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 September 15-17, 2009 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Rhd Montgomery county Methadone Center 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 and a plan of correction is due on October 17, 2009.
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Plan of Correction
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715.6(e) LICENSURE Physician Staffing
(e) A physician assistant or certified registered nurse practitioner may perform functions of a narcotic treatment physician in a narcotic treatment program if authorized by Federal, State and local laws and regulations, and if these functions are delegated to the physician assistant or certified registered nurse practitioner by the medical director, and records are properly countersigned by the medical director or a narcotic treatment physician. One-third of all required narcotic treatment physician time shall be provided by a narcotic treatment physician. Time provided by a physician assistant or certified registered nurse practitioner may not exceed two-thirds of the required narcotic treatment physician time.
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Observations
Based on a review of administrative documentation that included job descriptions, the facility failed to restrict the physician assistant's (PAc) duties to those allowed by regulation.
The findings include:
The job descriptions of all the positions of the facility were reviewed on September 15, 2009. The job description for the PAc allows for her to complete medication checks, which the regulations restrict to the physician's duties.
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Plan of Correction
Physician Assistant's job description has been amended to restrict the Physician Assistant from doing medication checks. Duties of the Pa-C have been revised to allow her to perform "Symptom Reviews". Time Frame - Revised 10/8/09 |
715.16(a)(3) LICENSURE Take-home privileges
(a) A narcotic treatment program shall determine whether a patient may be provided take-home medications.
(3) The narcotic treatment physician shall document in the patient record the rationale for permitting take-home medication.
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Observations
Based on the review of patient record documentation, the facility failed to ensure the physician document in the patient record the rationale for granting take home medication in three of three patient records.
The findings include:
Thirty patient records were reviewed on September 15-17, 2009. Three records were reviewed for take home medication documentation. Patient records # 1, 2 and 23 did not have the physician's rationale documented for granting the take home medication.
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Plan of Correction
A meeting will by the Program Director and the Narcotics Physician to review the rationale and process by which the Narcotics Physician approves Take Home Bottles and the program Director will monitor the documentation to ensure that all meets criteria and the physician rationale is clearly documentated. Time Frame 11/5/09 |
715.16(e) LICENSURE Take-home priveleges
(e) With an exception granted under subsection (d), a narcotic treatment program may not permit a patient to receive more than a 2-week take-home supply of medication.
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Observations
Based on a review of patient record documentation and discussion with the facility director, the facility failed to restrict the take home bottles to no more than 13 bottles in one of two records.
The findings include:
Thirty patient records were reviewed on September 15-17, 2009. Two records were reviewed for exceptions granted under subsection (d). Patient record # 28 was admitted into the facility in 1998 with a split dose and 13 take home bottles, according to the facility director. The record review showed documentation the patient was receiving 27 bottles that each contained 80 milligrams of methadone every other Thursday.
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Plan of Correction
Patient #28 was evaluated by the Narcotics Physician on 10/15/09 and medical documentation from patient's private physicians have been reviewed and it has been determined that there appears to be no current need for patient to receive split dose of MMT at this time as well as it has been determined by the Narcotic Physician that patient's medical conditions do not warrant a 13 day Take Home exception. Patient has been put on a 6 day Take Home schedule at this time as per our Narcotic physician orders. |
715.16(f) LICENSURE Take-home priveleges
(f) An exception granted under subsection (d) shall continue only for as long as the temporary disability or exceptional circumstance exists. When a patient is permanently disabled, that case shall be reviewed at least annually to determine whether the need for the exception still exists.
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Observations
Based on the review of patient records, the facility failed to complete an annual review to determine the need for the exception to continue.
The findings include:
Thirty patient records were reviewed on September 15-17, 2009. One patient record required annual documentation of the need for continuing the exception for a temporary medical disability, record # 28. The last documentation of continuing care by a treating physician was dated in July 2008. There was no documentation of the need for the exception even in that documentation.
