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 treatment of narcotic addiction. This inspection was conducted on March 9, 2009 by staff from the Division of of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, New Perspectives At White Deer Run was found not to be compliance with the applicable chapters of 28 PA Code which pertain to the facility. Deficiencies were identified during this inspection and a plan of correction is due on April 5, 2009.
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Plan of Correction
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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 a review of patient records, the facility failed to document psychosocial evaluations in four of ten patient records.
The findings include:
Ten patient records were reviewed on March 9, 2009. Psychosocial evaluations were required in all ten records. The facility did not document a psychosocial evaluation in patient records # 1, 2, 4 and 8.
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Plan of Correction
Each patient admitted to the detox buprenorphine program will have a nursing assessment and detox addendum completed within 24 hours of admission. All nursing staff will be retrained via an in- service training on the parameters of the document, as well as the timeliness of completing the document by the Lead Nurse no later than April 10, 2009.
Beginning March 10, 2009 and ending April 10, 2009 the nursing assessment and detox addendum on all patients were reviewed by the Lead Nurse within 72 hours of admission to ensure completion and to ensure compliance with the regulation. To ensure ongoing compliance, beginning April 13, 2009 and weekly thereafter, the Lead Nurse will conduct a minimum of three random chart reviews to audit for the completion of the nursing assessment and detox addendum.
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715.23(b)(22) LICENSURE Patient records
(b) Each patient file shall include the following information:
(22) Aftercare plan, if applicable.
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Observations
Based on a review of patient records, the facility failed to complete an aftercare plan in one of two patient records.
The findings include:
Ten patient records were reviewed on March 9, 2009. An aftercare plan was required in two patient records. The facility failed to document an aftercare plan for patient # 1 that was specific to the aftercare needs of the patient as the plan did not address patient goals with time frames.
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Plan of Correction
Aftercare planning begins upon admission to detox. Resources will be identified specific to the patients needs such as intensive outpatient, outpatient, follow up with primary care physician and/or a mental health provider. Time frame will be listed on the Aftercare Plan related to the appointment set up, or identified by the date of the appointment. Nursing staff will be in-serviced on proper completion of patient specific aftercare plans that address patient goals with time frames. This practice will begin no later than April 10, 2009. After the staff is retrained, the Lead Nurse will review all discharged charts for compliance for 6 weeks, thereafter, the facility audit policy will insure future compliance on a monthly basis. |