INITIAL COMMENTS
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This report is a result of an onsite follow-up inspection pertaining to the plans of correction for the October 18, 2010 Buprenorphine monitoring inspection. The follow-up inspection was conducted on May 12, 2011 by staff from the the Division of Drug and Alcohol Program Licensure. Based on the findings of the onsite follow-up 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. The following deficiencies were identified during this inspection.
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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 five patient records.
The findings include:
Fourteen patient records were reviewed on May 12, 2011. Five of the fourteen patient records were buprenorphine residential detoxification records. Five of the 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 five patient records, #10, 12, and 14 did not include completed consents to release information prior to the disclosure of information.
Patient record #10 included a release of information form for an emergency contact that did not include the specific information to be disclosed. The specific information section on the release of information form was blank. This form was signed by the patient on 2-1-11. The admission date for this patient was 2-1-11.
Patient record #12 included a release of information to the mother 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 on 3-7-11. The admission date for this patient was 3-7-11.
Patient record #14 included a release of information form to the father 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 on 2-4-11. The admission date for this patient was 2-4-11.
This was discussed and confirmed with the facility director and the clinical supervisor on May 12, 2011.
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Plan of Correction
Nursing supervisor will conduct a brief training on proper consent completion by 6/30/2011. Charts will be monitored by medical records department to ensure that consents are completed in full. Monitoring will continue monthly until benchmark of 100% is met for 90 days. Program Director will monitor completion. |
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 five patient records.
The findings include:
Fourteen patient records were reviewed on May 12, 2011. Five of the fourteen patient records were buprenorphine residential detoxification records. Five of the patient records were 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. The consultation documentation is missing in one of the five patient records.
Patient record #11 - The patient was admitted on 3-24-2011. The Certified Registered Nurse Practitioner (CRNP) completed the physical examination on 3-25-11. The narcotic treatment physician determined the initial dose on 3-25-11, but failed to document the consultation with the Certified Registered Nurse Practitioner who completed the physical examination.
This was discussed and confirmed with the director on May 12, 2011.
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Plan of Correction
The Nursing Supervisor will meet with all physicians and CRNPs to review the protocol for consultation as well as proper completion of the consultation form that was implemented in 2010. Nursing supervisor will monitor the completion of consultations as well as consultation form through monthly chart monitors to ensure completion. Monitoring will continue until 100% compliance is reached and maintained for 90 days. |
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 the review of patient records, the facility failed to document the attempt or completion of patient follow up contact in five out of five patient records reviewed.
The findings include:
Fourteen patient records were reviewed on May 12, 2011. Five of the fourteen patient records were buprenorphine residential detoxification records. The facility policy states a follow up attempt will be completed within seven days after discharge. Five of the patient records are required to document a patient follow up attempt or contact. Five out of five patient records do not include documentation of a follow up attempt or contact.
Patient record #10 - The patient was admitted on 2-1-11 and discharged on 2-6-11. A follow-up attempt was due by 2-13-11. There is no documentation of a follow up attempt as of 5-12-11.
Patient record #11 - The patient was admitted on 3-24-2011 and discharged on 3-29-11. A follow-up attempt was due by 4-5-11. There is no documentation of a follow up attempt as of 5-12-11.
Patient record #12 - The patient was admitted on 3-7-11, and discharged on 3-11-11. A follow-up attempt was due by 3-18-11. There is no documentation of a follow up attempt as of 5-12-11.
Patient record #13 - The patient was admitted on 4-7-11, and discharged on 4-12-11. A follow-up attempt was due by 4-19-11. There is no documentation of a follow up attempt as of 5-12-11.
Patient record #14- The patient was admitted on 2-4-11, and discharged on 2-9-11. A follow-up attempt was due by 2-16-11. There is no documentation of a follow up attempt as of 5-12-11.
This was discussed and confirmed with the clinical supervisor on May 12, 2011.
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Plan of Correction
Program Director will designate an individual on staff to conduct and document all follow-up calls. Calls will be made in timely fashion and prior to the 8th day after discharge. Follow-up calls will be monitored in closed chart monitors to guarantee protocol is being followed. Continuous monthly monitoring will occur until a bench mark of 100% is met for 90 days. |