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 January 7, 2009 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. Deficiencies were identified during this inspection and plan of correction is due on February 12, 2009.
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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 verify the individual has reached 18 years of age in one of two records.
The findings include:
Two records were reviewed on January 7, 2009. Verification that the individual has reached 18 years of age was required in two records. The facility did not provide documentation that they had verified the age of patient #2.
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Plan of Correction
Prior to administration of an agent, Cove Forge nursing department will screen each client to determine eligibility for admission by verifying client is 18 years of age.
Responsible Staff:
During the intake process the admissions staff will communicate the need for age verification to clients and referral sources. Clients will be required to bring a form of identification on admission. Nursing staff will verify and document age when client is admitted.
Admission's Coordinator and Detox Unit Coordinator are responsible for educating staff at department meetings on 2/10/09 and 2/19/09 respectively.
100% of opiate client records will be audited monthly for compliance.
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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 individual's identity in one of two records.
The findings include:
Two records were reviewed on January 7, 2009. Verification of individual's identity was required in two records. The facility did not provide documentation that they had verified patient # 2's identity as part of the admission process.
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Plan of Correction
Prior to administration of an agent, Cove Forge nursing staff will screen each client to determine eligibility for admission.
Nurses will verify the client's identity including name, address, date of birth, emergency contact and other identifying data.
Responsible Staff:
During the intake process the admissions staff will communicate the need for clients to bring identifying information with them on admission.
Information Requested: data with client's name, address, date of birth, emergency contact, and any other identifying data. Nursing staff will verify and document client's identity upon admission.
Admissions Coordinator and Detox Unit Coordinator are responsible for educating staff at department meetings on 2/10/09 and 2/19/09 respectively.
100% of opiate client records will be audited monthly for 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 the review of patient records, the facility failed to provide an initial drug screen urinalysis in one of two records.
The findings include:
Two records were reviewed on January 7, 2009. Initial drug screen urinalysis was required in two records. The facility did not provide documentation of an initial drug screen urinalysis in record #1.
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Plan of Correction
Cove Forge nursing department will complete an initial urine drug screen for each perspective client.
Responsible Staff:
Detox Unit Coordinator will remind nurses to collect specimen for urine drug screen initially on each perspective client. This re-education will occur at nursing department meeting on 2/19/09.
Ongoing monthly audits of all opiate client records to monitor for compliance.
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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 the review of patient records, the facility failed to provide a consultation between the Physicians Assistant and the Physician prior to determining the initial dose in one of two records.
The findings include:
Two records were reviewed on January 7, 2009. A consultation was required in two records. The facility did not provide documentation of a consultation between the Physician's Assistant who performed the physical examination and the Physician who determined the dose prior to determining the initial dose in record #2.
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Plan of Correction
The narcotic treatment physician shall determine the proper dosage level for a client. If the narcotic treatment physician determining the initial dose is not the narcotic treatment physician who conducted the client examination, the narcotic treatment physician shall consult with the narcotic treatment physician who performed the exam, before determining the client's initial dose and schedule .
At Cove Forge, the physician's assistant frequently completes the physical examination. 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 client's record.
The narcotic treatment physician will be responsible for doing the consultation. The Assistant Administrator and the Medical Director will be responsible for educating the medical staff. This will be completed by 2/19/09.
Ongoing monthly audits of opiate client records will be conducted to ensure compliance.
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