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 May 8-9, 2014 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, RHJ Medical Center, Inc. / Vandergrift, LLC was found not to be in compliance with the applicable chapters of 4 PA Code and 28 PA Code which pertain to the facility.
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Plan of Correction
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Observations
Based on the review of patient records, the narcotic treatment program failed to document, within three months after the termination of pregnancy, whether or not the patient should continue maintenance or receive detoxification treatment in one of one patient record.
The findings include:
Twenty three patient records were reviewed on May 8-9, 2014. An evaluation of the patient's treatment status within three months after termination of pregnancy was required in one patient record. The narcotic treatment program, specifically the physician, did not document this evaluation in patient record #5.
Patient #5 was admitted on September 6, 2013. Patient # 5 was pregnant at the time of admission and delivered her baby on January 24, 2014. An evaluation of the patient's treatment status within three months after termination of pregnancy was due by April 24, 2014. There was no documentation of this evaluation as of May 9, 2014.
The aforementioned information was reviewed with the counselor and project / facility director and was not disputed.
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Plan of Correction
The project director and medical director are responsible to ensure compliance with this regulation. In order to obtain and ensure compliance the project director will meet with clinical and medical staff to review the regulation and the clinical staff will be instructed to document the birth of all children to pregnant mothers on their caseloads when the child is born and to mark their calendars with the date that the three month follow-up with the physician will be due. The primary counselor will ensure that the client is scheduled with the physician for the pregnancy follow up appointment. The physicians will then be instructed to document their decision as to whether the client should remain in maintenance or receive detoxification treatment in their note for the three month post pregnancy follow up visit. |