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 buprenorphine, in the treatment of narcotic addiction. This inspection was conducted on August 27, 2009 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Gaudenzia, Inc. Fountain Springs was found not to be compliance with the applicable chapters of 28 PA Code which pertain to the facility. Deficiencies were identified during this inspection and a plan of correction is due on September 10, 2009.
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Plan of Correction
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715.6(a) 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
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Observations
Based on a review of policy and procedure, job description and staff interview the facility failed to provide documentation that the facility had a designated medical director.
The findings include:
A personnel review was conducted on August 27, 2009. The facility was required to provide documentation that identified a medical director. The documentation reviewed failed to specify that the facility's current physician had the responsibilities of the medical director. Specifically, the physician's name appeared on facility documents but there was no documentation available to stipulate that the facility had a medical director.
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Plan of Correction
The facility will maintain documentation that the physician has the responsibilities of the Medical Director. Program Director will ensure compliance. |
715.15(f) LICENSURE Medication dosage
(f) The narcotic treatment program shall develop written policies and procedures relating to narcotic treatment medication dosage which includes the requirements of subsections (a)--(e).
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Observations
Based on a review of policy and procedure and a staff interview, the facility failed to include a policy and procedure for medication dosage that included protocol for the physician to make a dose determination following the initial physician exam.
The findings include:
The policy and procedure for methadone medication was reviewed on August 27, 2009. The current procedure permitted a nurse to make an assessment of a new patient and telephone the physician with the this information. Based on this information the physician would determine the patient's dose and initiate and a verbal order to medicate. The policy permitted a patient to be dosed without first being assessed .
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Plan of Correction
The policies and procedures relating to narcotic treatment medication dosage (Buprenorphine) will include protocol for the physician to make a dose determination following the initial physician exam. The Program Director will ensure compliance. |