INITIAL COMMENTS
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This report is a result of an on-site inspection conducted for the approval to use narcotic agents, specifically methadone and buprenorphine, in the residential detoxification and maintenance treatment of narcotic addiction. This inspection was conducted on December 18 and 19, 2007 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, BGI of Brandywine, 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 January 21, 2008.
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Plan of Correction
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715.6(a)(2) LICENSURE Physician staffing
(a) A narcotic treatment program shall designate a medical director to assume responsibility for administering all medical services performed by the narcotic treatment program.
(2) When a narcotic treatment program is unable to hire a medical director who meets the qualifications in paragraph (1), the narcotic treatment program may hire an interim medical director. The narcotic treatment program shall develop and submit to the Department for approval a training plan for the interim medical director, addressing the measures to be taken for the interim medical director to achieve minimal competencies and proficiencies until the interim medical director meets qualifications identified in paragraph (1)(i), (ii) or (iii). The interim medical director shall meet the qualifications within 36 months of being hired.
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Observations
The facility failed to develop and submit a training plan for Department review and approval for the new interim medical director.
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Plan of Correction
Training plan submitted and approved by DAPL.
CRC Northeast Region Medical Director will work directly with Bowling Green Interim Medical Director to assure compliance with submitted training plan. |
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 a review of 18 patient records on December 19 and 20, 2007, the facility failed to provide a consistent method to record and maintain information that verified the patient age at admission.
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Plan of Correction
Facility will enroll in web based program: USA People Search which will allow us to run an unlimited number of people searches for name, addresses, birth dates and phone numbers. It will verify that name and birthdates match information being provided by the patient.
THis service will be used for those patients who show up in need of care but do not provide adequate ID as requested. Facility will continue to exaust all possibilities of obtaining adequate ID and document such. When no ID can be provided, the patient will be asked to sign a consent for us access the above mentioned web site to verify their information. Print out from the website will be placed in chart to serve as ID for age and identity. |
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 a review of 19 patient records on December 18 and 19, 2007, the facility failed to consistently document and record verification of the patient's identity.
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Plan of Correction
Facility will enroll in web based program: USA People Search which will allow us to run an unlimited number of people searches for name, addresses, birth dates and phone numbers. It will verify that name and birthdates match information being provided by the patient.
THis service will be used for those patients who show up in need of care but do not provide adequate ID as requested. Facility will continue to exaust all possibilities of obtaining adequate ID and document such. When no ID can be provided, the patient will be asked to sign a consent for us access the above mentioned web site to verify their information. Print out from the website will be placed in chart to serve as ID for age and identity. |
715.11 LICENSURE Confidentiality of patient records
A narcotic treatment program shall physically secure and maintain the confidentiality of all patient records in accordance with 42 CFR 2.22 (relating to notice to patients of Federal confidentiality requirements) and § 709.28 (relating to confidentiality).
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Observations
Based on a review of 19 patient records, the facility failed to obtain the required consent to release information in a timely and consistent manner. Specifically, patients # 7 and 18 did not have signed consents for information to be released to their home outpatient narcotic treatment facilities. The consent to release information for patient # 17 was signed after information had been released to the referral source.
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Plan of Correction
This function has been moved to the Admissions Department as of 1/14/08. An in-service has been held for the admissions staff regarding obtaining proper consents for opiate patients home outpatinet narcotic traetment facilities. This process will be monitored by Admissions Director and Primary Nursing Assistant to assure it is done via review of charts of opiate dependent patients. |
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
The facility failed to obtain the results of urine drug screens for patients prior to initial methadone dose. Specifically, patients # 3, 4, 16, 17, and 18 were all dosed before the results of initial drug screens were received by the facility. In several of these cases, the patients were weekend admissions and the facility was unable to obtain drug screen results for at least 48 hours post the initial admission dose.
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Plan of Correction
Effective immediately, no opiate clients will be dosed with Methadone prior to urine results being received back.
At this time, it has been difficult finding a 7 day a week lab, however, the facility does have a meeting on Friday 1/18 with a 7 day a week lab with the hope of being able to receive 7 day a week service to better treat our opiate clients.
