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 December 3, 2013, to December 5, 2013, 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.
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Plan of Correction
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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 records, the facility failed to ensure the physician documented in the patient record the rationale for granting take home medication in three of six patient records.
The findings included:
Fourteen patient records were reviewed during the on-site visit. Six records were reviewed for take home medication documentation.
Patient # 3 had take home doses suspended due to reports of diversion. The facility director documented the results of the investigation were unfounded. The physician signed off on the findings, however, did not indicate the rationale for reinstating the take home doses.
Patient # 8 had a travel take home dose for a holiday. The physician failed to document the rationale for granting the take home medication.
Patient # 10 had a travel take home dose for a holiday. The physician failed to document the rationale for granting the take home medication.
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Plan of Correction
A meeting was held between the Program Director, the Clinical Supervisor and the Medical Director to ensure that the Narcotic Physician shall document in the patient record the rationale for permitting take home medication. Program Director will monitor this for compliance. Completed 12/23/13 |