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 November 19 and November 20, 2012, by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Malvern Institute 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.
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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 a review of patient records, the facility failed to document the basis for determining current opiate dependency in one of six patient records.
The findings include:
Six patient records were reviewed for documentation of the basis for determining current opiate dependency.
Patient # 2 was admitted on 10/10/2012 and discharged on 10/6/2012. The narcotic treatment physician documented the patient was to begin the Suboxone protocol when the urinalysis results were received "whether negative or positive." The narcotic treatment physician failed to document the rationale for providing treatment with a narcotic agent without further review of current dependency.
The findings were reviewed with the facility director and nursing supervisor and confirmed.
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Plan of Correction
The Quality Manager and Executive Director will meet with the physician to re-educate her on the proper documentation of determining current opiate dependency including her rationale for ordering a narcotic.
The Assistant Director of Nursing will conduct medical record reviews to ensure the physician documents proper determination of current opiate dependency. Reviews will be conducted on a weekly basis for 4 weeks starting on December 27, 2012. Upon compeltion of weekly reviews the reviews will then be conducted monthly. |
715.23(b)(15) LICENSURE Patient records
(b) Each patient file shall include the following information:
(15) Psychosocial evaluations of the patient.
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Observations
Based on a review of patient records, the facility failed to document psychosocial evaluations that were a clinical assessment in one of four patient records.
The findings include:
Six patient records were reviewed. Four patient records were required to document psychosocial evaluations of the patient.
Patient # 2 was admitted on 10/10/2012 and discharged on 10/6/2012. The psychosocial evaluation documented a repeat of the historical data, the patient reported commentary with lists and no clinical assessment.
The findings were reviewed with the facility director and confirmed.
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Plan of Correction
The Clinical Supervisors will conduct a training with all counselors on how to complete an evaluative psychosocial assessment. This training will be completed by 12/20/12 and will be documented.
The Clinical Supervisors will conduct weekly medical record reviews starting on December 28th to ensure psychosocial assessments are evaluative. Results of the medical record reviews will be reviewed by the QM committee on a monthly basis. |
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 discharge summaries with all of the required information in three of four patient records.
The findings include:
Six patient records were reviewed. Four patient records were required to document discharge summaries. Three patient records failed to document all of the components of a discharge summary, # 2, 3 and 4.
Patient # 2 was admitted on 10/10/2012 and discharged on 10/6/2012. The discharge summary did not document the prognosis of the patient upon discharge.
Patient # 3 was admitted on 8/15/2012 and discharged on 8/30/2012. The medical discharge summary was documented. The clinical discharge that included reason for treatment, response to treatment, services offered and prognosis upon discharge was not documented.
Patient # 4 was admitted on 7/1/2012 and discharged on 7/10/2012. The discharge summary did not document the services offered and the prognosis of the patient upon discharge.
The findings were reviewed with the project director, facility director, clinical supervisors and nursing supervisor and confirmed.
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Plan of Correction
The Clinical Supervisors will conduct a training with all counselors on the completion of discharge summaries. This training will be held by 12/20/12 and will be documented.
The Medical Records Coordinator will monitor the completion of discharge summaries on a weekly basis and report the results of her monitoring to the Clinical Supervisors. Clinical Supervisors will follow-up with their counselors to ensure discharge summaries are completed within the required timeframes. |