INITIAL COMMENTS
|
This report is a result of an on-site inspection conducted for the approval to use a narcotic agent, specifically methadone and buprenorphine, in the treatment of narcotic addiction. This inspection was conducted on October 27 through 29, 2008 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, BGI of Brandywine, Inc. 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 December 4, 2008.
|
Plan of Correction
|
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.
|
Observations
Based on a review of 18 patient records on October 28 through 29, 2008, the narcotic treatment program failed to have a narcotic treatment physician make a face-to face determination and document in the patient's record the basis for determining an individual's physiological dependence upon a narcotic drug in 11 of 14 records, as required.
Findings:
In patient records #1, 3, 5, 6, 10, 12, 14, 24, 28, 30 and 32, there was no documentation verifying that the narcotic treatment physician made a face-to-face determination of the patient's physiological dependence upon a narcotic drug. This documentation was not presented during the monitoring.
|
Plan of Correction
As of 11/3/08, a new form was created that necessitates documentation of a "face to face" as opposed to the prior form which left it as an assumption.
Medical Director and Physician Assistant was Orientated to the use of the new form 11/3/08 by Executive Director.
Compliance will be maintained by chart audits completed by Medical Records on all charts at discharge. Feedback to Medical Staff with regards to non-compliance will be handled via the Medical Director.
|
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.
|
Observations
Based on a review of 18 patient records on October 28 through 29, 2008, the narcotic treatment program failed to complete an initial drug-screening urinalysis and random monthly urinalysis thereafter for each patient in two of fourteen records, as required.
Findings:
In patient record #10 the narcotic treatment program used an instant urine drug screen test that is Clinical Laboratory Improvement Amendments of 1998 (CLIA) waived. This was not a completed drug-screening urinalysis in that the laboratory performing the testing is not CLIA approved to provide this function.
In patient record #3 there was no documentation of a random urinalysis for the month of September 2008.
|
Plan of Correction
On the first Thursday of the month, as noted on the nursing assistant daily check list, edited 11/08, the Nursing Assistant will prepare the lab slip and urine cups. The afternoon Clinical Staff will obtain the observed specimens.
Staff has been re-instructed as of 11/8 that a dipped urine is not acceptable for dosing purposes
Compliance will be monitored by weekly random chart audits done by the Director of Nursing. |
715.15(b) LICENSURE Medication dosage
(b) The narcotic treatment physician shall determine the proper dosage level for a patient, except as otherwise provided in this section. If the narcotic treatment physician determining the initial dose is not the narcotic treatment physician who conducted the patient examination, the narcotic treatment physician shall consult with the narcotic treatment physician who performed the examination before determining the patient 's initial dose and schedule.
|
Observations
Based on a review of 18 patient records on October 28 through 29, 2008, the narcotic treatment program failed to document the consultation between the narcotic treatment physician determining the initial dose and the narcotic treatment physician performing the physical examination in 11 of 14 records, as required.
Findings
In patient records #1, 3, 5, 6, 10, 12, 14, 24, 28, 30 and 32, the narcotic treatment physician determining the initial dose failed to document the consultation with the certified physician assistant (PA-C) or other narcotic treatment physician completing the physical examination.
|
Plan of Correction
As of 11/3/08, a new form was created that necessitates documentation of a "face to face" as opposed to the prior form which left it as an assumption.
Due to our set up, under no circumstance is the narcotic treatment physician determining the dose different from the narcotic treatment physician completing the face to face exam, therefore, no consults will be had. The new form will address the issue.
Medical Director Orientated to the use of the new form 11/3/08 by Executive Director.
Compliance will be maintained by chart audits completed by Medical Records on all charts at discharge. Feedback to Medical Staff with regards to non-compliance will be handled via the Medical Director.
|
715.17(c)(7) 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:
(7) Drug reactions and medication errors. A narcotic treatment program shall report any adverse drug reaction or medication error to a narcotic treatment physician immediately and initiate corrective action. The narcotic treatment program shall record the reaction or error in the drug administration record and the clinical chart, and shall inform each person who is authorized to administer medication or supervise self-medication of the reaction or error.
|
Observations
Based on a review of 18 patient records on October 28 through 29, 2008, the narcotic treatment program failed to document that the Narcotic Treatment Physician and the Director of Nursing (DON) were notified of a medication error in one of eighteen records, as required.
