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 May 19, 2010 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Gaudenzia, Inc. Fountain Springs was found not to be in compliance with the applicable chapters of 4 PA Code and 28 PA Code which pertain to the facility. The following deficiencies were identified during this inspection and a plan of correction is due on June 13, 2010.
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Plan of Correction
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715.6(a)(3)(ii) LICENSURE Physician staffing
(a) A narcotic treatment program shall designate a medical director to assume responsibility for administering all medical services performed by the narcotic treatment program.
(3) The medical director 's responsibilities include the following:
(ii) Supervision of licensed practical nurses if the narcotic treatment program does not employ a registered nurse to supervise the nursing staff. In addition, the medical director in these instances shall ensure that licensed practical nurses adhere to written protocols for dispensing and administration of medication.
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Observations
Based on the review of administrative documentation, the facility failed to include all of the required duties for the medical director.
The findings include:
A review of the administrative documentation that included the contract between the facility and the physician employed as the medical director, failed to include the supervision of licensed practical nurses in the absence of a registered nurse manager in the medical director's responsibilities. There are no registered nurses at the facility.
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Plan of Correction
Dr. Eric Petterson's contract will include supervision of the medical unit. |
715.17(c)(4)(i-viii) LICENSURE Medication control
(c) A narcotic treatment program shall develop and implement written policies and procedures regarding the medications used by patients which shall include, at a minimum:
(4) Method for control and accountability of drugs. A narcotic treatment program shall develop and implement written policies and procedures regarding who is authorized to remove drugs from the storage area and the method for accounting for all stored drugs. An agent or other drug prescribed or administered shall be documented on an individual medication record or sheet in a manner sufficient to maintain an accurate accounting of medication at all times and shall include:
(i) The name of the medication.
(ii) The date prescribed.
(iii) The dosage.
(iv) The frequency.
(v) The route of administration.
(vi) The date and time administered.
(vii) The name of the person administering the medication.
(viii) The take-home schedule, if applicable.
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Observations
Based on the review of a patient record, the facility failed to ensure an accurate accounting of all medications administered to the patient in one of one patient record.
The findings include:
One patient record was reviewed May 19, 2010. There has been only one admission to the facility for detoxification since the last review. Patient # 1 was admitted January 14, 2010. A urine drug screen was completed January 14, 2010 and the results confirmed opiates in the urinalysis. The physician ordered a buprenorphine protocol for detoxification. The documentation of medications administered was not completed on the individual medication record for the patient. The medication count sheet demonstrated an initial count of 22 tablets. The documentation also showed that 18 tablets were destroyed after the patient was discharged. However, the four tablets documented as being given to the patient on the count sheet were not all documented on the patient's individual medication record. In addition, there was nursing documentation that identified the patient was administered buprenorphine for hallucinations, failing to document that the buprenorphine was ordered as part of the detoxification protocol
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Plan of Correction
All medications administered to a patient will be documented on the individual medication record for the patient in a manner to ensure an accurate accounting of the medication at all times. Program Director will review regulations pertaining to Medication Control with staff in meeting. The physician and Program Director will ensure compliance.
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715.24(3) LICENSURE Narcotic detoxification
If a narcotic treatment program provides narcotic detoxification services, the narcotic treatment program shall develop and implement narcotic detoxification policies and procedures which include the following:
(3) A 1-year physiologic dependence is not required for narcotic detoxification although documentation of current dependency is required.
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Observations
Based on a review of patient records, the facility failed to ensure the physician documented current dependency in one of one patient record.
The findings include:
One patient record was reviewed on May 19, 2010. One patient records required documentation of the physician's determination of current dependency prior to the administration of the narcotic, specifically buprenorphine.
Patient # 1 was admitted January 14, 2010, the patient was administered buprenorphine on January 16, 2010 at 7:40 AM. The patient record did not contain documentation that the physician determined current dependency of patient #1.
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Plan of Correction
The physician will document current dependency in all patient records. Program Director will review regulations with physician. Program Director will ensure compliance.
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