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 July 30-31, 2008 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Gateway Rehabilitation Center 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 August 25, 2008.
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Plan of Correction
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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 the patient record review on July 31, 2008, the facility failed to include verification of the patients age in one of five patient records. Refer to patient record #2.
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Plan of Correction
The Scheduling Specialists will tell all patients of the necessity of bringing verification of age to the evaluation, if they are to be considered for Buprenorphine detoxification. Admissions staff will photocopy the ID and it will be placed in the patient chart. Staff have been retrained on this procedure. The Admissions Office Manager and Managers of Evaluation Services will monitor for compliance. Any patient without verification of age will be ineligible to receive Buprenorphine. The Manager of Nursing and Nurse Coordinator will monitor eligibility. The facility will be in full compliance September 1, 2008 |
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 patient record reviews on July 31, 2008, the facility failed to include verification of the patients' identity in one of five patient records. Refer to patient record #2.
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Plan of Correction
The Sceduling Specialists will tell all patients of the necessity of bringing two forms of identification to the evaluation. Admissions staff will photocopy the ID and it will be placed in the patient chart. Staff have been retrained on this procedure. The Admissions Office Manager and Managers of Evaluation Services will monitor for compliance. Any patient without verification of identity will be ineligible to receive Buprenorphine. The Manager of Nursing and Nurse Coordinator will monitor eligibility. The facility will be in full compliance September 1, 2008. |
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 the patient record reviews on July 31, 2008, the facility failed to document the consult between the physician's assistant and the physician who is ordering the methadone. The omission was found in three of five patient records. Refer to patient records # 1, 3 and 4.
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Plan of Correction
A printed acknowledgement that the prescribing suboxone physician has reviewed the physical examination on each patient and has consulted with the person who performed the examination is now included on the pre-printed suboxone order form. The physicians have been trained and the Manager of Nursing and the Nurse Coordinator will monitor the patient charts for compliance. The new form went into effect on 8/11/08 and the facility will be in full compliance September 1, 2008. |
715.23(b)(4) LICENSURE Patient records
(b) Each patient file shall include the following information:
(4) The results of an initial intake physical examination.
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Observations
Based on the patient record reviews on July 31, 2008, the facility failed to document a physician countersignature on a physical exam completed by the physician assistant. The omission occurred in one out of five patient records. Refer to patient record # 4.
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Plan of Correction
A physician will countersign all physicals performed by the physician assistant. Additionally, a pre- printed acknowledgement that the prescribing suboxone physician has reviewed the physical examination on each patient and has consulted with the person who performed the examination is now included on the pre-printed suboxone order form. The physicians have been trained and the Manager of Nursing and the Nurse Coordinator will monitor the patient charts for compliance. The facility will be in full compliance September 1, 2008. |