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 18, 2010 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Pyramid Healthcare Inc. - Transitions 2, was found not to be in compliance with the applicable chapters of 28 PA Code which pertain to the facility. Deficiencies were identified during this inspection and plan of correction is due on November 10, 2010.
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Plan of Correction
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715.11 LICENSURE Confidentiality of patient records
A narcotic treatment program shall physically secure and maintain the confidentiality of all patient records in accordance with 42 CFR 2.22 (relating to notice to patients of Federal confidentiality requirements) and § 709.28 (relating to confidentiality).
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Observations
Based on a review of patient records, the facility failed to obtain an informed and voluntary consent from the patient prior to the disclosure of information in three of four patient records.
The findings include:
Six patient records were reviewed on October 18, 2010. Four patient records were reviewed for the requirement to include an informed and voluntary consent from the patient prior to the disclosure of information. Three of the four patient records, #1, 2, and 3 did not include completed consents prior to the disclosure of information.
Patient record #1 included a release of information form to a referral source that did not include the specific information to be disclosed. The specific information section on the release of information form was blank. This patient record also included a release of information form to an insurance company that did not include the purpose of the disclosure. The purpose section on the form was blank. This form was signed by patient and the staff member on 10-15-10. The admission date for this patient was 10-14-10.
Patient record #2 included a release of information to the primary care physician that did not include the specific information to be disclosed. The specific information section on the release of information form was blank. This was signed by patient and the staff member on 10-13-10. The admission date for this patient was 10-13-10.
Patient record #3 included a release of information form to criminal justice agency that did not include the specific information to be disclosed. The specific information section on the release of information form was blank. In addition, this same release of information form did not include the purpose of the disclosure. The purpose section on the form had "other" indicated, but the the explanation for other was blank. The admission date for this patient was 9-1-10.
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Plan of Correction
Clinical Trainer, Kathryn Coleman will conduct a training on confidentiality and proper consent completion by December 31, 2010. Program Director will then monitor consents monthly for 6 months to ensure completion. |
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 review of the patient records, the facility failed to obtain a complete urine drug screen urinalysis prior to the administration of Subutex, a narcotic agent in three of six patient records. A complete urine drug screen includes receiving the results from the CLIA and Department of Health approved laboratory.
The findings include:
Six patient records were reviewed on October 18, 2010. Six patient records are required to complete a drug screen urinalysis prior to the administration of Subutex, a narcotic agent. A complete drug screen includes receiving the results from the CLIA and Department of Health approved laboratory. The facility failed to obtain a complete drug screen urinalysis prior to the administration of Subutex, a narcotic agent in three of the six patient records.
Record #1 - Patient was admitted on 10-14-10. The urine screen results were reported on 10-16-10 at 2:07. The initial dose of Subutex was given on 10-15-10 at 11:00 pm.
Record #4 - Patient was admitted on 7-8-10. The urine screen results were not available at the time of the licensing survey. The initial dose of Subutex was given on 7-9-10 at 5:00 pm.
Record #6 - Patient was admitted on 4-14-10, and was discharged on 4-19-10. The urine screen results were reported on 4-16-10. The initial dose of Subutex was given on 4-15-10 at 9:00 am.
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Plan of Correction
Nursing Supervisor will continue the process of gaining exception for onsite screening. In the interim, nursing supervisor will monitor current protocol to ensure clients are not dosed prior to results of urine screen. Nursing to monitor this protocol weekly. |
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 three of six patient records.
The findings include:
Six patient records were reviewed on October 18, 2010. Six patient records are required to include documentation of a consult between the narcotic treatment physician determining the initial dose and the narcotic treatment physician performing the physical examination in three of the six records.
Record #2 - Patient was admitted on 10-13-10. The Certified Registered Nurse Practitioner (CRNP) completed the physical examination on 10-13-10. The narcotic treatment physician determined the initial dose on 10-14-10, but failed to document the consultation with the Certified Registered Nurse Practitioner who completed the physical examination.
Record #3 - Patient was admitted on 9-1-10. The physician assistant completed the physical examination on 9-1-10. The narcotic treatment physician determined the initial dose on 9-2-10, but failed to document the consultation with the physician assistant who completed the physical examination.
Record #6 - Patient was admitted on 4-14-10, and was discharged on 4-19-10. The Certified Registered Nurse Practitioner (CRNP) completed the physical examination on
4-15-10. The narcotic treatment physician determined the initial dose on 4-15-10, but failed to document the consultation with the Certified Registered Nurse Practitioner who completed the physical examination.
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Plan of Correction
Nursing Supervisor will ensure that appropriate form is used during client history and physical. This form will be montiored for appropriate completion in a monthly chart monitor. This monitor will be completed for 6 months with 100% accuracy. |
715.23(b)(24) LICENSURE Patient records
(b) Each patient file shall include the following information:
(24) Follow-up information regarding the patient.
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Observations
Based on a review of patient records, the narcotic treatment program failed to document the attempt to follow up with the patient in three of six patient records.
The findings include:
Six patient records were reviewed on October 18, 2010. Four patient records are required to include documentation of an attempt to follow-up. The agency policy states that an attempt to follow-up with patients will occur within seven days of discharge.
Record #4 - Patient was admitted on 7-8-10, and was discharged on 7-12-10. The follow up attempt was due within seven days of discharge on 7-19-10. There was no documentation of a follow up attempt.
Record #5 - Patient was admitted on 8-23-10, and was discharged on 9-2-10. The follow up attempt was due within seven days of discharge on 9-9-10. There was no documentation of a follow up attempt.
Record #6 - Patient was admitted on 4-14-10, and was discharged on 4-19-10. The follow up attempt was due within seven days of discharge on 4-26-10. There was no documentation of a follow up attempt.
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Plan of Correction
Policy will be rewritten to state that follow up call will take place within 7 days when no aftercare was completed in extenuating circumstances. All clients that are referred to another level will be called within 5 business days of their follow up appointment. Follow up calls will be documented and monitored by the clinical supervisor and the program director monthly to ensure completion. |