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 March 4 and 5, 2008 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, White Deer Run, Inc.- Lancaster 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 March 31, 2008.
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Plan of Correction
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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
A review of fourteen randomly selected patient records revealed that the facility failed to provide documentation verifying the individual's identity, to include proof of name, date of birth and address in patient record #3.
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Plan of Correction
Intake staff and driver personnel will be re-oriented by Lead nurse on the importance of obtaining proper identification by 4/01/08. The lead nurse will send out a memo to all nurses to obtain the copy of photo identification, which will be placed in MAR and nurses will be trained to look at this prior to dosing. They will be instructed to contact the regional administrator for alternatives to obtaining identification if patients arrive without proper id. This will be completed by 4/1/08. Compliance will be monitored by lead nurse auditing 100 percent of suboxone records for 6 months. |
715.9(a)(3) 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:
(3) Obtain a drug use history and current drug use status of the individual.
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Observations
A review of fourteen randomly selected patient records revealed that the facility failed to obtain the results of the urine drug screen prior to administering the initial dose of Suboxone; specifically, patients #1, 2 and 3.
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Plan of Correction
A nurses meeting will be held by 4/1/08 where 715.9 Intake policy will be reviewed for obtaining UDS. A checklist will be developed on the white board (also called a dry-erase or dry wipe board, a flat white board on which to write with eraseable markers) to identify that lab results were returned.
Lead nurse will monitor compliance by auditing 100 percent of suboxone charts for 6 months. This will all occur beginning 4/1/08
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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 fourteen randomly selected patient records, the facility failed to document complete personal histories for patients #1, 2, 3, 6, 7, 8, 10, 11 and 14. The history contained one word responses that failed to provide clarification of significant issues or left questions unanswered.
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Plan of Correction
Clinical Supervisor will provide training to the nursing staff on documentation of personal histories and data collection. This will be completed by 4/7/08. This area was also reviewed in Nursing Leadership on 3/20/08. The clinical supervisor will audit 10 percent of records with the lead for 6 months to monitor compliance. |