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 methadone, in the treatment of narcotic addiction. This inspection was conducted on September 18-20, 2012 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, John F. Kennedy Behavioral Health Center was found not to be in compliance with the applicable chapters of 4 PA Code and 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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715.11 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 patient records, the facility failed to obtain an informed and voluntary consent from the patient prior to the disclosure of information in two patient records.
The findings include:
Patient record # 6 contained a consent to release to a probation officer that stated the specific information to be released was treatment summary. Upon further review of the patient record, a form was found entitled "Treatment Summary" and was addressed to probation. On this form that was sent to the probation officer was the patients medication information.
Patient record # 11 contained consents to release information that failed to include the purpose of the consent. The offer of a copy was not documented and the witness signature was not included.
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Plan of Correction
By October 9, 2012 the Clinical Supervisor will conduct a staff training on the limitations on information released to individuals in the criminal justice system (Pa. 255.5). In addition, all items contained on our general release of information form will be reviewed and clarified. The Clinical Supervisor will monitor all consent to release information forms to ensure compliance. |
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 a review of patient records and discussion with medical staff, the facility failed to ensure monthly random drug screening urinalysis in nine of fourteen patient records reviewed.
The findings include:
Sixteen patient records were reviewed September 18-20, 2012. Fourteen patient records were reviewed for randomized drug screening urinalysis. Nine patient records demonstrated the urine drug screens were obtained the same time every month.
Patient # 2 was admitted May 2010. Urinalysis results were reviewed from February to August 2012. The screens were all done within the first four days of each month. This was not random testing.
Patient #4 was admitted December 1996. Urinalysis results were reviewed from May to August 2012. The screens were all done between the tenth and thirteenth days of each month. This was not random testing.
Patient # 5 was admitted February 1977 and receives six take home bottles per week. Urinalysis results were reviewed from February to August 2012. The screens were all done within the first four days of each month. This was not random testing.
Patient # 6 was admitted November 2011 and discharged May 2012. Urinalysis results were reviewed from January to April 2012. The screens were all done within the second week of each month.This was not random testing.
Patient # 9 was admitted May 2012. The three monthly urinalysis completed since admission were all done between the tenth and twelfth of each month. This was not random testing.
Patient # 10 was admitted March 2012. Urinalysis results were reviewed from May to August 2012. The screens were all done between the fourteenth and seventeenth of each month.This was not random testing
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Patient # 11 was admitted July 2012. The urinalysis done in August and September were done between the eighteenth and the twentieth.
Patient # 12 was admitted October 1986 and receives five take home bottles weekly. Urinalysis results were reviewed from May to August 2012. The screens were all done between the fourth and ninth of each month. This was not random testing.
Patient # 15 was admitted October 2011 and discharged August 1, 2012. There was no urinalysis completed in March 2012 due to the patient being hospitalized. Patient was last dosed July 3, 2012. The urinalysis completed April, May and June were done between the sixteenth and twenty third. This was not random testing.
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Plan of Correction
Effective November 1, 2012 medical staff will utilize Methasoft's random urine drug screen software. The Clinical Supervisor will coordinate technical assistance training for medical staff by Netalytics for October 16, 2012. The Clinical Supervisor will monitor our newly implemented process to ensure compliance. |
715.17(b) LICENSURE Medication control
(b) A narcotic treatment program shall develop policies and procedures regarding verbal medication orders, including the issuing and receiving of orders, identifying circumstances when orders are appropriate and documenting orders, in accordance with applicable Federal and State statutes and regulations.
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Observations
Based on the review of patient records, the facility failed to ensure the physician signed the order after submitting a verbal order in one of one patient record.
The findings include:
Sixteen patient records were reviewed September 18-20, 2012. One record contained documentation of a physician's verbal orders. There was no physician signature on the documented verbal order.
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Plan of Correction
On September 21, 2012 our policy and procedure regarding verbal orders was revised to ensure that the physician issuing the verbal order will also be the physician who write and signs the order in the patient record. Our lead nurse, under the supervision of the Medical Director, will monitor all verbal orders to ensure compliance. |