Findings
In patient record #28 the documented medication order was for 30 mg. of methadone to start on August 22, 2008. However, the patient did not received the first dose until August 23, 2008 and it was only for 25 mg. There was no documentation in the patient record that the administering nurse reported this error to the narcotic treatment physician or the DON, as is required by the narcotic treatment program's policies and procedures. This documentation was not presented during the on-site monitoring.
|
Plan of Correction
In-service completed by Director of Nursing 11/8/08 to re-orient all nursing staff to curent policy related to medication errors.
Compliance will be maintained by weekly random Methadone MAR audits, follow up on medication errors to assure Physician notification was done.
Responsible person: Director of Nursing
|
715.20(3) LICENSURE Patient transfers
A narcotic treatment program shall develop written transfer policies and procedures which shall require that the narcotic treatment program transfer a patient to another narcotic treatment program for continued maintenance, detoxification or another treatment activity within 7 days of the request of the patient.
(3) The transferring narcotic treatment program shall document what materials were sent to the receiving narcotic treatment program.
|
Observations
Based on a review of 18 patient records on October 28 through 29, 2008, the narcotic treatment program failed to document what materials were sent to the receiving narcotic treatment program in six of seven records, as required.
Findings
In patient record #6, 10, 12, 16, 24 and 32 there was no documentation of the material sent to the receiving narcotic treatment program. This documentation was not presented during the on-site monitoring.
|
Plan of Correction
All faxed information will be kept in the chart with fax confirmation sheet of faxed materials sent to receiving narcotic treatment programs.
Staff instruction given regarding this process by DON at 11/8/08 nursing staff meeting.
Compliance will be monitored by random weekly chart audits by Director of Nursing or designee responsible for assuring materials are properly faxed.
|
715.20(4) LICENSURE Patient transfers
A narcotic treatment program shall develop written transfer policies and procedures which shall require that the narcotic treatment program transfer a patient to another narcotic treatment program for continued maintenance, detoxification or another treatment activity within 7 days of the request of the patient.
(4) The receiving narcotic treatment program shall document in writing that it notified the transferring narcotic treatment program of the admission of the patient and the date of the initial dose given to the patient by the receiving narcotic treatment program.
|
Observations
Based on a review of 18 patient records on October 28 and 29, 2008, the narcotic treatment program failed to document, in writing, that it notified the transferring narcotic treatment program of the admission of the patient and the initial dose given in two of two records, as required.
Findings
In patient records #3 and 5, there was no documentation in the record that the narcotic treatment program notified the transferring narcotic treatment program of the patient's admission and initial dose. This documentation was not presented during the on-site monitoring.
|
Plan of Correction
With appropriately executed consent, the admitting patient's admission date and initial dose given will be faxed to transferring narcotic treatment program. Faxed information will be kept in the chart with fax confirmation sheet sent to receiving narcotic treatment programs. Staff instruction given regarding this process by Director of Nursing at 11/8/08 nursing staff meeting. Compliance will be monitored by random weekly chart audits by Director of Nursing or designee responsible for assuring materials are properly faxed.
|
715.23(a) LICENSURE Patient records
(a) A narcotic treatment program shall maintain patient records in conformance with 42 CFR 2.16 and 2.22 (relating to security for written records; and notice to patients of Federal confidentiality requirements) and State statutes and regulations. A narcotic treatment program shall maintain a complete file on the premises for each present and former patient of the narcotic treatment program for at least 4 years after the patient has completed treatment or treatment has been terminated. Files shall be updated regularly so that the information is current.
|
Observations
Based on a review of 18 patient records on October 28 and 29, 2008, the narcotic treatment program failed to maintain patient records in accordance with 42 CFR 2.16 and 2.22 and State statutes and regulations in two of twelve records, as required.
Findings
In patient records #10 documentation indicated that information was released to another narcotic treatment program without the patient's signed consent. No signed consent to release information was presented during the on-site monitoring.
