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 6-7, 2013 by staff from the Program Licensure Division. Based on the findings of the on-site inspection, PA Care LLC d/b/a/ State College Medical, 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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715.15(b) LICENSURE Medication dosage
(b) The narcotic treatment physician shall determine the proper dosage level for a patient, except as otherwise provided in this section. If the narcotic treatment physician determining the initial dose is not the narcotic treatment physician who conducted the patient examination, the narcotic treatment physician shall consult with the narcotic treatment physician who performed the examination before determining the patient 's initial dose and schedule.
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Observations
Based on a review of patient records, the narcotic treatment program failed to document the consultation between the narcotic treatment physician determining the initial dose and schedule and the narcotic treatment physician performing the physical examination in one of one record where required.The findings include: Fifteen patient records were reviewed on August 6-7, 2013. In patient record #14, the narcotic treatment physician determining the initial dose failed to document the consultation with the narcotic treatment physician completing the physical examination. The Certified Registered Nurse Practitioner completed the patient's initial physical examination on May 14, 2013. The patient received their initial dose 30 mg of methadone on May 15, 2013. There was no documentation in the patient record that a consultation took place with the Certified Registered Nurse practitioner who performed the physical examination before determining the patient's initial dose and schedule.
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Plan of Correction
Facility Director will review protocol with medical staff on or before 8/29/13. Protocol includes : after CRNP conducts intake physical, the Medical Director will consult with CRNP about the intake physical and review the physical documentation. This will be documented by Medical Director in patient medical chart under portion of physical exam marking "physician impressions". Facility Director will monitor medical charts to ensure that this is being done consistently. |
715.16(a)(3) LICENSURE Take-home privileges
(a) A narcotic treatment program shall determine whether a patient may be provided take-home medications.
(3) The narcotic treatment physician shall document in the patient record the rationale for permitting take-home medication.
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Observations
Based on the review of patient record documentation, the facility failed to ensure the physician documented the rationale for granting take home medication in three of six patient records.The findings include:Fifteen patient records were reviewed on August 6-7, 2013. Six records were reviewed for documentation that included the doctor's rationale for granting take home medication. Patient records # 3, 8, and 12 did not have the physician's rationale for granting the take home medication.This is a repeat citation from the September 25-26 monitoring inspection.
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Plan of Correction
Facility Director will meet with Medical Director on or before 8/29/13 to review protocol for granting take home privileges. Medical Director will document his specific rationale on the take home request form. His documentation will reflect consultation with other clinic staff. Nurses will check that his specific rationale is documented on each take home request form before entering the order into the computer dosing system. Facility Director will monitor completed take home forms to ensure that doctor rationale is being documented regularly. |
715.16(a)(4) LICENSURE Take-home privileges
(a) A narcotic treatment program shall determine whether a patient may be provided take-home medications.
(4) A narcotic treatment physician may rescind take-home medication privileges.
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Observations
Based upon record review, the facility failed to ensure the physician rescinded the take-home medication privileges in two of two patient records. The findings include:Fifteen patient records were reviewed August 6-7, 2013. Two patient records were reviewed for documentation that the narcotic treatment physician rescinded the take home privileges. The narcotic treatment physician failed to document that he rescinded the privileges in patient records 8 and 12. A review of patient record # 8 revealed a document completed by clinical staff on June 17, 2013. The doctor signed the form and indicated that the information for the take homes to be rescinded was "noted and approved." This documentation leads the reader to believe the narcotic treatment physician was not the person who initially rescinded the take homes from this patient.A review of patient record # 12 revealed a document completed by clinical staff on June 17, 2013. The doctor signed the form and indicated that the information for the take homes to be rescinded was "noted." This documentation leads the reader to believe the narcotic treatment physician was not the person who initially rescinded the take homes from this patient.This finding was discussed with the facility director and was not disputed.
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Plan of Correction
Facility Director will meet with Medical Director on or before 8/29/13 to review protocol for rescinding take home privileges. Medical Director will document his specific rationale for rescinding privileges on the take home request form. His documentation will reflect consultation with other clinic staff. Nurses will check that his specific rationale is documented on each take home request form before entering the order into the computer dosing system. Facility Director will monitor completed take home forms to ensure that doctor rationale is being documented regularly. |
715.21(1)(i-iv) LICENSURE Patient termination
A narcotic treatment program shall develop and implement policies and procedures regarding involuntary terminations. Involuntary terminations shall be initiated only when all other efforts to retain the patient in the program have failed.
(1) A narcotic treatment program may involuntarily terminate a patient from the narcotic treatment program if it deems that the termination would be in the best interests of the health or safety of the patient and others, or the program finds any of the following conditions to exist:
(i) The patient has committed or threatened to commit acts of physical violence in or around the narcotic treatment program premises.
(ii) The patient possessed a controlled substance without a prescription or sold or distributed a controlled substance, in or around the narcotic treatment program premises.
