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 5, 2011 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, White Deer Run Of Lancaster 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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715.17(b) LICENSURE Medication control
(b) A narcotic treatment program shall develop policies and procedures regarding verbal medication orders, including the issuing and receiving of orders, identifying circumstances when orders are appropriate and documenting orders, in accordance with applicable Federal and State statutes and regulations.
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Observations
Based on the review of patient records, the facility failed to ensure the physician dated the signature after submitting a verbal order in two of four patient records reviewed.
The findings include:
Five patient records were reviewed October 5, 2011. Four records contained documentation of a physician's verbal orders. Two patient records contained telephone verbal orders by one physician, but they were signed within 24 hours by another physician.
Verbal orders must be signed by the physician who initially issued the order.
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Plan of Correction
Nursing will obtain verbal orders from the physician who is scheduled next. In the event that this is not possible, the order form with the written telephone/verbal order will be faxed to the physician who gave the order for immediate signature. The order will then be faxed back to the facility and placed in the record. This will be monitored on a daily basis by the night shift nurse during chart audits to ensure all orders are signed within the 24 hour time frame.
This will be implemented ASAP. |