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 and buprenorphine, in the treatment of narcotic addiction. This inspection was conducted on January 23-25, 2012 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, The Family Center Of Thomas Jefferson University Hospital 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(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
Based on the review of patient records and discussion with administrative staff, the facility failed to ensure that each medication order and dosage change was written and signed by the narcotic treatment physician in three of four patient records reviewed. The regulation requires that the physician write and sign the narcotic medication order.
The findings include:
Twelve patient records were reviewed January 23-25, 2012. Four records were specifically reviewed for medication orders. Three of those records contained medication orders that were documented by personnel other than the narcotic treatment physician and signed by the physician.
Patient # 5 was admitted September 19, 2011. On September 27, 2011, October 18, 2011 and November 10, 2011 the counselor documented dose changes and the physician signed the document.
Patient # 6 was admitted November 29, 2011. On December 16, 2011 a nurse documented a 5 milligram dose change and the physician signed the document.
Patient # 8 was admitted August 29, 2011. The counselor documented a 5 milligram decrease in dose change and the physician signed.
Discussion with administrative personnel confirmed the procedures for dose adjustments occurs within the context of the treatment team meeting which includes the physician. The patient is discussed and the "requestor" of the medication change does the documentation of the decision and the physician signs.
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Plan of Correction
The form will be revised to include a "requester" section. However, no dose changes will be written in that section. In a separate section, all dose changes will be written and signed by the physician.
The revision will be reviewed in the administrative meeting and with the staff in the treatment team meeting. All previous prescription forms will be destroyed.
Person(s) responsbile: Medical Director, Nurse coordinator, Clinic Director/Supervisor, Program Director
Timeframe for completion: 2 weeks |
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 a review of patient records, the narcotic treatment program failed to document what materials were sent to the receiving narcotic treatment program in two of two patient records.
The findings include:
Twelve patient records were reviewed January 23-25, 2012. Two patient records required documentation of the materials sent to the receiving narcotic treatment program.
Patient # 9 was admitted December 18, 2004. The patient was transferred to another narcotic treatment program September 16, 2011. There was no documentation that the required documents were sent to the receiving program.
Patient # 11 was admitted October 17, 2008. The patient was transferred to another narcotic treatment program November 18, 2011. There was no documentation that the required documents were sent to the receiving program.
Staff reviewed the records and confirmed that the documentation was not found.
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Plan of Correction
The transferring fax document, along with the required consent forms, will be part of the transfer packet for all discharges. The transferring fax document will include a listing of all documents permitted under PA State Code 255.5. The packet will be reviewed and distributed to all clinical staff and the administrative clinic coordinator.
Person(s) responsbile:nnPrimary counselor, Aministrative Clinic Coordinator,Clinic Director/Clinical Supervisor, Program Director
Timeframe for completion: 2 weeks |