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 September 23-24, 2009 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, White Deer Run, 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 October 15, 2009.
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Plan of Correction
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Observations
Based on the review of the patient records, the facility failed to document that it was the physician who determined that the patient had current physiological dependence upon a narcotic drug in six of six patient records.
The findings include:
Six patient records were reviewed on September 24, 2009. The facility utilized a form titled, "Medical/Methadone order sheet #2" and "Medical/Suboxone order sheet #6". The top portion of the form included the criteria for the determination of current dependency, and the bottom portion was the medication order. The top portion, to include the current determination of dependency, was documented by the nursing staff. It could not be determined that it was the physician who determined the patients' current physiological dependence in six of six patient records; records # 1, 2, 3, 4, 5, and 6.
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Plan of Correction
Effective September 25, 2009, physicians have been documenting on the form titled "Medical/Methadone order sheet #2" and "Medical/Suboxone order sheet #6" during and upon completion of the face-to-face History and Physical.
At least 5 days per week beginning September 25, 2009, the Nurse Manager or designee will audit 100% of the patient records for 2 weeks and then randomly thereafter, to ensure compliance.
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