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 September 28, 2011 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Cove Forge Behavioral Health System at Williamsburg, was found not to be in compliance with the applicable chapters of 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 the review of clinical documentation, the facility physician failed to document the basis for determining current opiate dependency in two of five patient records.
The findings include:
Five patient records were reviewed on September 28, 2011. Five patient records were required to include the physicians' documentation of the basis for determining current opiate dependency. Two patient records did not include this documentation, patients # 3 and 4.
Record #3 - Patient was admitted on 9-23-11. The physician's documentation of current opiate dependency was not completed at the time of the monitoring survey.
Record #4 - Patient was admitted on 9-6-11. The physician's documentation of current opiate dependency was not completed at the time of the monitoring survey.
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Plan of Correction
The narcotic treatment physician will perform a face-to-face determination of whether an individual is currently physiologically dependent for at least one 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 one year history of addiction.
The narcotic treatment physician will be responsible for doing the face-to face determination of dependence and documenting it in the chart. The nursing director and the medical director will be responsible for educating the medical staff. This was completed on 10-05-2011.
Ongoing monthly audits of opiate records will be conducted to ensure compliance.
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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 review of the patient records, the facility failed to obtain a complete drug screen urinalysis prior to the administration of Subutex, a narcotic agent in five of five patient records. A complete drug screen includes receiving the results from the CLIA and Department of Health approved laboratory.
The findings include:
Five patient records were reviewed on September 28, 2011. Five patient records were required to include a drug screen urinalysis prior to the administration of Subutex, a narcotic agent. A complete urine drug screen includes receiving the results from the CLIA and Department of Health approved laboratory. The facility failed to obtain a complete drug screen urinalysis prior to the administration of Subutex, a narcotic agent in five of the five records.
Record #1 - Patient was admitted on 6-10-11. The urine screen results from the CLIA and Department of Health approved laboratory were not available during the record review on 9-28-11. The initial dose of Subutex was given on 6-10-11 at 18:30.
Record #2 - Patient was admitted on 8-8-11. The urine screen results from the CLIA and Department of Health approved laboratory were not available during the record review on 9-28-11. The initial dose of Subutex was given on 8-9-11 at 14:00.
Record #3 - Patient was admitted on 9-23-11. The urine screen results from the CLIA and Department of Health approved laboratory were not available during the record review on 9-28-11. The initial dose of Subutex was given on 9-24-11 at 10:00.
Record #4 - Patient was admitted on 9-6-11. The urine screen results from the CLIA and Department of Health approved laboratory were not available during the record review on 9-28-11. The initial dose of Subutex was given on 9-7-11 at 13:00.
Record #5 - Patient was admitted on 7-10-11. The urine screen results from the CLIA and Department of Health approved laboratory were not available during the record review on 9-28-11. The initial dose of Subutex was given on 7-11-11 at 14:00.
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Plan of Correction
The Cove Forge Assistant Administrator will be responsible for submitting a letter of exception for on-site urine drug screening urinalysis to Director of the Division of Drug and Alcohol Program Licensure. This letter will be sent separately via US mail on October 13th.
The Assistant Administrator will be the responsible party.
Cove Forge will obtain a drug-screen urinalysis on each prospective subutex patient prior to administration of subutex.
Nursing supervisors will make sure all staff understands that a drug-screening urinalysis needs completed prior to a patent receiving subutex. This was done on 10-24-2011.
Ongoing monthly audits of opiate records will be conducted to ensure compliance.
The Nursing Coordinator will be the responsible party.
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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 a review of patient records, 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 five of five patient records.
The findings include:
Five patient records were reviewed on September 28, 2011. Five patient records are required to document a consult between the narcotic treatment physician determining the initial dose and the narcotic treatment physician performing the physical examination in five of five patient records.
Record #1 - Patient was admitted on 6-10-11. The Physician Assistant (PA) completed the physical examination on 6-11-11. The narcotic treatment physician determined the initial dose on 6-10-11, but failed to document the consultation with the Physician Assistant who completed the physical examination.
Record #2 - Patient was admitted on 8-8-11. The Physician Assistant (PA) completed the physical examination on 8-9-11. The narcotic treatment physician determined the initial dose on 8-9-11, but failed to document the consultation with the Physician Assistant who completed the physical examination.
Record #3 - Patient was admitted on 9-23-11. The Physician Assistant (PA) completed the physical examination on 9-24-11. The narcotic treatment physician determined the initial dose on 9-24-11, but failed to document the consultation with the Physician Assistant who completed the physical examination.
Record #4 - Patient was admitted on 9-6-11. The Physician Assistant (PA) completed the physical examination on 9-7-11. The narcotic treatment physician determined the initial dose on 9-7-11, but failed to document the consultation with the Physician Assistant who completed the physical examination.
Record #5 - Patient was admitted on 7-10-11. The Physician Assistant (PA) completed the physical examination on 7-11-11. The narcotic treatment physician determined the initial dose on 7-11-11, but failed to document the consultation with the Physician Assistant who completed the physical examination.
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Plan of Correction
The narcotic treatment physician determining the initial dose and schedule will consult with the physician's assistant who conducted the examination prior to determining client's initial dose. This consultation will be documented in the client's record.
The narcotic treatment physician will be responsible for doing the consultation. The nursing director and the medical director will be responsible for educating the medical staff. This was completed on 10-05-2011.
Ongoing monthly audits of the opiate client records will be conducted to ensure compliance.
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