(iii) The patient has been absent from the narcotic treatment program for 3 consecutive days or longer without cause.
(iv) The patient has failed to follow treatment plan objectives.
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Observations
Based on the review of patient records, the facility failed to restrict the reasons for involuntary termination to those allowed by regulation in one of two patient records.The findings include:Fifteen patient records were reviewed August 6-7, 2013, 2013. Two patient records were reviewed for involuntary or therapeutic discharge. One patient record contained documentation of the patient being discharged for reasons other than those listed by regulation.Patient # 3 was admitted July 31, 2012 and discharged on June 24, 2013. The patient received a termination notification letter on May 22, 2013 that stated she had one month to pay off her balance or she would be discharged from the program. The patient owed $1030. She signed a payment contract on May 22, 2013. The record indicated that the patient turned in her application for medical assistance on June 5, 2013. There was no follow-up documented by the facility to determine where the patient's application was in the process prior to discharging the patient. The facility failed to document efforts were made to retain the patient in the program.
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Plan of Correction
Facility Director will provide training for counselors on 8/21/13 regarding the appropriate circumstances under which a patient can be involuntarily discharges from the program.
In addition, training will be provided on the importance of clear documentation, including follow up with outside resources, in the clinical chart. Counselors will be trained on ways to assist patients with financial hardships before their outstanding balances become unmanageable, in an effort to retain patients in treatment.
Lead Counselor and Facility Director will monitor patient balances regularly and will work with individual counselors to ensure that patients are receiving timely help with financial hardships. |
715.23(b)(5) LICENSURE Patient records
(b) Each patient file shall include the following information:
(5) The results of all annual physical examinations given by the narcotic treatment program which includes an annual reevaluation by the narcotic treatment physician.
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Observations
Based on the review of patient records, the facility failed to ensure the annual physical examinations given by the narcotic treatment program included an annual reevaluation by the narcotic treatment physician in three of nine records. The findings include: Fifteen patient records were reviewed on August 6-7, 2013. Nine patient records were reviewed for an annual physical examination that included an annual reevaluation by the narcotic treatment physician. Three patient records, # 3, 9, and 14 included annual physical examinations that were documented by the Certified Registered Nurse Practitioner. A review of the patient records revealed that the narcotic treatment physician did not document an annual reevaluation in these records.Patient # 3's annual physical exam was completed by the Certified Registered Nurse Practitioner (CRNP) on June 3, 2013. The Narcotic Treatment Physician failed to document an annual reevaluation in the patient record. Patient # 9's annual physical exam was completed by the Certified Registered Nurse Practitioner (CRNP) on June 17, 2013. The Narcotic Treatment Physician failed to document an annual reevaluation in the patient record. Patient # 14's annual physical exam was completed by the Certified Registered Nurse Practitioner (CRNP) on May 14, 2013. The Narcotic Treatment Physician failed to document an annual reevaluation in the patient record.
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Plan of Correction
Facility Director will meet with Medical Director on or before 8/29/13 to discuss protocol for annual reevaluation of patients. When the CRNP completes the annual physical, the Medical Director will consult with CRNP and review the physical documentation. He will document his annual reevaluation of the patient in the section marked "Physician Impressions" in the physical exam section of the medical chart.
The nurses and Facility Director will monitor patient charts to ensure that this protocol is being followed. |
709.32(b) LICENSURE Medication Control
709.32. Medication control.
(b) Verbal medication orders may be accepted but shall be put in writing and signed within 24 hours thereafter by the prescribing physician.
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Observations
Based on a review patient records, the facility failed to ensure that verbal medication orders were put in writing and signed with 24 hours thereafter by the prescribing physician, as required by regulation and facility policy and procedure, in three of three patient records.The findings include:Fifteen patient records were reviewed on August 6-7, 2013. All verbal medication orders are required to be signed within 24 hours by the prescribing physician. Patient records # 8, 12 and 13 contained documentation of a verbal medication order that was not signed by the prescribing physician within 24 hours.Patient #8 had verbal orders contained in the patient record dated March 1, 2013 that did not have the prescribing physician's signature. A verbal order dated March 28, 2013 was not signed by the prescribing physician within 24 hours. The prescribing physician signed the order on April 3, 2013. Patient #12 had verbal order dated March 15, 2013 that was not signed by the prescribing physician within 24 hours. The prescribing physician signed the order on May 16, 2013. Patient #13 had a verbal order dated May 3, 2013 that ws not signed by the prescribing physician within 24 hours. The prescribing physician signed the order on May 5, 2013. The above information was confirmed by staff.
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Plan of Correction
Facility Director met with nursing staff and Medical Director on 8/14/13 to review the protocol for doctor signing off on verbal orders within 24 hours of the order being written. Doctor will sign off on all verbal orders (given to nurses by telephone, and documented in medical chart by nurses) no later than 24 hours after the order was written.
Facility Director will monitor medical charts to ensure that this protocol is being followed. |