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 5, 2008 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Pyramid Healthcare, Inc. - Transitions 2 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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715.2(a)(b) LICENSURE Relationship of Federal and State Regulations
(a) A narcotic treatment program shall comply with Federal regulations and requirements governing the administration, dispensing and storage of agents.
(b) This chapter is intended to supplement the Federal regulations governing narcotic treatment programs in 21 CFR Chapter II, 1300-1399 (relating to Drug Enforcement Administration, Department of Justice).
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Observations
Based on a review of the DEA registration on January 5, 2009, the facility failed to provide DEA registrations for this facility address.
The findings include:
The DEA registrations failed to include the facility address on the documentation; current registration included the name of the physician and an address other than the facility address.
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Plan of Correction
715.2 (a) (b) Relationship of Federal and State Regulations
Transitions is currently pursuing changing the DEA address to match the facility address. The Program Director and Assistant Director of Nursing will be submitting the appropriate paperwork to achieve this goal. We will complete this by 4/01/09.
715.2 (a) Addendum
Physicians DEA License has been approved as is.
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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 that the individual had reached 18 years old in one of four records.
The findings include:
Four records were reviewed on January 5, 2009. Verification that the individual has reached 18 years old was required in four records. The facility did not document this verification in patient record # 3.
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Plan of Correction
715.9(a)(1) Intake
Admissions staff will notify all potential detoxification clients to bring in a valid form of identification (i.e. a driver's license, state photo ID, and/or birth certificate). Transitions Nursing department and the Evaluation Counselor will not admit any opiate detoxification clients for buprenorphine detoxification without verified identification of age. When the physician approves a client for buprenorphine administration, their photocopied driver's license, state photo ID, and/or birth certificate will be initialed by the first nurse administrating the buprenorphine. Transitions Program Director will distribute a memo to the Nursing Department and to the Evaluation Counselor by 2/23/09. Compliance will be monitored by the Assistant Director of Nursing through chart monitoring.
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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 four records. The facility failed to document an emergency contact in two of the four records.
The findings include:
Four records were reviewed on January 5, 2009. Verification of the individual's identity was required in four records; the facility did not document this verification in patient record # 3. Emergency contact information was missing in records # 2 and 4.
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Plan of Correction
715.9 (a)(2) Intake
Admissions staff will notify all potential detoxification clients to bring in a valid form of identification (i.e. a driver's license, state photo ID, birth certificate, or all of the following: social security card, photo ID, birth certificate, and mail with clients name and address on it). Transitions Nursing staff and the Evaluation Counselor will obtain and verify all client emergency contact information. The medical secretary will obtain a written consent for the emergency contact. This emergency contact will be listed on the page with the client's photograph, inside of the chart. Transitions Program Director will distribute a memo to the Nursing Department and to the Evaluation Counselor/Assessor by 2/23/09. Compliance will be monitored by the Assistant Director of Nursing through chart monitoring
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715.13(b) LICENSURE Patient identification
(b) A narcotic treatment program shall maintain onsite a photograph of each patient which includes the patient 's name and birth date. The narcotic treatment program shall update the photograph every 3 years.
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Observations
Based on the review of patient records, the facility failed to maintain an onsite photograph of each patient which includes the patient's name and birth date in one of four records.
The findings include:
Four records were reviewed on January 5, 2009. An onsite photograph of each patient that included the patient's name and birth date was required in four records. Patient record # 3 did not contain a patient photograph.
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Plan of Correction
715.13 (b) Patient Identification
Upon admission, clients will be photographed by a Transitions Medical Secretary. All client photographs will be placed in the client chart and detoxification Medical Administration Record(MAR). Transitions will obtain a new camera by 2/23/09. Compliance will be monitored by the Assistant Director of Nursing through chart monitoring.
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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 complete an initial drug screen urinalysis in three of four patient records.
The findings include:
Four records were reviewed on January 5, 2009. An initial drug screen urinalysis was required in four records. The facility did not document the results of initial drug screen urinalysis in patient records #1, 2, and 3.