In patient record #24 documentation indicated that information was released to another treatment program without the patient's signed consent. No signed consent to release information was presented during the on-site monitoring.
|
Plan of Correction
Proper procedures surrounding the necessity of a properly executed consent form prior to release of any information was reviewed at nursing staff meeting on 11/8/08 by Director of Nursing.
Compliance will be mainained by weekly random chart audits completed by the Director of Nursing. |
715.23(b)(2) LICENSURE Patient records
(b) Each patient file shall include the following information
(2) A complete drug and alcohol history.
|
Observations
Based on a review of 18 patient records on October 28 through 29, 2008, the narcotic treatment program failed to obtain a complete drug and alcohol history in three of twelve records, as required.
Findings:
In patient record #5, the drug and alcohol histories dated August 22, 2008 and September 13, 2008 contained conflicting information regarding the patient's past drug use with no further clarification. In addition, the drug use history was incomplete in that it contained a start use date and last use date, but no chronological record of significant use dates or an explanation of their causes.
In patient record #10, the drug and alcohol history only contained information regarding the patient's past and current opiate use. The drug and alcohol history did not reflect whether or not the patient had past or present use of other drugs. In addition, the drug use history was incomplete in that it contained a start use date and last use date, but no chronological record of significant use dates or an explanation of their causes.
In patient record #12, the drug and alcohol history only contained information regarding the patient's past and current opiate use. The drug and alcohol history did not reflect past or present use of other drugs, which was noted in the psychiatric evaluation. In addition, the drug use history was incomplete in that it contained a start use date and last use date, but no chronological record of significant use dates or an explanation of their causes.
|
Plan of Correction
Proper procedures as to how to properly complete a Drug and Alcohol history was taught/reveiwed at nursing staff meeting on 11/8/08 by Director of Nursing.
Compliance will be mainained by weekly random chart audits completed by the Director of Nursing or designee assigned to this task. |
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.
|
Observations
Based on a review of 18 patient records on October 28 through 29, 2008, the narcotic treatment program failed to complete an initial intake physical examination in two of fourteen records, as required.
Findings
In patient record #1 the patient was admitted to the narcotic treatment program on September 26, 2008, but the initial intake physical examination was not completed until September 29, 2008. The initial physical examination was completed later than the 48 hours required by the narcotic treatment program's policies and procedures.
In patient record #5 the patient was first admitted to the narcotic treatment program on August 22, 2008, but the initial intake physical examination was not completed until August 25, 2008. The initial physical examination was completed later than 48 hours as required by the narcotic treatment program's policies and procedures. The patient was re-admitted on September 12, 2008, but no new physical examination was required.
|
Plan of Correction
Policy has been changed to accurately reflect practice that all History and Physicals are to be done within 72 hours of admit.
This was changed as of 11/3/08 and approved by this Executive Director. |
715.23(b)(11) LICENSURE Patient records
(b) Each patient file shall include the following information:
(11) Counselor notes regarding patient progress and status.
|
Observations
Based on a review of 18 patient records on October 28 through 29, 2008, the narcotic treatment program failed to document complete progress notes and status in six of nine records, as required.
Findings
In patient records #1, 3, 5 and 7 the group progress notes were missing individual assessments for each patient participating in the group.
In patient record #5 the individual progress notes did not address the data of the session, the clinician's assessment of the session and the patient or contain a specific plan. The individual progress notes were documented as treatment updates.
In patient record #6 the individual progress notes did not address the status of the pregnant patient in regards to compliance with detoxification treatment.
In patient record #10 there were no progress notes for individual therapy sessions. There was no documentation to determine that the patient received individual sessions. No progress notes were presented during the on-site monitoring.
|
Plan of Correction
Clinical Supervisor held in-service 11/25/08 with all clinical staff on the proper way to complete a group note.
Compliance will be monitored by group note collection at least weekly, random chart audits and supervision done by the Clinical Supervisor.
|
715.23(b)(15) LICENSURE Patient records
(b) Each patient file shall include the following information:
(15) Psychosocial evaluations of the patient.
|
Observations
Based on the review of patient records, the narcotic treatment program failed to document psychosocial evaluations in seven of ten patient records.
