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 October 15, 2009 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, UHS Recovery Foundation, 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 and a plan of correction is due on November 7, 2009.
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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 on October 15, 2009, the facility failed to verify that the patient was at least 18 years old in four of five patient records.
The findings include:
Five patient records were reviewed on October 15, 2009. Five patient records were required to have documentation that the facility verified the patient was at least 18 years old prior to dosing the patient. There was no documentation that the facility verified the patient was at least 18 years old in patient records #1, 2, 3 and 4.
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Plan of Correction
715.9(a)(1): In-service conducted by Director of Admissions for all admissions staff on 11/4/09 to review policy and procedure regarding documented verification of client's identity, age, and other demographic information. Copies of necessary identifying credentials will be included in the medical record. Director of Admissions will perform monthly random audits of medical records to monitor compliance. Results reported monthly to Performance Improvement Committee. |
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 on October 15, 2009, the facility failed to verify the patient's identity in four of five patient records.
The findings include:
Five patient records were reviewed on October 15, 2009. Five patient records were required to have documentation that the facility verified the patient's identity prior to dosing the patient. There was no documentation that the facility verified the patients identity in patient records #1, 2, 3 and 4.
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Plan of Correction
715.9(a)(2): In-service conducted by Director of Admissions for all admissions staff on 11/4/09 to review policy and procedure regarding documented verification of client's identity, age, and other demographic information. Copies of necessary identifying credentials will be included in the medical record. Director of Admissions will perform monthly random audits of medical records to monitor compliance.Results reported monthly to Performance Improvement Committee. |
715.12(1-5) LICENSURE Informed patient consent
A narcotic treatment program shall obtain an informed, voluntary, written consent before an agent may be administered to the patient for either maintenance or detoxification treatment. The following shall appear on the patient consent form:
(1) That methadone and LAAM are narcotic drugs which can be harmful if taken without medical supervision.
(2) That methadone and LAAM are addictive medications and may, like other drugs used in medical practices, produce adverse results.
(3) That alternative methods of treatment exist.
(4) That the possible risks and complications of treatment have been explained to the patient.
(5) That methadone is transmitted to the unborn child and will cause physical dependence.
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Observations
Based on the review of patient records on October 15, 2009, the facility failed to obtain an informed, voluntary, written consent prior to dosing the patient in two of five patient records.
The findings include:
Five patient records were reviewed on October 15, 2009. Five patient records were required to have documentation that the facility obtained an informed, voluntary, written consent prior to dosing the patient. There was no documentation that the facility obtained an informed, voluntary, written consent in patient records #2 and 4.
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Plan of Correction
715.12(1-5): Medical director reviewed policy and procedure with medical and nursing staff regarding obtaining informed, voluntary, written consent from all clients prior to Suboxone induction on 11/2/09. Daily medical record review by night charge nurse will occur to monitor compliance. |
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.
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Observations
Based on the review of patient records on October 15, 2009, the facility failed to complete an initial drug-screening urinalysis for each patient in four of five patient records.
The findings include:
Five patient records were reviewed on October 15, 2009. Five patient records were required to have documentation that the facility completed an initial drug-screening urinalysis for each patient prior to dosing the patient. There was no documentation that the facility completed an initial drug-screening urinalysis in patient records #1, 2, 3 and 4. Urine testing was done using a dipstick for patient records #1, 2, 3 and 4. Patients #1, 2, 3 and 4 were dosed using the results of the dipstick rather than waiting for the results from a Clinical Laboratory Improvement Amendment of 1998 (CLIA) laboratory.
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Plan of Correction
715.14(a): Effective 11/9/09, CLIA Waived panel dipsticks will no longer be utilized for initial UDS. Arrangements have been made with our CLIA certified laboratory for daily specimen pick-ups so that we may meet this regulation. Medical director included this in his 11/2/2009 review with medical and nursing staff. Daily medical record review by night charge nurse will occur to monitor compliance.
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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.
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Observations
Based on the review of patient records on October 15, 2009, the facility failed to provide documentation that a consultation was held between the CRNP/physician who completed the physical examination and the physician who determined the dosage level for the patient in five of five patient records.
The findings include:
Five patient records were reviewed on October 15, 2009. Five patient records were required to have documentation of a consultation between the CRNP/physician who completed the physical examination and the physician who determined the dosage level for the patient. Documentation of a consultation between the CRNP/physician who completed the physical examination and the physician who determined the dosage level for the patient was missing in patient records #1, 2, 3, 4 and 5.
Additionally, there was not documentation of physical evaluations in patient records #1, 2, 3, 4 and 5.
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Plan of Correction
715.15(b): Effective immediately the Suboxone physician responsible for Suboxone induction will perform and document results of H&P prior to induction. Daily medical record review by night charge nurse will occur to monitor compliance. |
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 the review of patient records on October 15, 2009, the facility failed to document a discharge summary in one of two patient records.
The findings include:
Five patient records were reviewed on October 15, 2009. Two patient records were required to have a discharge summary. A discharge summary was not documented in patient record #4.
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Plan of Correction
715.23(b)(23): Director of Nursing held staff training on 10/29/09 to review policy and procedure regarding discharge summary documentation and patient follow-up documentation. Monthly random chart audits will be performed by DON to monitor for compliance.Results reported monthly to Performance Improvement Committee.
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715.23(b)(24) LICENSURE Patient records
(b) Each patient file shall include the following information:
(24) Follow-up information regarding the patient.
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Observations
Based on the review of patient records on October 15, 2009, the facility failed to document follow-up in two of two patient records.
The findings include:
Five patient records were reviewed on October 15, 2009. Two patient records were required to have follow-up information documented. Follow-up information was not documented in patient records #4 and 5.
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Plan of Correction
715.23(b)(24): Director of Nursing held staff training on 10/29/09 to review policy and procedure regarding discharge summary documentation and patient follow-up documentation. Monthly random chart audits will be performed by DON to monitor for compliance. Results reported monthly to Performance Improvement Committee. |