INITIAL COMMENTS
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This report is a result of an onsite follow-up inspection pertaining to the plans of correction for the February 28, 2012 buprenorphine monitoring inspection. The follow-up inspection was conducted on July 27, 2012 by staff from the the Division of Drug and Alcohol Program Licensure. Based on the findings of the onsite follow-up 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)(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 eight patient records.
The findings include:
Eight patient records were reviewed on July 27, 2012. All patient records were required to document the physician's documentation of the basis for determining current opiate dependency. The narcotic treatment physician date was not legible for the documentation of current opiate dependence in patient records # 3, 6, 7, and 8. There was no way to determine if the documentation was completed prior to the administration of a narcotic agent, specifically Subutex.
This finding was confirmed by Director of Nursing and was not disputed.
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Plan of Correction
Medical secretary supervisor will obtain date stamp to be used on opiate dependency documentation to ensure completion in a timely manner. Detox Program Director will ensure completion of this being done. This will continue to be a part of our monthly chart monitoring process. This will be completed and put into place by September 10,2012. |
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 eight patient records. A complete drug screen includes receiving the results from the CLIA and Department of Health approved laboratory.
The findings include:
Eight patient records were reviewed on July 27, 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 # 7 and 8.
Patient # 7 was admitted on 7-24-2011. The urine screen results were received by the facility on July 25, 2012 at 9:25 p.m.. The initial dose of Subutex was given on 7-25-2012 at 1:00 p.m..
Patient # 8 was admitted on 7-24-2012. The urine screen results were received by the facility on July 26, 2012 at 1:29 a.m.. The initial dose of Subutex was given on 7-25-2012 at 10:00 a.m..
This finding was confirmed by the Director of Nursing and was not disputed. This is a repeat citation from the February 28, 2012 buprenorphine inspection.
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Plan of Correction
Nursing staff will ensure drug screen results are obtained before initial dose of subutex is administered, if results are not available from lab at that time, an instant urine drug screen must be performed and results reviewed with physician. Will continue to have checklist in place and nursing staff will need to document using their initials instead of a check mark that all things are in place before initial dose is administered. This will be monitored by Detox Program Director/Nurse Manager. The checklist was added to our monthly chart monitoring process and we will continue that. This will be completed by September 10,2012. |
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 Nursing, the facility failed to ensure that the documentation included in the patient record was legible in all records reviewed. Eight patient records were reviewed on July 27, 2012. All records included documentation by the narcotic treatment physician that was not legible. The Director of Nursing was asked to translate the information in the patient record. The finding was confirmed and was not disputed by the facility.
This is a repeat citation from the February 28, 2012 buprenorphine inspection.
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Plan of Correction
Medical Secetary Supervisor will obtain stamp with physician's full signature and credentials. Physician will then verify stamped signature with hand written signature. This will also remain as part of our monthly chart monitoring process. Detox Program Director will ensure completion. This will be completed by September 10,2012. |