The findings include:
Eighteen patient records were reviewed on October 28 through 29, 2008. Psychosocial evaluations were required in ten patient records. The narcotic treatment program did not include evaluations in all the required areas in the psychosocial evaluation in patient records #1, 3, 5, 7, 10, 12 and 14.
In patient records 1, 3, 5, 7, 10 and 14 the psychosocial evaluations did not include an evaluation of the patient problems/needs, assets/strengths, support systems, coping mechanism, factors that may inhibit treatment or recommendations.
In patient record #14 the psychosocial evaluation did not include the clinician's impressions and recommendations.
|
Plan of Correction
Clinical Supervisor held in-service 11/26/08 with all clinical staff on the proper way to complete the Psychosocial Evaluation.
Compliance will be monitored by weekly random chart audits and supervision done by the Clinical Supervisor.
|
715.23(b)(23) LICENSURE Patient records
(b) Each patient file shall include the following information:
(23) Discharge summary.
|
Observations
Based on the review of patient records, the narcotic treatment program failed to document discharge summaries in seven of ten patient records.
The findings include:
Eighteen patient records were reviewed on October 28 through 29, 2008. Discharge summaries were required in seven patient records. The narcotic treatment program did not document discharge summaries that included all the required areas in patient records #2, 4, 6, 18 and 20.
In patient records #2, 4 and 6 the discharge summaries did not include the patient's response to treatment and the reason for the patient's discharge.
In patient records #18 and 20 the discharge summaries were not completed within seven days from the date of the patients' discharge. In patient record #18 and 20 the patient was discharged on October 19, 2008. The discharge summaries were required to be documented by October 26, 2008, but were not completed.
|
Plan of Correction
Clinical Supervisor held in-service 11/26/08 with all clinical staff on the proper way to complete a Discharge Summary.
Compliance will be monitored by random closed chart audits and supervision done by the Clinical Supervisor.
|
715.23(d)(1) LICENSURE Patient records
(d) A narcotic treatment program shall prepare a treatment plan that outlines realistic short and long-term treatment goals which are mutually acceptable to the patient and the narcotic treatment program.
(1) The treatment plan shall identify the behavioral tasks a patient shall perform to complete each short-term goal.
|
Observations
Based on the review of patient records, the narcotic treatment program failed to document treatment plans in twelve of twelve patient records.
The findings include:
Eighteen patient records were reviewed on October 28 through 29, 2008. Treatment plans were required in twelve patient records. The narcotic treatment program did not document individualized short and long term goals in the treatment plan in patient records #1, 2, 3, 4, 5, 6, 7, 10, 12. 14, 24 and 28.
|
Plan of Correction
Clinical Supervisor held in-service 11/26/08 with all clinical staff on the proper way to complete a Treatment Care Plan.
Compliance will be monitored by weekly random chart audits and supervision done by the Clinical Supervisor.
|
715.23(d)(2) LICENSURE Patient records
(d) A narcotic treatment program shall prepare a treatment plan that outlines realistic short and long-term treatment goals which are mutually acceptable to the patient and the narcotic treatment program.
(2) The narcotic treatment physician or the patient 's counselor shall review, reevaluate, modify and update each patient 's treatment plan as required by Chapters 157, 709 and 711 (relating to drug and alcohol services general provisions; standards for licensure of freestanding treatment activities; and standards for certification of treatment activities which are a part of a health care facility).
|
Observations
Based on the review of patient records, the narcotic treatment program failed to document treatment plan updates in three of seven patient records.
The findings include:
Eighteen patient records were reviewed on October 28 through 29, 2008. Treatment plan updates were required in seven patient records. The narcotic treatment program did not document in the treatment plan updates the patient's progress in relationship to the stated goals in patient records #1, 3 and 5.
|
Plan of Correction
Clinical Supervisor held in-service 11/26/08 with all clinical staff on the proper way to complete a Treatment Care Plan Update including time frame compliance.
Compliance will be monitored by weekly random chart audits and supervision done by the Clinical Supervisor.
|