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 residential detoxification from opioid dependence. This inspection was conducted on March 17, 2008 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 28 PA Code which pertain to the facility. Deficiencies were identified during this inspection and plan of correction is due on April 21, 2008.
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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 review of four patient records, the facility failed to provide documentation verifying that the individual had reached age 18 in two of three records, specifically patient records # 2 and 3.
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Plan of Correction
The admissions department will require proof of identification on admission. The admissions counselor will make a photocopy of the identification and retain this copy in the chart. The identification will show a date of birth and verify a patient's name and address. |
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 review of four patient records, the facility failed to provide documentation verifying the individual's identity, to include proof of name, date of birth and address in two of three records, specifically patient records # 2 and 3.
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Plan of Correction
The admissions department will require proof of identification on admission. The admissions counselor will make a photocopy of the identification and retain this copy in the chart. The identification will show a date of birth and verify a patient's name and address. |
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 four patient records and discussion with administrative and medical staff, the facility failed to obtain a complete urine drug screen prior to the administration of Suboxone, a narcotic agent, in four of four records reviewed, # 1, 2, 3 and 4. A complete urine drug screen must be obtained from a CLIA and Department of Health approved laboratory.
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Plan of Correction
A complete urine drug screen will be obtained from a CLIA and Department of Health approved laboratory before Suboxone will be administered. A sample will be obtained from the admitting patient and sent to the contract laboratory for a complete urine drug screen analysis. Once confirmation of results has been received, the patient, if a Suboxone candidate, will be assessed by the narcotic treatment physician and Suboxone will be initiated if deemed appropriate. |
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 review of four patient records, the facility did not provide documentation verifying that the physician who determined the dose level for the patient consulted with the Certified Nurse Practitioner (CRNP) who had conducted the patient's physical examination in four of four records reviewed, # 1, 2, 3 and 4.
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Plan of Correction
The narcotic treatment physician will consult with the physician who conducted the patient's physical examination to determine the patient's initial dose, schedule, and risks prior to initiating Suboxone. The narcotic treatment physician will document his consultation with the physician who conducted the physical exam in the Suboxone induction note. |
715.23(b)(6) LICENSURE Patient records
(b) Each patient file shall include the following information:
(6) Results of laboratory tests or other special examinations given by the narcotic treatment program.
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Observations
Based on the review of four patient records, there was no documentation the facility had completed a tuberculosis Mantoux test for two of four records reviewed, record # 1 and 3.
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Plan of Correction
All nurses to be re-educated in a staff meeting and individually about PPD documentation and filing of the record. DON, or designee, will audit on a monthly basis to ensure compliance. |
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 review of four patient records, the facility failed to provide an evaluative assessment of the historical data obtained that included the counselor's clinical analysis of the patient's attitude toward treatment and overall impressions. Instead, the psychosocial evaluations of the patient consisted primarily of the repetition of the history and statements reported by the patient in three of three records reviewed, specifically #1, 3 and 4.
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Plan of Correction
Clinical staff responsible for completion of the psychosocial assessment will be retrained on the need for an evaluative summary of the clinical and historical data. Psychosocial summaries will be audited on a monthly basis through open and closed chart audits with results reported monthly to the Performance Improvement Committee. |
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 documentation and staff interviews, the facility failed to provide follow-up services to three of three patients that required follow-up according to the standards and the facility's policy. Specifically, patient records # 1, 2, 3.
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Plan of Correction
Staff assigned to provide follow-up services will be retrained per facility policy. Follow-up services will be audited monthly through closed chart audits with results reported to the Performance Improvement Committee. |