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 January 19, 2011 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Gaudenzia Common Ground was found not to be compliance with the applicable chapters of 28 PA Code which pertain to the facility. Deficiencies were identified during this inspection and a plan of correction is due on February 15, 2011.
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Plan of Correction
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715.6(a)(3)(i) 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:
(i) Supervision of narcotic treatment physicians.
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Observations
Based on the review of the policy and procedure manual, personnel contract agreements, and an interview with the facility director, the facility failed to include the supervision of narcotic treatment physicians in the medical director's job duties, as required.
The findings include:
Based on the review of the medical director's job duties documented in the contract on January 19, 2011, the facility failed to include the supervision of narcotic treatment physicians in the medical director's job duties. An interview with the facility director confirmed that these duties were not included on the duties of the medical director in the contract.
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Plan of Correction
The Central Region Director will negotiate a newly revised contract with the Medical Director which shall include the supervision of narcotic treatment physicians in the Medical Director's job duties.
The Program Director will assume responsibility for follow up with the Regional Director and Medical Director to assure regulatory conformance.
Targeted Resolution Date: 3/31/11 |
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 review of patient records, the facility failed to verify that the individual has reached 18 years of age.
The findings include:
Ten patient records were reviewed on January 19, 2011. Nine records were reviewed for verification that the patient had reached 18 years of age. The facility failed to verify the patient had reached 18 in five out out nine records, specifically records # 1, 2, 6, 7, and 8.
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Plan of Correction
The Program Director conducted training/reviewed the regulation with all detoxification/intake personnel.
The Referral Sheet/Initial Screening form was revised to include an area reflecting the source of verification of age to be completed at the time of client referral or admission to services.
Nurses will obtain a copy of the source of age verification which may include a photo identification card, insurance card, documentation from a hospital or referral source, or other evidence identifying the client birthdate/age. Verification will be placed in the client record.
The Program Director will monitor ongoing conformance via monthly chart audits and the Continuous Quality Improvement process.
The facility's admission criteria requires a minimum age of 18 years old.
Target Resolution Date: 2/13/11 |
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 policy and procedure manual, and an interview with the facility director, the facility failed to verify the identity of the patient prior to the administration of an agent in five of nine patient records.
The findings include:
Ten patient records were reviewed on January 19, 2011. Nine patient records were specifically reviewed for patient identity information. Patient records # 1, 2, 6, 7, and 8 did not contain documentation of verification of a client's identify prior to administration of an agent. Additionally, the policy and procedure manual indicated that in cases where a client lacks photo identification at time of admission (i.e. drivers license) a client photo ID may be produced by the Administration Department upon verification of identity. The policy failed to include what documentation would be acceptable in order to verify a patient's identity. An interview with the facility director confirmed the ambiguity of this policy.
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Plan of Correction
The Program Director conducted training/reviewed the regulation with all detoxification/intake personnel.
The Referral Sheet/Initial Screening form was revised to include an area reflecting the source of verification of identity to be completed at the time of client referral or admission to services. A narcotic agent will not be administered until after verification of client identity.
Nurses/Intake Staff will obtain a copy of the source of identity verification which may include a photo identification card, insurance card, documentation from a hospital or referral source, or other evidence of client identity. Verification will be placed in the client record.
The Program Director will monitor ongoing conformance via monthly chart audits and the Continuous Quality Improvement process.
Target Resolution Date: 2/14/11 |
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 clinical documentation, the facility, particularly the physician, failed to accurately document the basis for determining current dependency in two of nine patient records.
The findings include:
Ten patient records were reviewed January 19, 2011 and nine were reviewed for physician documentation of the basis for determining current and one year of dependency.
Patient # 1 was admitted January 17, 2011. The physician documented that the patient had a polydrug dependence and did not specifically indicate that they were opiate dependent. Additionally, the patient's urine drug screen was negative for opiates.
Patient # 3 was admitted December 22, 2010. The Certified Registered Nurse Practitioner completed the physical on December 23, 2010 and made the diagnosis of opioid abuse. The physician failed to document that the patient had an opiate dependence.
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Plan of Correction
The Program Director conducted training/reviewed the regulations with all detoxification personnel and the Narcotic Treatment Physician.
The Narcotic Treatment Physician will document his basis for determining a client's current opiate dependency on the Physician Justification of Buprenorphine Administration form.
A narcotic treatment agent will not be administered without prior determination of dependency.
Third shift Nurses will conduct daily record reviews to assure accurate documentation by the Physician.
The Program Director will monitor ongoing regulatory conformance via monthly record audits and the Continuous Quality Improvement process.
Target Resolution Date: 2/12/11 |
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.
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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 one record, as required. Additionally, one of eight patient records failed to include the narcotic treatment physician's documentation for determining the proper dose.
The findings include:
Ten patient records were reviewed on January 19, 2011. One patient record required the narcotic treatment physician to document a consultation with the Certified Registered Nurse Practitioner (CRNP) in determining the initial dose. In patient record # 3, the CRNP completed the history and physical on 12/23/2010. The narcotic treatment physician failed to document a consultation with the CRNP prior to the initial dose. The narcotic treatment physician documented that he reviewed the history and physical on 12/24/2010; however, the patient received a first dose on 12/23/2010.