Director of Nursing will be responsible for assuring that no nurse doses clients prior to urine screen results being received via random audits of MAR's vs. Methadone checklist. |
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 19 patient records on December 18 and 19, 2007, the facility failed to document that the physician determined the dose and schedule. Specifically, patient records # 3, 4, 5, 6, 8, 11, 13, 14, 15, 16, 17 and 18 provided documentation that identified the Physician's Assistant was making determinations that included assessments and orders that patients could be started on opiate protocol and also that methadone tapers could begin. Only the narcotic treatment physician or the medical director may make these determinations.
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Plan of Correction
The PA-C has been educated on this standard regarding determining dose or starting an opiate protocol. PA-C may not order the above protocols. The Medical Director and Psychiatrist will be educated to this standard as well to assure efficiency in this area.
Systematic chart audits will be periodically reviewed for compliance with this standard.
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715.20(4) LICENSURE Patient transfers
A narcotic treatment program shall develop written transfer policies and procedures which shall require that the narcotic treatment program transfer a patient to another narcotic treatment program for continued maintenance, detoxification or another treatment activity within 7 days of the request of the patient.
(4) The receiving narcotic treatment program shall document in writing that it notified the transferring narcotic treatment program of the admission of the patient and the date of the initial dose given to the patient by the receiving narcotic treatment program.
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Observations
Based on random review of 5 patient records , the facility failed to provide documentation that the transferring narcotic treatment program was notified of the patient's admission to the facility and the date of the initial dose for three patient records reviewed, patients # 4, 14, and 15.
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Plan of Correction
Facility has reinstated system utilizing "Methadone Patient Transfer to Bowling Green" form effective 1/14/08.
This form has all necessary parameters needed to comply with this standard.
N.A. will be responsible for filling out the checklist form and faxing to transferring narcotic tratment program.
Director of Nursing will be responsible for random chart audits to assure ongoing compliance. |
715..23(b)(1) LICENSURE Patient records
(b) Each patient file shall include the following information:
(1) A complete personal history.
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Observations
Based on a random review of 19 patient records, the facility failed to document a complete personal history for each patient. Specifically, patient records # 1, 2, 4, 17 and 19 contained personal histories that contained minimal information, one word responses to questions and lack of follow through to responses that indicated possible problem areas and barriers to treatment.
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Plan of Correction
An in-service will be held for all nursing staff by the DON by 1/25/08 to address the importance of documenting complete personal histories for each patient and the importance of acting upon information that may be an issue during their treatment.
RAndom chart audits done by DON will assure ongoing compliance of this standard. |
715.23(b)(2) LICENSURE Patient records
(b) Each patient file shall include the following information
(2) A complete drug and alcohol history.
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Observations
Based on a random review of 19 patient records, the facility failed to provide documentation of progression of the patient's drug and alcohol use in patient records # 1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 16, 17, 18 and 19.
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Plan of Correction
A revised nursing assessment has been implemented as of 1/14/08 to capture history of drug and alcohol use, progression, and periods of sobriety. Nursing staff has been oriented/trained by DON on our new nursing drug and alcohol assessment form. Ongoing monitoring by the DON via random chart audits will occur to evaluate completeness of documentation.
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715.23(b)(13) LICENSURE Patient records
(b) Each patient file shall include the following information:
(13) Patient record of services.
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Observations
Based on a review of 19 patient records, the facility failed to document patient specific record of services that were consistent with progress notes and other documentation contained in the patient record. Specifically, nine of eighteen patient records did not contain a record of services that was consistent with information contained in the patient record, patients # 2, 3, 7, 9, 10, 12, 15, 16 and 19.
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Plan of Correction
A staff training was held on January 09, 2008 to review how to properly complete a record of service and discuss the importance of completeness. This will be monitored during monthly chart audits and supervision done by Clinical Director. |
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 random review of patient records, the facility failed to develop an evaluative assessment of the historical data obtained that included the counselor's clinical impressions. Instead, the psychosocial evaluations of the patient consisted primarily of the repetition of the history 5 of 15 patient charts, patients # 3, 6, 7, 8, 17 and 19.
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Plan of Correction
A clinical staff training was held on January 09, 2008 to review how to properly extract information from all assessment data bases to properly formulate a complete and comprehensive Diagnostic summary.
Will also meet with the Biopsychosocial team to discuss was to increase completeness of the patient history for treatment as well as drug and alcohol history, when it started, progression and clean time, if any.
This will be monitored during monthly chart audits and supervision by Clinical Director
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