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 methadone, in the treatment of narcotic addiction. This inspection was conducted on June 20-21, 2011 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, RHJ Medical Center, Inc/ Vandergrift, LLC was found not to be in compliance with the applicable chapters of 4 PA Code and 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 dosing observation and an interview of the nurse, the facility failed to physically secure and maintain the confidentiality of all patient records in accordance with 42 CFR Part 2, Subpart B, 2.22 (relating to notice to patients of Federal confidentiality requirements) and 28 Pa. Code 709.28 (relating to confidentiality).
The findings include:
During the observation of the methadone dispensing on June 21, 2011 between 8:50 AM and 9:20 AM, patients were observed returning their take home bottles to the nurse. The nurse observed the labels and the patient then placed the bottles in the trash. The trash in this can is placed in with the general trash; which could be accessed by the public. Upon removing take home bottles from the trash can, it was observed that the bottles had patient first and last names that were clearly visible. This practice did not ensure that the patient's confidentiality was physically secure and maintained, as required by Federal and State regulations.
The dosing nurse was interviewed on June 21, 2011 at 9:20 A.M. The dosing nurse confirmed she was unaware that all patient names must be removed from the bottles before placing into the general trash.
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Plan of Correction
The project director is responsible to ensure compliance with this regulation. In order to obtain and remain in compliance the nursing staff of the facility will be educated on the regulation by the project director and will be instructed to request that all clients utilize the marker placed outside of the nurses station to black out their personal information on all take-home bottles prior to placing them into the trash for disposal. If the client fails to do so the nursing staff will be instructed to black out the label for the client and then place the take-home bottles in the trash. |
715.20(4) LICENSURE Patient transfers
A narcotic treatment program shall develop written transfer policies and procedures which shall require that the narcotic treatment program transfer a patient to another narcotic treatment program for continued maintenance, detoxification or another treatment activity within 7 days of the request of the patient.
(4) The receiving narcotic treatment program shall document in writing that it notified the transferring narcotic treatment program of the admission of the patient and the date of the initial dose given to the patient by the receiving narcotic treatment program.
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Observations
Based on a review of patient records and an interview with the clinical supervisor, the facility failed to document in writing that it notified the transferring narcotic treatment program of the date of the initial dose given to the patient by the receiving narcotic treatment program in three of three patient records.
The findings include:
Twenty three patient records were reviewed on June 20-21, 2011. Three patients were transferred into treatment from a narcotic treatment program. Per regulation, the receiving narcotic treatment program shall document in writing that it notified the transferring narcotic treatment program of the admission of the patient and the date of the initial dose given to the patient by the receiving narcotic treatment program. The facility failed to document in writing that it notified the transferring narcotic treatment program of the date of the initial dose given to the patient in patient records # 13, 14 and 15
Patient # 13 was transferred from a narcotic treatment program and admitted into treatment on December 10, 2010. There was no documentation that the facility notified the transferring narcotic treatment program of the date of the initial dose given to the patient.
Patient # 14 was transferred from a narcotic treatment program and admitted into treatment on May 16, 2011. There was no documentation that the facility notified the transferring narcotic treatment program of the date of the initial dose given to the patient.
Patient # 15 was transferred from a narcotic treatment program and admitted into treatment on March 18, 2011 There was no documentation that the facility notified the transferring narcotic treatment program of the date of the initial dose given to the patient.
The clinical supervisor was interviewed on June 21, 2011 at 9:30 A.M.. The clinical supervisor reviewed patient records # 13, 14 and 15 and confirmed there was no documentation that the transferring narcotic treatment program had been notified of the date of the initial dose given to the patient.
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Plan of Correction
The project director and nursing staff are responsible to ensure compliance with this regulation. In order to obtain and maintain compliance the project director will educate the nursing staff on the requirements of the regulation and instruct all nurses to document in their nurses note the date of the clients initial dose when they call the facilities to notify them of the completion of the initial dose for transferring clients. The project director will then randomly audit transferring clients to ensure continued compliance. |