INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection, monitoring inspection and two complaint investigations conducted on September 18, 2014 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Pyramid Healthcare, Inc- Pyramid Pittsburgh 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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709.32(b) LICENSURE Medication Control
709.32. Medication control.
(b) Verbal medication orders may be accepted but shall be put in writing and signed within 24 hours thereafter by the prescribing physician.
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Observations
Based on the review of client records, the facility failed to document that verbal medication orders were put in writing and signed within 24 hours thereafter by the prescribing physician in eight of eight client records.
The findings include:
Sixteen client records were reviewed on September 18, 2104. Eight client records documented verbal orders. The facility did not document that verbal orders were signed within 24 hours by the prescribing physician in client records # 1, 2, 3, 4, 9, 12, 13 and 14.
Client # 1 was admitted on September 15, 2014. A verbal order, dated September 16, 2014 @ 6 AM was signed by the prescribing physician. The date and time of the physician's signature was not documented.
Client # 2 was admitted on September 15, 2014. Verbal orders, dated September 15, 2014 @ 6 AM and September 16, 2014 @ 1 AM were signed by the prescribing physician. The date and time of the physician's signature was not documented.
Client # 3 was admitted on July 28, 2014. A verbal order, dated July 28, 2014 was signed by the prescribing physician. The date and time of the physician's signature was not documented.
Client # 4 was admitted on July 8, 2014. Verbal orders, dated July 8, 9 and 11 , 2014 were signed by the prescribing physician. The date and time of the physician's signature was not documented.
Client # 9 was admitted on July 29, 2014. A verbal order, dated July 29, 2014 was signed by the prescribing physician. The date and time of the physician's signature was not documented.
Client # 12 was admitted on February 17, 2014. A verbal order, dated February 17, 2014, was not signed by the prescribing physician.
Client # 13 was admitted on January 30, 2014. A verbal order, dated January 30, 2014, was not signed by the prescribing physician.
Client # 14 was admitted on December 9, 2013. A verbal order, dated December 9, 2014, was not signed by the prescribing physician.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The nursing staff will flag all verbal orders after writing them.
The nursing staff will provide the physician with a stamper which has blank areas for both the time and date by 11/03/2014.
The charge nurses will monitor this activity beginning immediately, prior to the use of the stamp the physician will be prompted to write the date and time next to their signature.
The charge nurses will monitor charts on a weekly basis to ensure compliance.
If the prescribing physician is not rounding that day, he will be faxed all verbal orders that he authorized that need to be signed.
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715.6(e) LICENSURE Physician Staffing
(e) A physician assistant or certified registered nurse practitioner may perform functions of a narcotic treatment physician in a narcotic treatment program if authorized by Federal, State and local laws and regulations, and if these functions are delegated to the physician assistant or certified registered nurse practitioner by the medical director, and records are properly countersigned by the medical director or a narcotic treatment physician. One-third of all required narcotic treatment physician time shall be provided by a narcotic treatment physician. Time provided by a physician assistant or certified registered nurse practitioner may not exceed two-thirds of the required narcotic treatment physician time.
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Observations
Based on the review of patient records, the facility failed to document that a physical examination, completed by a certified registered nurse practitioner, was countersigned by the medical director or a narcotic treatment physician in one of four patient records.
The findings include:
Sixteen patient records were reviewed on September 18, 2014. Four records were reviewed as Buprenorphine patients. The facility failed to document that a physical examination, completed by a certified registered nurse practitioner was countersigned by the medical director or a narcotic treatment physician in patient record # 3.
Patient # 3 was admitted on July 28, 2014. The physical examination, completed by a certified registered nurse practitioner on July 29, 2014 was not countersigned by the medical director or a narcotic treatment physician.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
All completed H&P's that are done by a CRNP will be flagged and given to the physician that is rounding that day or the next day to co-sign.
The charge nurses will monitor this process for compliance weekly beginning 10/13/2014.
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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, prior to administration of an agent, that the individual had reached 18 years of age in one of four patient records.
The findings include:
Sixteen patient records were reviewed on September 18, 2014. Four patient records were reviewed as Buprenorphine patients. The facility failed to verify that patient # 3 had reached 18 years of age.
Patient # 3 was admitted on July 28, 2014. The patient was initially dosed on July 28, 2014. The verified age of the patient documented that the patient had not reached the age of 18.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
As of 9/18/2014 no clients under the age of 18 will be administered buprenorphine unless a proper exception form has been approved by DDAP. All staff were informed of this requirement.
The Director of Nursing will be responsible for all applications for exceptions and will monitor compliance in this area. |
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 patient records, the facility failed document that, prior to the administration of an agent, the narcotic treatment physician made a face to face determination that an individual was currently physiologically dependent upon a narcotic drug and had been physiologically dependent for at least 1 year prior, in two of four patient records.
The findings include:
Sixteen patient records were reviewed on September 18, 2014. Four patient records were reviewed as Buprenorphine patient records. The facility did not document that, prior to the administration of an agent, the narcotic treatment physician made the face to face determination in patient records # 2 and 3.
Patient # 2 was admitted on September 15, 2014 and first dosed on September 16, 2014. The documentation by the narcotic treatment physician of a face to face determination of current physiologically dependency upon a narcotic drug and physiologically dependency for at least 1 year prior was dated September 17, 2014.
Patient # 3 was admitted on July 28, 2014 and first dosed on July 28, 2014. The documentation by the narcotic treatment physician of a face to face determination of current physiologically dependency upon a narcotic drug and physiologically dependency for at least 1 year prior was dated July 29, 2014.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The regulation was distributed amongst the nursing staff on 9/18/2014 for all to review.
An order form which provides for an exception to this regulation, in which a client can receive one dose of buprenorphine or one dose divided in two with a physician's verbal order, will be used as of 11/03/2014. This form will document that all requirements have been met prior to obtaining a verbal order. All other clients will only be given buprenorphine after a face-to-face evaluation by a physician.
Charge nurses will monitor compliance with this process on a weekly basis.
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