Patient # 1 was admitted on January 17, 2011. The patient tested negative for opiates on the urine drug screen. The narcotic treatment physician failed to document a determination that explained the reason for dosing this patient. The record did include a form, " Justification of Buprenorphine Administration;" however, the form failed to include specific documentation as to why this patient should be dosed. Additionally, the doctor documented polydrug dependence without specifying opioid dependence on the history and physical.
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Plan of Correction
The Program Director conducted training/reviewed the regulations with all detoxification personnel and the Narcotic Treatment Physician.
Prior to the initial dose administration of a narcotic agent the Narcotic Treatment Physician will document face to face contact with the client as well as consultation between himself as the physician determining dosage and any other physician/certified registered nurse practitioner who completed the client's physical examination.
The Narcotic Treatment Physician will also clearly document a diagnosis of current opiate dependency as well as his basis/reasons for determination on the Physician Justification of Buprenorphine Administration form.
A narcotic treatment agent will not be administered without prior face to face determination of dependency.
Third shift Nurses will conduct daily record reviews to assure accurate documentation by the Physician.
The Program Director will monitor ongoing regulatory conformance via monthly record audits and the Continuous Quality Improvement process.
Target Resolution Date: 2/12/11
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715.17(b) LICENSURE Medication control
(b) A narcotic treatment program shall develop policies and procedures regarding verbal medication orders, including the issuing and receiving of orders, identifying circumstances when orders are appropriate and documenting orders, in accordance with applicable Federal and State statutes and regulations.
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Observations
Based on review of patient records and an interview with the facility director the facility failed to have the narcotic treatment physician sign a verbal order within 24-hours as required by this regulation in one of one record. Additionally, in three of three records there were verbal orders documented for the induction of buprenorphine.
The findings include:
Ten patient records were reviewed on January 19, 2011. In patient records 3, 7, and 10 there were verbal orders written for the induction of buprenorphine.
Patient record # 3 had a verbal order written by the nurse for the induction of buprenorphine. The documentation in the record was not dated by the nurse or the narcotic treatment physician. Therefore there was not way to determine if the order was signed within 24-hours as required.
Patient record # 7 and 10 had a verbal order written for the induction of buprenorphine. This is not permitted in accordance with applicable Federal and State statutes and regulations.
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Plan of Correction
The Program Director conducted training/reviewed the regulations with all detoxification personnel and the Narcotic Treatment Physician.
The Narcotic Treatment Physician will sign all verbal orders within 24 hours of an order being issued.
Verbal orders for induction of a narcotic treatemnt agent such as Buprenorphine will not be accepted.
The Narcotic Treatment Physician will provide a written order of Buprenorphine induction after making face to face contact with the client to determine narcotic dependence and appropriateness of dosing.
Third shift Nurses will conduct daily record reviews to assure accurate documentation by the Physician.
The Program Director will monitor ongoing regulatory conformance via monthly record audits and the Continuous Quality Improvement process.
Target Resolution Date: 2/14/11
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715.23(b)(6) LICENSURE Patient records
(b) Each patient file shall include the following information:
(6) Results of laboratory tests or other special examinations given by the narcotic treatment program.
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Observations
Based on the review of patient records and an interview with the facility director, the facility failed to complete all laboratory tests, as required.
The findings include:
Ten patient records were reviewed on January 19, 2011. All records were reviewed for documentation of completed blood serology tests for Syphilis. The facility failed to provide testing for this in 8 of 10 records, specifically in patient records # 1, 2, 3, 4, 7, 8, 9, and 10.
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Plan of Correction
The Program Director conducted training/reviewed the regulations with all detoxification personnel and the Narcotic Treatment Physician.
Nursing staff will assure that a blood serology test for Syphilis will be included in laboratory testing ordered by the Narcotic Treatment Physician and completed on all narcotic treatment/detoxification clients.
Test results will be maintained in the client record.
The Program Director will monitor ongoing regulatory conformance via monthly record audits and the Continuous Quality Improvement process.
Target Resolution Date: 2/14/11 |
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 the review of patient records, the facility failed to complete a discharge summary within seven days in two of five patient records.
The findings include:
Ten patient records were reviewed on January 19, 2011. Five records were discharged patients and required a discharge summary within seven days of discharge per regulation.
In patient records # 3 and 4, the counselor failed to date the signature on the discharge summary and therefore, there was no way to determine if the documentation was completed within the required timeframe.
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Plan of Correction
The Program Director conducted training/reviewed the regulatory requirements for the completion of discharge summaries with all detoxification program personnel.
Although a primary task of third shift nurses, all detoxification personnel (nurses) will assume responsibility to complete/enter into the record a discharge summary within seven days of a client's discharge.
Third shift nurses will complete a nightly record review to assure document completion. Any remaining incomplete tasks shall be documented on the shift report for follow up.
The Administrative Coordinator will monitor ongoing regulatory via monthly record audits and report such to the Program Director and Quality Improvement Committee.
Target Resolution Date: 2/11/11 |