INITIAL COMMENTS
|
This report is a result of an on-site licensure renewal inspection and buprenorphine monitoring inspection conducted on August 10 - 11, 2015 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Twin Lakes Center, Inc. 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.
|
Plan of Correction
|
715.15(b) LICENSURE Medication dosage
(b) The narcotic treatment physician shall determine the proper dosage level for a patient, except as otherwise provided in this section. If the narcotic treatment physician determining the initial dose is not the narcotic treatment physician who conducted the patient examination, the narcotic treatment physician shall consult with the narcotic treatment physician who performed the examination before determining the patient 's initial dose and schedule.
|
Observations
Based on a review of patient records, the narcotic treatment program failed to document the consultation between the narcotic treatment physician determining the initial dose and the narcotic treatment physician performing the physical examination in one of four patient records.
The findings include:
Sixteen client records were reviewed on August 10 - 11, 2015. Four patients were prescribed a narcotic agent, Subutex. These four patient records were reviewed for documentation of a consult between the narcotic treatment physician determining the initial dose and the narcotic treatment physician performing the physical examination. The narcotic treatment program failed to document the consultation between the narcotic treatment physician determining the initial dose and the narcotic treatment physician performing the physical examination in patient record # 4.
Patient # 4 was admitted into treatment on July 1, 2015 and discharged on July 5, 2015. The Physician Assistant completed the physical examination on July 1, 2015. The narcotic treatment physician determined the initial dose of Subutex on July 2, 2015 but failed to document the consultation with the Physician Assistant who completed the physical examination.
The findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
The nursing supervisor will add a box at the bottom of the history and physical that the prescribing physician can check that he consulted with the physician's assistant prior to ordering buprenorphine and then the prescribing physician will sign the form to verify that he consulted with the examining physician's assistant. The nursing supervisor will monitor this monthly to ensure completion. This will be completed by 10/31/15. |
709.52(a) LICENSURE Individual TX and REHAB Plan
709.52. Treatment and rehabilitation services.
(a) An individual treatment and rehabilitation plan shall be developed with a client. This plan shall include, but not be limited to, written documentation of:
|
Observations
Based on a review of client records, the facility failed to document the type and frequency of treatment and rehabilitation services on the individualized treatment and rehabilitation plan in four of four residential client records. In addition, the facility failed to document the proposed type of support service on the individual treatment and rehabilitation plan in four of four residential client records.
The findings include:
Sixteen client records were reviewed on August 10 - 11, 2015. Four residential client records were reviewed for an individualized treatment plan including the type and frequency of treatment and rehabilitation services and the proposed type of support services. The facility failed to document the type and frequency of treatment and rehabilitation services and the proposed type of support service on the individualized treatment and rehabilitation plan in client records # 5, 6, 7 and 8.
Client # 5 was admitted into treatment on July 19, 2015. An individualized treatment plan was developed on July 23, 2015. The facility failed to document the type and frequency of treatment and rehabilitation services and the proposed type of support service on the individualized treatment and rehabilitation plan of client # 5.
Client # 6 was admitted into treatment on July 13, 2015. An individualized treatment plan was developed on July 17, 2015. The facility failed to document the type and frequency of treatment and rehabilitation services and the proposed type of support service on the individualized treatment plan of client # 6.
Client # 7 was admitted into treatment on July 6, 2015 and discharged on August 4, 2015. An individualized treatment plan was developed on July 13, 2015. The facility failed to document the type and frequency of treatment and rehabilitation services and the proposed type of support service on the individualized treatment plan of client # 7.
Client # 8 was admitted into treatment on March 19, 2015 and discharged on April 19, 2015. An individualized treatment plan was developed on March 27, 2015. The facility failed to document the type and frequency of treatment and rehabilitation services and the proposed type of support service on the individualized treatment plan of client # 8.
The findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
The Assistant Director will have the electronic health record vendor push the type and frequency of treatment and rehabilitation services and the proposed type of support service on the individual treatment and rehabilitation plan from the initial treatment plan to the master treatment plan by 10/31/15 so that the above information is listed as part of the master treatment plan. The residential supervisor will monitor this monthly to ensure that the type and frequency of treatment services and the proposed type of support services are on the master treatment plan. |