This report is a result of a supervisory review of the written report of the findings of an on-site licensure inspection that was conducted on October 27-28, 2015, by staff from the Division of Drug and Alcohol Program Licensure. Based on the supervisory review of findings from the on-site inspection, Pennsylvania Associates, LLC dba Mount Pocono Medical, 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 this supervisory review:
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Plan of Correction
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Observations
Based on the review of administrative documentation, the facility failed to provide at least one hour of physician time a week, on site, for every ten patients.
The findings include:
Physician time sheets and the census report at the time of the inspection show that the Narcotic Treatment Physician was working 8.5 hours per week. The active methadone patient census on the date of inspection was 321 current patients. The required hours for the NTP would then be 10.7, as one third of all required NTP time shall be provded by the physician.
There were insufficient onsite physician hours.
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Plan of Correction
The Facility Director Reviewed the citation and acknowledged the physician hours were below the amount noted on the narcotic treatment program monitoring questionnaire dated 9/15/15. Physicians hours were provided at 13.5 per week at time of inspection. The physician hours have been provided at 13.5 weekly since 10/4/15. The facility director will continue to monitor and track physician hours to ensure that the correct ratios are in place through time sheet tracking procedures. The schedule will be reviewed two weeks in advance and facility director will schedule doctor hours to meet the ratio. |