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 September 9, 2010 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Cove Forge Behavioral Health System at Williamsburg, was found not to be in compliance with the applicable chapters of 28 PA Code which pertain to the facility. Deficiencies were identified during this inspection and plan of correction is due on October 7, 2010.
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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 the 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 September 9, 2010. Five patient records were reviewed for documentation of verification that the individual has reached 18 years of age. Prior to administration of an agent, a narcotic treatment program shall screen each individual to determine eligibility for admission. Two patient records did not include the documentation.
Patient record #4 was admitted on January 10, 2010 and was discharged on January 14, 2010. The initial dose of Subutex was given to the patient on January 11, 2010. The facility failed to document verification that the individual has reached 18 years of age prior to administration of Subutex.
Patient record #5 was admitted on May 21, 2010 and was discharged on May 22, 2010 . The initial dose of Subutex was given to the patient on May 22, 2010 . The facility failed to document verification that the individual has reached 18 years of age prior to administration of Subutex.
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Plan of Correction
Prior to administration of an agent, Cove Forge nursing department will screen each client to determine eligibility for admission by verifying the client is 18 years of age.
Responsible Staff:
During the intake process, the admissions staff will communicate the need for age verification to clients and referral sources. Clients will be required to bring a form of identification on admission. Nursing staff will verify and document age when client is admitted. Admission's Coordinator and Detox Unit Coordinator are responsible for educating staff at their next monthly department meeting. 100% of opiate client records will be audited monthly for three months for compliance.
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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 the review of patient records, the facility failed to document verification of the individual 's identity, including name, address, date of birth, emergency contact and other identifying data in two of five patient records.
The findings include:
Five patient records were reviewed September 9, 2010. Five patient records were reviewed for documentation of verification of the individual 's identity, including name, address, date of birth, emergency contact and other identifying data. Prior to administration of an agent, a narcotic treatment program shall screen each individual to determine eligibility for admission. Two patient records did not include the documentation.
Patient record #4 was admitted on January 10, 2010 and was discharged on January 14, 2010. The initial dose of Subutex was given to the patient on January 11, 2010. The facility failed to document verification of the individual's identity prior to administration of Subutex.
Patient record #5 was admitted on May 21, 2010 and was discharged on May 22, 2010 . The initial dose of Subutex was given to the patient on May 22, 2010 . The facility failed to document verification of the individual's identity prior to administration of Subutex.
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Plan of Correction
Prior to administration of an agent, Cove Forge nursing staff will screen each client to determine eligibility for admission. Nurses will verify the client's identity including name, address, date of birth, emergency contact, and other identifying data.
Responsible Staff:
During the intake process, the admissions staff will communicate the need for clients to bring identifying information with them on admission.
Information Requested:
Verification of client's name, address, date of birth, emergency contact, and any other identifying data. Nursing staff will verify and document client's identity upon admission. Admissions Coordinator and Detox Unit Coordinator are responsible for educating staff at their next monthly department meeting. 100% of opiate client records will be audited monthly for three months for compliance.
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715.17(c)(1)(i-vi)) 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:
(1) Administration of medication.
(i) A narcotic treatment physician shall determine the patient 's initial and subsequent dose and schedule. The physician shall communicate the initial and subsequent dose and schedule to the person responsible for the administration of medication. Each medication order and dosage change shall be written and signed by the narcotic treatment physician.
(ii) An agent shall be administered or dispensed only by a practitioner licensed under the appropriate Federal and State laws to dispense agents to patients.
(iii) Only authorized staff and patients who are receiving medication shall be permitted in the dispensing area.
(iv) There shall be only one patient permitted at a dispensing station at any given time.
(v) Each patient shall be observed when ingesting the agent.
(vi) Administering and dispensing shall be conducted in a manner that protects the patient from disruption or annoyance from other individuals.
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Observations
Based on review of the patient records, the facility failed to document that the narcotic treatment physician determined the patient 's initial and subsequent dose and schedule in five of five patient records.