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Plan of Correction
715.4 (a) Urine testing
Client charts #1,#2,and #3 were open charts. According to Pyramid Healthcare policy, urine screens must first be collected prior to the administration of buprenorphine. Client #1,#2, and #3's urine samples were collected prior to buprenorphine being started, however, the urinalysis results were not available to us. It typically takes about 48 hours for our facility to receive client urinalysis results from the laboratory. In this case, all three clients came in on a holiday weekend and gave their urinalysis samples on a Friday. Transitions received the urinalysis results, from the laboratory, on a Tuesday. Transitions Program Director and Assistant Director of Nursing will attempt to find a way to more rapidly obtain our urinalysis results and we will do this by 2/23/09.
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715.21(1)(i-iv) LICENSURE Patient termination
A narcotic treatment program shall develop and implement policies and procedures regarding involuntary terminations. Involuntary terminations shall be initiated only when all other efforts to retain the patient in the program have failed.
(1) A narcotic treatment program may involuntarily terminate a patient from the narcotic treatment program if it deems that the termination would be in the best interests of the health or safety of the patient and others, or the program finds any of the following conditions to exist:
(i) The patient has committed or threatened to commit acts of physical violence in or around the narcotic treatment program premises.
(ii) The patient possessed a controlled substance without a prescription or sold or distributed a controlled substance, in or around the narcotic treatment program premises.
(iii) The patient has been absent from the narcotic treatment program for 3 consecutive days or longer without cause.
(iv) The patient has failed to follow treatment plan objectives.
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Observations
Based on the review of patient records, the facility failed to provide written notification to the patient of an involuntary termination in one of one patient records.
The findings include:
Four records were reviewed on January 5, 2009. Written notification of an involuntary termination was required in one record. The facility did not provide documentation that an involuntary written notice was provided to patient #3.
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Plan of Correction
715.12 (1) (i-iv) Patient termination
Transitions will utilize written notifications of involuntary termination for every client who is involuntarily discharged. Upon discharge, this notice of involuntary termination form will be given to the client by Transitions Nursing Staff. The Program Director will monitor all involuntary discharges from the detoxification unit to ensure that all efforts to retain the patient have failed. Transitions will begin this process by 2/23/09.
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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 the review of patient records, the facility failed to provide an aftercare plan in one of one patient records.
The findings include:
Four records were reviewed on January 5, 2009. An aftercare plan was required in one record. The facility did not document an aftercare plan in patient record # 4.
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Plan of Correction
715.23 (b) (22) Patient records
Transitions will utilize a Detoxification Behavioral Health Technician to assist the detoxification client in completing their aftercare plan. The Detoxification Behavioral Health Technician will assist the client in developing an aftercare plan for their next phase in treatment, be it inpatient or outpatient. Transitions will continue to utilize our detoxification aftercare plan forms. Two copies of this form will be made, one will go to the client and the other will be filed in the clients chart. The Assistant Director of Nursing will ensure that this form is complete and filed in the clients chart. This process will begin by 2/23/09.
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715.23(b)(24) LICENSURE Patient records
(b) Each patient file shall include the following information:
(24) Follow-up information regarding the patient.
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Observations
Based on the review of patient records, the facility failed to document follow up in one of one patient records.
The findings include:
Four records were reviewed on January 5, 2009. Follow up was required in one patient record. The facility failed to document follow up in patient record # 4.
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Plan of Correction
715.23 (b) (24) Patient records
Transitions Detoxification Behavioral Health Technician will provide the receptionist with the completed detoxification aftercare plan form. The receptionist will contact the agency, to which the client was referred, to follow-up on whether the client has or has not adhered to their aftercare plan. If the client has refused aftercare, the receptionist will contact the client directly to follow-up with them. The receptionist will document any follow-up calls on the aftercare plan, which is maintained as a permanent part of the client record. This process will be overseen by the Clinical Supervisor and will begin by 2/23/09.
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