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 buprenorphine, in the treatment of narcotic addiction. This inspection was conducted on September 5, 2013 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Cove Forge Behavioral Health System at Williamsburg 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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715.15(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 a review of patient records, the narcotic treatment program failed to document the consultation between the narcotic treatment physician determining the initial dose and the narcotic treatment physician performing the physical examination in two of four patient records.
The findings include:
Four patient records were reviewed on September 5, 2013. Four patient records are required to document a consult between the narcotic treatment physician determining the initial dose and the narcotic treatment physician performing the physical examination in four of four patient records.
Record #2 - Patient was admitted on 4-26-13 and was discharged on 5-1-13. The Physician Assistant (PA) completed the physical examination on 4-27-13. The narcotic treatment physician determined the initial dose on 4-27-13, but failed to document the consultation with the Physician Assistant who completed the physical examination.
Record #4 - Patient was admitted on 7-27-13 and was discharged on 8-2-13. The Physician Assistant (PA) completed the physical examination on 7-28-13. The narcotic treatment physician determined the initial dose on 7-28-13, but failed to document the consultation with the Physician Assistant who completed the physical examination.
The findings were reviewed with the director and were not disputed.
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Plan of Correction
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.
The Narcotic treatment physician determining the initial dose and schedule will consult with the physician's assistant who conducted the examination prior to determining client's initial dose. The consultation will be documented on the Opiate Dependency Determinations form. The form is being revised so that only one signature will be required by the physician.
The Narcotic treatment physician will be responsible for doing the consultation. The nursing director and the medical director will be responsible for educating the medical staff. This was completed 9/25/13.
Ongoing monthly chart audits of the opiate client records will be conducted to ensure compliance.
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