INITIAL COMMENTS
|
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 February 21-23, 2012 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Esper Treatment Center, Inc 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.
|
Plan of Correction
|
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.
|
Observations
Based on the review of patient records, the facility failed to document initial drug-screening urinalysis for each prospective patient in four of seven patient records. The findings include:Twenty one patient records were reviewed on February 21-23, 2012. Seven patient records reviewed required an initial drug-screening urinalysis. The facility did not document an initial drug-screening urinalysis prior to the patient's first dose in patient records # 1, 2, 3 and 6. Patient # 1 transferred from another narcotic treatment program and was admitted on July 7, 2011. The initial initial drug-screening urinalysis was collected on July 28, 2011 and the results were received on August 13, 2011. Patient # 2 was admitted on September 21, 2011. The patient was initially dosed on September 21, 2011. The patient's initial drug-screening urinalysis was not received until September 23, 2011. Patient # 3 transferred from another narcotic treatment program and was admitted on January 13, 2012. The initial initial drug-screening urinalysis was collected on January 25, 2012 and the results were received on January 29, 2012. Patient # 6 transferred from another narcotic treatment program and was admitted on November 23, 2011. The initial initial drug-screening urinalysis was collected on November 30, 2011 and the results were received on December 2, 2011. An interview with the lead counselor on February 23, 2012 confirmed the findings.
|
Plan of Correction
The staff attended a manadtory training on the ETC policy of obtaining a urine drug screen on all prospective patients prior to admission. New patients will not be admitted into the facility without the results being recieved and reviewed by the medical doctor. Transfer patients must have a urine drug screen completed either before admit or at admsission. All pre admissions will be reviewed by the clinical director to ensure pre admit urine was recieved prior to admission. Clinical Director facilitated training for all staff. The Clinical Director is responsible for ensuring the deficeincy does not reoccur. |
715.17(c)(1)(i-vi)) LICENSURE Medication control
(c) A narcotic treatment program shall develop and implement written policies and procedures regarding the medications used by patients which shall include, at a minimum:
(1) Administration of medication.
(i) A narcotic treatment physician shall determine the patient 's initial and subsequent dose and schedule. The physician shall communicate the initial and subsequent dose and schedule to the person responsible for the administration of medication. Each medication order and dosage change shall be written and signed by the narcotic treatment physician.
(ii) An agent shall be administered or dispensed only by a practitioner licensed under the appropriate Federal and State laws to dispense agents to patients.
(iii) Only authorized staff and patients who are receiving medication shall be permitted in the dispensing area.
(iv) There shall be only one patient permitted at a dispensing station at any given time.
(v) Each patient shall be observed when ingesting the agent.
(vi) Administering and dispensing shall be conducted in a manner that protects the patient from disruption or annoyance from other individuals.
|
Observations
Based on observation, the facility failed to administer and dispense medication in a manner that protected the patient from disruption from other individuals.The findings include: The observation of the medication dosing area was conducted on February 22, 2012 from approximately 8:30 am to 9 am. During this time, two incidents of patient disruption were observed while at the dosing window. At approximately 8:40 am, a patient who was dosing was disrupted by a child who had approached the patient and asked for a drink of water. The patient then asked the dosing nurse for water for the child. The dosing nurse stopped what she was doing and poured a cup of water for the child. She then handed the cup of water to the patient who then handed the cup of water to the child. At approximately 8:42 am a second patient was observed dosing. While being dosed, a second nurse came to the window and began discussing the patient's pregnancy with the patient.
|
Plan of Correction
The nursing supervisor will review with the medical staff the state regualtions and ETC policies regarding proper dosing procedures. This includes policy that states no one is to be permitted at the dosing window except the dosing nurse and the patient being dosed.If a patient needs to speak with medical personnel, they will be asked to speak with them in a medical office, not in the dosing area to help ensure there are no disruptions from other individuals.The nursing Supervior is responsible for training the medical staff and ensuring that the deficiency does not occur again. |
715.28(c)(1-5) LICENSURE Unusual incidents
(c) A narcotic treatment program shall file a written Unusual Incident Report with the Department within 48 hours following an unusual incident including the following:
(1) Complaints of patient abuse (physical, verbal, sexual and emotional).
(2) Death or serious injury due to trauma, suicide, medication error or unusual circumstances.
(3) Significant disruption of services due to a disaster such as a fire, storm, flood or other occurrence.
(4) Incidents with potential for negative community reaction or which the facility director believes may lead to community concern.
(5) Drug related hospitalization of a patient.
|
Observations
Based on the review of the Unusual Incident Reports, the facility failed to provide documentation that an unusual incident report involving a death was filed with Department within 48 hours.The findings include:The Unusual Incident Reports were reviewed on February 21-23, 2012. The facility did not document that a written report was sent to the Department with within 48 hours of a patient's death in patient record #21. Patient #21 was admitted on October 4, 2007 and was discharged on March 15, 2011 due to his death. There was no documentation that the facility had filed an unusual incident report. An interview with the lead counselor on February 23, 2012 confirmed the findings.
|
Plan of Correction
Review state regulations on reproting deaths with the all staff. If a staff member knows of a patient death they will report it to the Project Director. If the Director is unavailable they will report it to the Clinical Director. It will be the clinical director's responsibility to inform the Project Director of any unusual incidents or deaths that ETC becomes aware of. The Project Director will complete an Unusual Incident report within 48 hours of the event and it will be sent to the state. |