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 October 17, 2013, through October 18, 2013, by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Malvern Institute, 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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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 a review of patient records, the facility failed to document the basis for determining current and one year history of dependency in two of five records.
The findings included:
Five patient records were reviewed October 17-18, 2013. All patient records were reviewed for physician documentation of a face to face determination of dependency.
Patient # 2 was admitted on October 14, 2013. The Buprenorphine Detoxification Protocol form was completed by the nurse practitioner. The form did not include the response to the physician questions addressing the completion of a face to face evaluation, dependency, withdrawal status, criteria for detox protocol, contraindications considered and the determination of dependence. The record did not contain any other documentation by the physician.
Patient # 3 was admitted on October 13, 2013. The Buprenorphine Detoxification Protocol form was completed by the nurse practitioner. The form included circled "yes" responses to the physician questions addressing the completion of a face to face evaluation, dependency, withdrawal status, criteria for detox protocol, and contraindications considered. The form did not contain the determination of dependence. The record did not contain any other documentation by the physician.
The findings were reviewed and confirmed with the quality assurance director, facility director, physician and assistant director of nursing.
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Plan of Correction
This deficiency was due to the CRNP not documenting that the physician conducted the face-to-face determination via Skype. The Buprenorphine Protocol form has been revised to include a question regarding whether the face-to-face determination was ocmpleted via Skype. All CRNP's and physicians were educated on the changes made to the form and proper use of the form. This revised form was implemented on 11/18/13
The Assistant Director of Nursing will conduct monthly medical record reviews to monitor the completion of the revised form that includes the documentation of the facec-to-face determination.
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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 a review of patient records, the facility failed to document a complete drug screen urinalysis based on the facility protocol provided to the Department.
The findings included:
Five patient records were reviewed October 17-18, 2013. All patient records were reviewed for a complete drug screen urinalysis prior to the administration of a narcotic agent.
The facility provided a request and was given permission for an exception to use a dipstick, or instant, procedure for drug screen urinalysis. The facility policy presented for the exception stated "(t)he nurse will Xerox a copy of the actual drug screen and place this in the patient's medical record. The Xerox copy must contain the patient's name, date for birth, date of screening, lot number and expiration date of the instant drug screen." Based on the approval for the exception, the facility was not documenting per their identified procedure.
The findings were reviewed and confirmed with the assistant nursing director.
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Plan of Correction
Malvern's Waived Testing policy and procedure was revised to state "two nurses will verify the results for all instant urine drug screens and this verification will be documented in the patient's medical record. In addition the Urnie Dip Test Results form was revised to include two signature spaces for the two nurses to verify.
All nurses will be trained in this revised policy and in the use of the revised form. Training will be completed by 11/21/13 and will be documented.
The Assistant Director of Nursing will conduct monthly medical record reviews to monitor that the verification of instant urine drug screens is being completed per the revised policy. |
715.23(b)(23) LICENSURE Patient records
(b) Each patient file shall include the following information:
(23) Discharge summary.
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Observations
Based on a review of patient records, the facility failed to document discharge summaries that included all of the required information in two of two records.
The findings included:
Five patient records were reviewed October 17-18, 2013. Two patient records were reviewed for discharge summary documentation, # 4 and 5.
Patient # 4 was admitted on May 16, 2013, to detoxification and discharged on June 6, 2013, from inpatient rehabilitation. The discharge summary was documented on June 6, 2013, and did not include the reason the patient entered treatment and the response to treatment.
Patient # 5 was admitted on June 27, 2013, to detoxification and discharged on July 17, 2013, from inpatient rehabilitation. The discharge summary was documented on July 17, 2013, and did not include the reason the patient entered treatment and the response to treatment.
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Plan of Correction
Clinical Supervisors will provide training for counselors on documenting the reason the patient entered treatment and the patient's response to treatment on discharge summaries This training was conducted on 11/19/13 and was documented.
Clinical Supervisors will conduct monthly medical record reviews to ensure discahrge summaries include the patient's reason for entering treatment and response to treatment. |
715.29(5) LICENSURE Exceptions
A narcotic treatment program is permitted, at the time of application or any time thereafter, to request an exception from a specific regulation.
(5) If the exception relates to a specific patient, the narcotic treatment program shall maintain documentation of the exception in the patient 's record.
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Observations
Based on a review of patient records, the facility failed to document the exception as it relates to the specific patient in two of two records.
The findings included:
Five patient records were reviewed October 17-18, 2013. Two patient records were reviewed for exception to the physician documentation of a face to face determination of dependency.
Patient # 2 was admitted on October 14, 2013. The Buprenorphine Detoxification Protocol form was completed by the nurse practitioner based on a teleconference with the physician. The form did not identify the use of teleconferencing as the medium used for the completion of a face to face evaluation.
Patient # 3 was admitted on October 13, 2013. The Buprenorphine Detoxification Protocol form was completed by the nurse practitioner based on a teleconference with the physician. The form did not identify the use of teleconferencing as the medium used for the completion of a face to face evaluation.
The findings were reviewed and confirmed with the quality assurance director, facility director, physician and assistant director of nursing.
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Plan of Correction
The Buprenorphine Protocol form has been revised to include a question regarding whether the face-to-face determination was ocmpleted via Skype. All CRNP's and physicians were educated on the changes made to the form and proper use of the form. This revised form was implemented on 11/18/13.
The Assistant Director of Nursing will conduct monthly medical record reivews to monitor the completion of the revised protocol form. |
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 a review of patient records, the facility failed to ensure that verbal medication orders were put in writing and signed with 24 hours thereafter by the prescribing physician in three of five patient records.
The findings include:
Five patient records were reviewed October 17-18, 2013. All verbal medication orders are required to be signed within 24 hours by the prescribing physician. Patient records # 2 and 3 contained documentation of a verbal medication order that was not signed by the prescribing physician within 24 hours.
Patient # 2 was admitted on October 14, 2013. Verbal orders dated October 14, 2013, were signed by a nurse practitioner on October 16, 2013, who was also not the prescribing nurse practitioner. Verbal orders dated October 15, 2013, at 11:23 a.m. were signed by the physician on October 16, 2013; however, the physician did not time his signature to verify he signed off within 24 hours.
Patient # 3 was admitted on October 13, 2013. Verbal orders dated October 13, 2013, at 2:30 p.m. were not signed by the physician.
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Plan of Correction
Malvern Institute will be requesting an exception to this standard.
In the interim Malvern developed a procuedure for nursing to fax all verbal orders to the ordering practioners on a daily basis. The practitioner will sign their verbal orders and then fax the orders back to Malvern Institute.
The Assistant Director of Nursing will conduct mediacl record reviews on a monthly basis to ensure verbal orders are verified byt he ordering practioner. |