The findings include:
Five patient records were reviewed on September 9, 2010. Five patient records are required to document that the narcotic treatment physician determined the patient 's initial and subsequent dose and schedule. A standard physician order was utilized for the narcotic agent, Subutex, in the five records reviewed.
Record #1 - Patient was admitted on September 5, 2010. The standing order was signed by the physician on September 6, 2010. The facility failed to document that the narcotic treatment physician determined the patient's initial and subsequent dose and schedule for this patient.
Record #2 - Patient was admitted on September 6, 2010. The standing order was signed by the physician on September 7, 2010. The facility failed to document that the narcotic treatment physician determined the patient 's initial and subsequent dose and schedule for this patient.
Record #3 - Patient was admitted on August 14, 2010. The standing order was signed by the physician on August 15, 2010. The facility failed to document that the narcotic treatment physician determined the patient's initial and subsequent dose and schedule for this patient.
Patient record #4 was admitted on January 10, 2010 and was discharged on January 14, 2010. The standing order was signed by the physician on January 11, 2010. The facility failed to document that the narcotic treatment physician determined the patient's initial and subsequent dose and schedule for this patient.
Patient record #5 was admitted on May 21, 2010 and was discharged on May 22, 2010. The standing order was signed by the physician on May 22, 2010. The facility failed to document that the narcotic treatment physician determined the patient's initial and subsequent dose and schedule for this patient.
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Plan of Correction
Cove Forge will follow their written policies and procedures regarding medications ordered by the narcotic treatment physician. The narcotic treatment physician determines the patient's initial and subsequent dose and schedule of administration of Buprenorphine. The physician shall verbally communicate and/or write the order to a nurse responsible for administering the Buprenorphine. Each medication order and dosage change shall be written and signed by the narcotic treatment physician.
Responsible Staff:
The narcotic treatment physicians will be responsible for writing specific initial doses of Buprenorphine and the subsequent schedule of administration. The Detox Coordinator will be responsible for monitoring patient Buprenorphine orders routinely for compliance beginning November 1, 2010.
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715.23(b)(4) LICENSURE Patient records
(b) Each patient file shall include the following information:
(4) The results of an initial intake physical examination.
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Observations
Based on review of the patient records, the facility failed to document the results of an initial intake physical examination in three of five patient records.
The findings include:
Five patient records were reviewed on September 9, 2010. Five patient records are required to document the results of an initial intake physical examination. Three of the five records reviewed did not have a complete physical examination.
Record #1 - Patient was admitted on September 5, 2010. The physical examination did not include vital signs. The medical history/physical examination form was started on September 6, 2010 by one physician, and was completed and signed on September 9, 2010 by a different physician and a physicians's assistant. The initial dose of Subutex, a narcotic agent, was given on September 6, 2010, prior to the completion of the documentation of the physical examination.
Record #3 - Patient was admitted on August 14, 2010. The physical examination was completed and signed by the physicians assistant on August 15, 2010. The physician did not sign the physical examination. The facility failed to document the narcotic treatment physicians signature on the physical examination.
Patient record #5 was admitted on May 21, 2010 and was discharged on May 22, 2010. The physical examination was completed and signed by the physicians assistant on May 22, 2010. One physician signed the physical examination on May 31, 2010, and a second physician signed the physical examination on June 1, 2010. The initial and only dose of Subutex, a narcotic agent, was given on May 22, 2010, prior to the signature of the physician on the physical examination.
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Plan of Correction
The initial history and physical shall be completed in its entirety within twenty-four hours of each client's admission.
Responsible Staff:
The Physician Assistants and/or Physicians will see each new admission within twenty-four hours to complete the patient's History & Physical. The completed History & Physical will be signed and co-signed by the Physician Assistant and the Physicians respectively. 100% of opiate client records will be audited monthly by Detox staff for compliance for three months. The Medical Director will be responsible for ensuring compliance.
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