INITIAL COMMENTS
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This report is a result of an onsite licensure renewal and methadone monitoring inspection. The inspection was conducted on August 9-10, 2017 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the onsite inspection, WPIC Narcotic Addiction Treatment Program 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 the inspection:
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Plan of Correction
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715.11 LICENSURE Confidentiality of patient records
A narcotic treatment program shall physically secure and maintain the confidentiality of all patient records in accordance with 42 CFR 2.22 (relating to notice to patients of Federal confidentiality requirements) and § 709.28 (relating to confidentiality).
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Observations
The facility failed to maintain the confidentiality of patients in two of two patient records reviewed on August 9-10, 2017.
Sixteen patient records were reviewed. Eleven were reviewed as narcotic treatment patients. Patient # 11 had an unusual incident documented. The unusual incident was sent to a third party payor and a county agency. The information released exceeded 42 CFR 2.22 and specifically the information exceeds the parameters of 4 Pa. Code 255.5.
These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
Under the direction of the Facility Director or designee:
A. All patient information released to the county or third party payors will fall within the 5 points of the Pa. Code 255.5; nature of the project, whether patient is in treatment, relapse history, prognosis, brief statement of progress effective 10/1/17.
B. Clinical Supervisors will perform a review of incident reports to ensure that no information outside the 5 points identified in the Pa Code 255.5 has been released to the county or to insurance providers, effective 10/1/17
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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
The facility failed to document that the narcotic treatment physician determined the patient 's initial and subsequent dose and schedule and that each medication order dosage change was written and signed by the narcotic treatment physician in ten of ten patient records reviewed on August 9-10, 2017.
Sixteen patient records were reviewed. Eleven were reviewed as narcotic treatment patients. Ten were reviewed for the required documentation of determination. There were no initial or subsequent dosing orders, written and signed by the narcotic treatment physician, documented in patient records # 1, 2, 3, 4, 5, 6, 7, 8, 9 and 10.
These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
Under the direction of the Medical Director or designee:
A. All physicians will sign medications orders electronically in methasoft effective 9/1/17
B. Nursing Manager will perform monthly chart audits to ensure that medication orders are signed and are in compliance effective 10/1/17.
C. Medical Director will address any unsigned orders each month with the Physicians effective 10/1/17
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