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 February 28, 2012 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Pyramid Healthcare, Inc., 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)(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 the review of patient records, the facility failed to document verification that the patient had reached 18 years of age in one of six patient records.
The findings include:
Six patient records were reviewed February 28, 2012. Six patient records were reviewed for documentation of verification of eligibility for services. Based on the facility's policy and procedures, Pyramid Healthcare will accept legal picture ID as proof of identity . For those who do not drive, they must have valid picture ID from their state of residence. The facility failed to verify the patient had reached 18 years of age in patient record # 1.
The program director confirmed this finding.
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Plan of Correction
Detox Program Director will develop a checklist for the nursing staff to complete prior to initiating Buprenorphine treatment. The checklist will include verification that the client is 18 years of age or older. The checklist items will be added to the monthly chart monitor which will be reviewed by the Detox Program Director. This will be completed by 4/15/12. |
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 the review of patient records, the facility failed to verify the identity of the patient prior to the administration of an agent in one of six patient records.
The findings include:
Six patient records were reviewed on February 28, 2012. According to the facility's policy and procedures, the admissions staff will screen each individual for the appropriateness prior to admission to the Buprenorphine Program. The individual's identity will be verified by information obtained, but not limited to: the individual's name, address, date of birth social security number and any other pertinent identifying information.. Pyramid Healthcare will accept legal picture ID as proof of identity . For those who do not drive, they must have valid picture Id from their state of residence. In questionable cases, the second form will be a birth certificate or a piece of mail addressed to the address where the client resides. Pyramid will not accept a client who cannot prove their identity. Six patient records were specifically reviewed for patient identity information. Record #1 did not contain documentation confirming their identity.
The program director confirmed this finding.
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Plan of Correction
Detox Program Director will develop a checklist for nursing staff to complete prior to initiating Buprenorphine treatment. This checklist will include verification of client identity. This checklist will be added to the monthly chart monitor, which the Detox Program Director will review to ensure completion. |
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 accurately document the basis for determining current opiate dependency in four of six patient records.
The findings include:
Six patient records were reviewed on February 28, 2012. All patient records were required to document the physician's documentation of the basis for determining current opiate dependency. The narcotic treatment physician did not date his signature on the documentation of current opiate dependence in patient records # 1, 4, 5, and 6. There was no way to determine if the documentation was completed prior to the administration of a narcotic agent, specifically Subutex.
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Plan of Correction
Director of Nursing met with physician on 2/28/12 to review proper procedure for completion of Documentation of Addiction, including date of assessment. This will be added to the monthly chart monitor to ensure completion, which will be monitored by Detox Program Director. |
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 two of six patient records. A complete drug screen includes receiving the results from the CLIA and Department of Health approved laboratory.
The findings include:
Six patient records were reviewed on February 28, 2012. All 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 patient records # 1 and 6
Patient # 1 was admitted on 12-18-2011. The urine screen results were received by the facility on December 20, 2011. The initial dose of Subutex was given on 12-19-2011 at 8:00 am.
Patient # 6 was admitted on 2-24-2012. There was an instant urine screen documented in the patient's record; however, the results did not include the patient's name or the date the drug screen was provided. There was no way to determine if the results were those of patient # 6 due to the lack of identifying information. The initial dose of Subutex was given on 2-28-2012 at 11:00 am.
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Plan of Correction
Detox Program Director will develop a checklist for nursing staff to complete prior to initiating buprenorphine treatment. This checklist will include obtaining urine drug screen results prior to the administration of the buprenorphine. This checklist will be added to the monthly chart monitor, which the Detox Program Director will review for completion. This will be completed by 4/15/2012. |
715.23(e) LICENSURE Patient records
(e) Patient file records, information and documentation shall be legible, accurate, complete, written in English and maintained on standardized forms or electronically.
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Observations
Based on the review of patient records, the facility failed to ensure that the documentation in the record was legible.
The findings include:
Based on the review of patient records and an interview with the Director of detoxification services, the facility failed to ensure that the documentation included in the patient record was legible in all records reviewed. Six patient records were reviewed on February 28, 2012. All records included documentation by the narcotic treatment physician that was not legible. The program director of the detoxification services was asked to translate the information in the patient record. The finding was confirmed and was not disputed by the facility
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Plan of Correction
Director of Nursing met with Physician on 2/28/2012 to discuss illegible documentation in client records. Physician agreed to improve legibility effective 2/29/2012. Detox Program Director will monitor through chart review. |
709.28(c) LICENSURE Confidentiality
709.28. Confidentiality.
(c) The project shall obtain an informed and voluntary consent from the client for the disclosure of information contained in the client record. The consent shall be in writing and include, but not be limited to:
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Observations
Based on the review of patient records, the facility failed to ensure that an informed and voluntary consent to release information was obtained in four of seven patient records reviewed. The facility exceeded 4 Pa. Code, Subsection 255.5(b) in three of six records reviewed.
The findings included:
Six patient records were reviewed February 28, 2012. Six records were reviewed regarding release of information documentation. The facility failed to ensure that an informed and voluntary consent to release information was obtained in three patient records reviewed, # 1, 2, and 3.
A review of patient record # 1 revealed information was released to a funding source on December 5. 2011. The patient did not sign a release prior to releasing information for the funding entity. The consent to release for the funding source was signed on December 18, 2011.
A review of patient record # 2 revealed information was released to a funding source on November 29, 2011. The patient did not sign a release prior to releasing information for the funding entity. The consent to release for the funding source was signed on November 30, 2011.
These findings were reviewed and confirmed with the program director of detoxification services.
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Plan of Correction
The admissions department will no longer run EVS checks prior to obtaining consent from the client to release this information. This will be inforced and monitored by the Admissions supervisor and will be effective 3/15/2012. |
709.32(b) LICENSURE Medication Control
709.32. Medication control.
(b) Verbal medication orders may be accepted but shall be put in writing and signed within 24 hours thereafter by the prescribing physician.
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Observations
Based on a review of the patient records, the facility failed to ensure that verbal medication orders are put in writing and signed within 24 hours by the prescribing physician, as required by regulation and facility policy and procedure, in two of six patient records.
The findings include:
Six detoxification patient records were reviewed on February 28, 2012. All verbal medication orders are required to be signed within 24 hours by the prescribing physician. Based on the facility's policy and procedures, the physician will authenticate all verbal orders within 24 hours of their receipt. Authentication includes the physician's signature, the date and the time. Patient records # 1 and 2 contained documentation of a verbal medication order that did not include the date and time by the prescribing physician. Therefore, there was no way to determine if the orders were signed within the required 24 hours.
Patient #1 was admitted on December 18, 2011. There was a verbal order written on December 22, 2011. The order was signed by the physician, however, the physician failed to record the date and time that he signed the verbal order. There was no way to verify that the order was signed within 24 hours.
Patient # 3 was admitted on October 22, 2011. There was a verbal order written on October 23, 2011 and October 24, 2011. The orders were signed by the physician, however, the physician failed to record the date and time that he signed the verbal orders. There was no way to verify that the orders were signed within 24 hours.
The above information was confirmed by the program director during and interview during the inspection.
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Plan of Correction
Director of Nursing met with physician on 2/28/2012 to review proper procedure for authenticating verbal orders. Physician agreed to include signature, date and time on verbal orders. This will be in effect by 3/16/2012. This will be monitored through monthly chart monitors and peer review. Director of Nursing will monitor peer review for completion and Detox Program Director will monitor chart monitors for completion. |