Observations
Based on a review of medical staff coverage, the facility failed to provide narcotic treatment physician services at least one hour per week onsite for every ten patients for one of sixteen weeks.
Physician service hours were reviewed from February 18, 2024 through June 8, 2024.
During the week of February 18, 2024 through February 24, 2024, the facility ' s census was 263 patients. The facility was required to provide 26.3 hours of onsite physician services, however they provided only provided 23.5 hours.
This finding was reviewed with the facility staff during the licensing process.
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Plan of Correction
Initial Discussion: July 26, 2024 Follow-up Meeting: August 7, 2024
Issue Identified by our State Inspection on 7/24/2024
On July 24, 2024, the Project Director and Medical Director identified that during the week of February 18, 2024, the clinic fell short of the required on-site medical hours due to a federal holiday on February 19, 2024, when the clinic was closed. This situation affected the compliance with required medical hours for our active patient caseload.
Corrective Action Plan:
On August 7, 2024, the Project Director and Medical Director met with the physician, PA, and NP to discuss the issue and develop a plan to ensure compliance moving forward.
Medical Hours Compliance:
The medical staff reviewed the required weekly on-site medical hours based on the patient census. It was agreed that if the clinic ever falls short of meeting these hours from Monday to Friday, the hours will be made up during Saturday operations.
Monitoring and Adjustments:
The project and medical directors will continue daily monitoring of active patient caseloads and required medical hours. With the added flexibility of scheduling medical hours on Saturdays, the clinic is confident in maintaining compliance, especially during short work weeks caused by federal holidays.
Staffing Contingency Plan:
If there is a significant increase in the active caseload necessitating additional medical staff, Progressive Medical will seek out, interview, and hire new staff to cover the required medical hours on-site.
This plan is expected to prevent future shortfalls in medical hours and ensure ongoing compliance with regulations.
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