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Plan of Correction
Patient #28 was evaluated by the Narcotics Physician on 10/15/09 and medical documentation from patient's private physicians have been reviewed and it has been determined that there appears to be no current need for patient to receive split dose of MMT at this time as well as it has been determined by the Narcotic Physician that patient's medical conditions do not warrant a 13 day Take Home exception. Patient has been put on a 6 day Take Home schedule at this time as per our Narcotic physician orders. |
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 a review of patient records, the facility failed to restrict the determination of dose and schedule to the physician in two of eleven patient records.
The findings include:
Thirty patient records were reviewed on September 15-17, 2009. Eleven patient records were reviewed for documentation of dose and schedule changes. Two patient records, # 21 and 22, contained documentation that staff other than the physician determined the detoxification schedule.
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Plan of Correction
A meeting was held by the Program Director and the Medical Director to clarify the need for the Medical Director only to determine patient detox schedules. A clinical meeting held by the clinical supervisor on 10/07/09 also addressed this issue with the clinical staff to ensure that the Medical Director only can determine patient detox schedules.Program Director will review all detox schedules with the Medical Director at Case Consults weekly to ensure that this does not happen again. Program Director will monitor ongoing compliance. |
715.21(2) LICENSURE Patient termination
A narcotic treatment program shall develop and implement policies and procedures regarding involuntary terminations. Involuntary terminations shall be initiated only when all other efforts to retain the patient in the program have failed.
(2) A patient terminated involuntarily, except a patient who commits or threatens to commit acts of physical violence, shall be afforded the opportunity to receive detoxification of at least 7 days. The detoxification may take place at the facility or the patient may be referred to another narcotic treatment program or hospital licensed and approved by the Department for detoxification.
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Observations
Based on the review of patient records, the facility failed to afford at least 7 days to receive detoxification services in two of three patient records.
The findings include:
Thirty patient records were reviewed on September 15-17, 2009. Three patient records were reviewed for involuntary termination documentation. Two patient records, #11 and 14 contained documentation of being offered only three days for involuntarily detoxification.
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Plan of Correction
MCMC Policy has been revised the Program Director regarding Involuntary Terminations and that Involuntary Terminations shall be initiated only after all other methods of intervention have failed and shall be 7 days or greater except in situations whereby a patient commits a physical act of violence and termination may be immediate. Program Director will monitor this policy to insure that this does not happen again. Time Frame - Immediately |
715.23(b)(5) LICENSURE Patient records
(b) Each patient file shall include the following information:
(5) The results of all annual physical examinations given by the narcotic treatment program which includes an annual reevaluation by the narcotic treatment physician.
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Observations
Based on the review of patient records, the narcotic treatment program failed to document the results of annual reevaluations by the narcotic treatment physician six of nine patient records.
The findings include:
Thirty patient records were reviewed on September 15-17, 2009. Nine patient records were reviewed for annual physical examination reevaluations by the narcotic treatment physician. Six patient records, # 1, 2, 6, 21, 27 and 29 contained an annual physical exam completed by the Physician Assistant (PAc), without the physician's documentation of an annual reevaluation.
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Plan of Correction
A meeting will be held by the Program Director with the Medical Director and the Physician's Assistant to ensure that all patient annual reevaluations will be reviewed by the Medical Director. Time Frame: 10/26/2009 |
715.23(b)(15) LICENSURE Patient records
(b) Each patient file shall include the following information:
(15) Psychosocial evaluations of the patient.
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Observations
Based on the review of patient records, the facility failed to ensure the psychosocial evaluations were a clinical assessment of the historical data collected in five of ten patient records.
The findings include:
Thirty patient records were reviewed on September 15-17, 2009. Ten patient records were reviewed for psychosocial evaluations.
Patient record # 13 was admitted July 28, 2009 and transferred September 1, 2009. An evaluation had not been completed.
Patient records # 4, 5, 7, and 22 had psychosocial documents that contained a repeat of the data, patient reported commentary and no clinical assessment.
Patient record # 25 had an evaluation that did not reflect the historical data collected, but was a statement of the patient's current status.
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Plan of Correction
The Psychosocial Evaluation form has been revised to include patient historical data summation and counnselor clinical assessment. A clinical meeting was held to instruct clinicians by the clinical supervisor on the proper documentation needed on psychosocials. Clinical Supervisor will monitor this revision to ensure proper documentation. Time Frame: Completed October 7, 2009 |