INITIAL COMMENTS
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This report is the result of an onsite follow-up inspection pertaining to the plans of correction for the July 18, 19 and 20, 2012, methadone monitoring inspection. The follow-up inspection was conducted on January 22 and 23, 2013, by staff from the Department of Drug and Alcohol Programs Licensure. Based on the findings of the onsite follow-up inspection, RHD Montgomery County Methadone Center 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(c) LICENSURE Intake
(c) If a patient was previously discharged from treatment at another narcotic treatment program, the admitting narcotic treatment program, with patient consent, shall contact the previous facility for the treatment history.
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Observations
Based on the review of patient records, the facility failed to contact the previous narcotic treatment facility for the patient's treatment history in two of three patient records reviewed.
The findings include:
Twenty patient records were reviewed July 18 to 20, 2012. The review of patient records revealed that three patients possessed prior narcotic treatment experiences that required the facility to contact the prior narcotic treatment program for treatment histories. Patient records # 3 and 15 both contained documentation of previous narcotic treatment involvement but neither record provided documentation of any efforts to obtain prior treatment histories.
The findings were reviewed with the Facility Director and Clinical Supervisor.
This remained out of compliance at the time of the follow-up conducted on January 23, 2013.
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Plan of Correction
A meeting was held by the Program Director with the Intake Coordinator and Intake Worker to review the needed documentation and releases of patients that have had previous treatment at an NTP to contact the NTP for treatment histories. Intake Coordinator will monitor this for compliance and Program Director will oversee this compliance. Completed 2/19/2013 |
715.17(c)(7) 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:
(7) Drug reactions and medication errors. A narcotic treatment program shall report any adverse drug reaction or medication error to a narcotic treatment physician immediately and initiate corrective action. The narcotic treatment program shall record the reaction or error in the drug administration record and the clinical chart, and shall inform each person who is authorized to administer medication or supervise self-medication of the reaction or error.
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Observations
Based on observation of the dispensing area and a review of the facility's procedures, the facility failed to follow procedure for ensuring take home bottles are labeled accurately.
The findings include:
Observation of the dispensing area occurred on January 23, 2013. At approximately 9:15 a.m., the dispensing area was observed which included the observation of the process for dispensing of 6 take home bottles. Based on the plan of correction for July 20, 2012, the process of labeling take home medication bottles was to be done individually including printing the label after each pour.
The dispensing nurse printed six medication labels. The dispensing nurse poured six medication bottles. After dispensing the six bottles, the dispensing nurse removed the label from the backing and placed a label on each bottle. The facility did not follow their procedures by placing the label on each take home bottle after the medication bottle was dispensed.
This is a repeat citation from July 20, 2012.
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Plan of Correction
A meeting was held between the Program Director and the Charge Nurse to reiterate the necessity to enforce the policy regarding the placement of labelson each poured dose individually as dispensed. Program Director will monitor this project for compliance. This meeting was held on 1/24/13. |
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.
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Observations
Based on the review of administrative documentation, the facility failed to ensure filing of unusual incident reports involving the potential for negative community reaction with the Department within 48 hours.
The findings include:
Administrative documentation was reviewed on January 23, 2013 which included the review of unusual incident reports. The facility had documentation of an incident on January 10, 2013 that included the involvement of the county coroner with a current patient of the facility. The incident report was filed with the Department on January 15, 2013 which was beyond the 48 hours required by regulation.
On October 12, 2012, the facility documented the use of EMT services to care for a patient who presented to the medication window. The use of emergency services was not filed with the Department as of the date of the review.
This is a repeat citation from July 20, 2012.
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Plan of Correction
A meeting was held between the Program Director and the Clinical Supervisor to discuss the regulations regarding the reporting of unusual incidents to the DOH within 48 hours of the occurrence, Program Director or Clinical Supervisor, in the abscence of PD will file appropriate documentation of these incidences. PD and CS will monitor each other to ensure that this documentation is sent in a timely manner within the guidelines. Date 2/25/13 |