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 July 6-7, 2009 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, RHJ Medical Center Inc. 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 and a plan of correction is due on August 8, 2009.
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Plan of Correction
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715.6(a)(2) LICENSURE Physician staffing
(a) A narcotic treatment program shall designate a medical director to assume responsibility for administering all medical services performed by the narcotic treatment program.
(2) When a narcotic treatment program is unable to hire a medical director who meets the qualifications in paragraph (1), the narcotic treatment program may hire an interim medical director. The narcotic treatment program shall develop and submit to the Department for approval a training plan for the interim medical director, addressing the measures to be taken for the interim medical director to achieve minimal competencies and proficiencies until the interim medical director meets qualifications identified in paragraph (1)(i), (ii) or (iii). The interim medical director shall meet the qualifications within 36 months of being hired.
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Observations
Based on a review of the Medical Director qualifications, the facility failed to receive Department approval for a training plan for the medical director.
The findings include:
The Medical Director qualifications were reviewed on July 8, 2009. The Medical Director does not meet the qualifications, therefore is considered an interim medical director. The facility submitted a letter that identified a staff change, dated May 18, 2009, to the Department, but did not have an approved training plan.
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Plan of Correction
The project director and interim medical director are working to complete a detailed training plan to submit to the department that will enable the medical director to meet the qualifications necessary to comply with this regulation. Once the training plan is completed it will be sent to the department for approval and the submissiona and approval will be retained in the interim medical directors chart. |
715.13(b) LICENSURE Patient identification
(b) A narcotic treatment program shall maintain onsite a photograph of each patient which includes the patient 's name and birth date. The narcotic treatment program shall update the photograph every 3 years.
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Observations
Based on a review of the patient identification cards, the facility failed to provide a current patient identification card.
The findings include:
Seventeen patient identification cards were reviewed on June 6-7, 2009. Upon conversation with the director, the facility policy was to update the patient identification cards annually. In accordance with the facility policy, ten patient identification cards had exceeded the one year time frame and had not been updated. Seven of the ten expired identification cards were in the patient records (record # 6, 7, 8, 9, 10, 11 and 12) and three of the ten expired identification cards were reviewed during the dosing observation (records # 15, 16, and 17).
The patient identification card for patient record #6 expired 10-17-08, and discharge date was 1-22-09.
The patient identification card for patient record #7 expired 10-17-08; the card was never updated before the patient was discharged on 1-22-09.
The patient identification card for patient record #8 expired 3-30-09; the card was never updated updated before the patient was discharged on 6/01/09.
The patient identification card for patient record #9 expired 10-15-08; the card was never updated before the patient was discharged on 5/29/09.
The patient identification card for patient record #10 expired 4-26-08; the card was never updated before the patient was discharged on 4/01/09.
The patient identification card for patient record #11 expired 4-2-08; the card was never updated before the patient was discharged on 4-7-09.
The patient identification card for patient record #12 expired 4-2-08; the card was never updated before the patient was discharged on 2-10-09.
The patient identification card for patient record #15 expired 4-2-08.
The patient identification card for patient record #16 expired 10-22-08.
The patient identification card for patient record #17 expired 3-12-08
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Plan of Correction
The front desk administrator is responsible to ensure that all client ID cards are not expired. To ensure compliance the front desk administrator has begun to systematically update all expired client ID cards. The front desk adminisrator has been trained to update all client ID cards when the clients come in for their annual physical appointment with the medical doctor. New photos will be taken annually and the ID cards will be updated at the annual physical appointment. The project director will randomly sample the client ID cards to ensure continuous compliance with this regulation. |