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 Suboxone, in the residential detoxification from opioid dependence. This inspection was conducted on October 16, 2012, by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Gaudenzia Common Ground, 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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715.9(e) LICENSURE Intake
(e) A narcotic treatment program shall secure a personal history from the patient within the first week of admission. The personal history shall be made a part of the patient record.
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Observations
Based on a review of patient records, the facility failed to document that a personal history was completed per facility policy in three of nine patient records.
The findings include:
Nine patient records were reviewed for personal histories. The facility policy is 48 hours from admission for completion of the personal histories. The facility did not document the personal history within 48 hours of admission in patient records # 1, 2 and 3.
Patient # 1 was admitted on October 10, 2012. The personal history was dated October 14, 2012.
Patient # 2 was admitted on October 9, 2012. The personal history was dated October 15, 2012.
Patient # 3 was admitted on July 24, 2012. The personal history was dated July 29, 2012.
The findings were reviewed with the clinical supervisor and quality manager and were not disputed.
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Plan of Correction
The Program Director reviewed the facility policy for completion of detoxification client's personal histories within 24-48 hours of admit with all responsible personnel including newly hired nursing staff.
The Program Supervisor will assign Counseling staff to assist as needed to assure timely completion of histories.
The Program Supervisor and Director will monitor ongoing conformance via monthly chart audits and report as appropriate in the Continuous Quality Improvement Committee meetings.
Target Resolution Date: 11/13/12
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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 review of patient records, the facility failed to document that a consultation took place between the physician who determined the initial dose and the nurse practitioner who completed the physical examination in three of nine patient records.
The findings include:
Nine patient records were reviewed on October 16, 2012. Three records were reviewed for documentation that a consultation took place between the narcotic treatment physician and the Certified Nurse Practitioner (CRNP), # 1, 2, and 4.
Patient # 1 was admitted on October 10. 2012. The patient received a physical examination by the CRNP on October 10, 2012. The narcotic treatment physician documented a face to face with the patient on October 11, 2012, but failed to indicate that the narcotic treatment physician consulted with the CRNP who completed the history and physical examination on the patient. The patient's first dose was October 11, 2012, at 6 p.m. The physical examination was signed off by another narcotic treatment physician on October 16, 2012.
Patient # 2 was admitted on October 9. 2012. The patient received a physical examination by the CRNP on October 10, 2012. The narcotic treatment physician documented a face to face with the patient on October 10, 2012, but failed to indicate that the narcotic treatment physician consulted with the CRNP who completed the history and physical examination on the patient. The patient's first dose was October 10, 2012, at 6 p.m. The physical examination was signed off by another narcotic treatment physician on October 16, 2012.
Patient # 4 was admitted on September 14. 2012. The patient received a physical examination by the CRNP on September 15, 2012. The narcotic treatment physician documented a face to face with the patient on September 15, 2012, but failed to indicate that the narcotic treatment physician consulted with the CRNP who completed the history and physical examination on the patient. The patient's first dose was September 15, 2012, at 1:30 p.m. The physical examination was signed off by another narcotic treatment physician on September 19, 2012.
The findings were reviewed with the clinical supervisor and quality manager and were not disputed.
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Plan of Correction
The Program Director reviewed the regulations and new facility protocols with all medical personnel and contractees.
When a client history and physical examination is completed by a CRNP, the Narcotic Treatment Physician shall document a consultation between himself and the nurse practitioner.
To assure appropriate documentation, the physical examination form has been revised to include an area for consultation note and signature by the Narcotic Treatment Physician.
The Program Director and Supervisor shall monitor ongoing conformance. Monthly chart audits will be completed and reported accordingly to the Continuous Quality Improvement Committee.
Target Resolution Date: 11/13/2012 |
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.
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Observations
Based on the review of patient records, the facility failed to ensure that the narcotic treatment physician is determining the initial and subsequent dose and schedule in three of nine patient records.
The findings include:
Nine patient records were reviewed for documentation of the narcotic treatment physician determining the patient's initial and subsequent dose and schedule. Patient records # 1, 2, and 4 contained documentation of medication orders that were completed by someone other than the narcotic treatment physician.
Patient # 1 was admitted on October 10. 2012. The patient received a physical examination by the CRNP on October 10, 2012. The physical exam documentation included a diagnosis of opioid dependency and the plan of for detoxification with Suboxone.
Patient # 2 was admitted on October 9. 2012. The patient received a physical examination by the CRNP on October 10, 2012. The physical exam documentation included a diagnosis of opioid dependency and the plan of for detoxification with Suboxone.
Patient # 4 was admitted on September 14. 2012. The patient received a physical examination by the CRNP on September 15, 2012. The physical exam documentation included a diagnosis of opioid dependency and the plan of for detoxification with Suboxone.
The findings were reviewed with the clinical supervisor and quality manager and were not disputed.
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Plan of Correction
Per facility policy, only the Narcotic Treatment Physician is permitted to prescribe Suboxone and document his determination of the initial and subsequent dose and schedule.
To assure conformance of this policy the Narcotic Treatment Physician will continue to document his orders on an appropriate Physician Orders form.
To assure additonal clarification, the protocols for documentation of a client's physical examination have been revised. Although a CRNP may complete a client's physical examination and note findings, the section referring to the client's diagnosis of opioid dependency and the plan for detoxification with Suboxone will be documented only by the Narcotic Treatment Physician upon face to face meeting with the client.
The Program Director is responsible to assure that medical personnel and vendors are aware of the new protocols.
The Program Director and Supervisor will monitor ongoing conformance. Monthly chart audits will be completed and reported as appropriate to the Continuing Quality Improvement Committee.
Target Resolution Date: 11/18/12 |