) A complete drug and alcohol history.
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Observations
Based on a review of patient records, the facility failed to obtain a complete drug and alcohol history in seven of seven records reviewed.
The findings include:
Eight patient records were reviewed on October 25, 2012. Seven records were reviewed for documentation of drug and alcohol history that included lengths and patterns related to the client's progression of use. The facility failed to document the lengths and patterns related to the client's progression of use in patient records 1, 3, 4, 5, 6, 7 and 8.
This finding was discussed with facility staff and was not disputed.
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Plan of Correction
A complete drug and alcohol history will be included in the newly implemented self assessment workbook for the client to complete. Nursing will review with client and sign, will also provide a summary in the progress notes. Nursing supervisor/Program director will ensure completion by 12/17/12. |
715.23(b)(23) LICENSURE Patient records
(b) Each patient file shall include the following information:
(23) Discharge summary.
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Observations
Based on a review of patient records, the facility failed to document all of the required components of a discharge summary in four of four patient records.
The findings include:
Eight patient records were reviewed October 25, 2012. Four patient records were required to have discharge summaries.
Patient # 5 was admitted September 24, 2012 and discharged September 27, 2012 for behavioral issues. The discharge summary failed to accurately document the services offered to the client and it did not include the client's prognosis upon discharge.
Patient # 6 was admitted October 16, 2012 and was successfully discharged on October 21, 2012. The discharge summary failed to accurately document the services offered to the client and it did not include the client's prognosis upon discharge.
Patient # 7 was admitted on September 13, 2012 and successfully discharged on September 18, 2012. The facility failed to document the patient's reason for admission, services offered and prognosis on the discharge summary.
Patient # 8 was admitted on on September 11, 2012 and successfully discharged on September 16, 2012. The facility failed to document the patient's reason for admission and the patient's prognosis upon discharge on the discharge summary.
This finding was reviewed with the Director of Detox Services and was not disputed.
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Plan of Correction
Program director will inform the physician of the missing required components of the discharge summary. The discharge summary will include reason for admission, services offered and prognosis. Nursing supervisor/Program director will monitor through monthly chart monitor. This will be completed by 12/17/12. |