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 August 12, 2014 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Discovery House PA 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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715.17(b) LICENSURE Medication control
(b) A narcotic treatment program shall develop policies and procedures regarding verbal medication orders, including the issuing and receiving of orders, identifying circumstances when orders are appropriate and documenting orders, in accordance with applicable Federal and State statutes and regulations.
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Observations
Based on the review of patient records, the facility failed to document that the prescribing physician signed the verbal orders and/or that the orders were signed within 24 hours in two of four patient records.
The findings include:
Eighteen patient records were reviewed on August 11, 2014. Four patient records reviewed documented verbal orders. Patient records # 2 and 9 documented verbal orders that were not signed by the prescribing physician and/or not signed within 24 hours.
Patient # 2 was admitted on May 6, 2014. A verbal order dated May 15, 2014 was signed on May 16, 2014. The physician signing the the order was not the prescribing physician.
Patient # 9 was admitted on February 13, 2014. A verbal order dated February 28, 2014 was signed on March 3, 2014. The verbal order was not signed within 24 hours and the physician signing the the order was not the prescribing physician.
The Facility Director and Clinical Supervisor were interviewed on August 12, 2014 and did not dispute the findings.
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Plan of Correction
Only the physician who gave the order will sign the verbal order. These orders will be signed within 24 hours of when the verbal order was submitted. This will be immediate and ongoing. Program Director will monitor for compliance. |
715.20(3) LICENSURE Patient transfers
A narcotic treatment program shall develop written transfer policies and procedures which shall require that the narcotic treatment program transfer a patient to another narcotic treatment program for continued maintenance, detoxification or another treatment activity within 7 days of the request of the patient.
(3) The transferring narcotic treatment program shall document what materials were sent to the receiving narcotic treatment program.
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Observations
Based on the review of patient records, the facility failed to document what materials were sent to the receiving narcotic treatment program in one of two patient records.
The findings include:
Eighteen patient records were reviewed on August 12, 2014. Two patient records were reviewed as transferring out patients. The facility did not document what materials were sent to the receiving narcotic treatment program in patient record # 15.
Patient # 15 was admitted on February 20, 2014 and transferred to another narcotic treatment program on June 17, 2014. There was no documentation of what materials had been sent to the receiving program.
The Clinical Supervisor was interviewed on August 12, 2014 and confirmed the findings.
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Plan of Correction
All transferring patients' ERM files will include documentation of what materials were sent to the receiving narcotic treatment program. The documentation that was sent will be scanned into the patient's ERM and then shredded. Clinical Supervisors will monitor for compliance. |