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 January 5-6, 2011 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Esper Treatment Center 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 January 26, 2011.
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Plan of Correction
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715.6(d) LICENSURE Physician Staffing
(d) A narcotic treatment program shall provide narcotic treatment physician services at least 1 hour per week onsite for every ten patients
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Observations
Based on the review of administrative documentation, the facility failed to provide at least one hour of physician time a week, on site for, every ten patients for three of the five weeks reviewed.
The findings include:
Physician time sheets for the months of September, October, November, and December were reviewed on January 6, 2011. Five weeks were chosen and the director was asked to provide the patient census for those five weeks. Two weeks provided sufficient onsite physician hours for the patient census. Three weeks provided insufficient onsite physician hours during October, November and December.
During the week of October 25-29, 2010, the patient census was 182. The facility was required to provide at least 18.2 physician hours. There were 18 physician hours documented. The amount of physician hours documented is less than the amount of hours required.
During the week of November 15-19, 2010, the patient census was 182. The facility was required to provide at least 18.2 physician hours. There were 18 physician hours documented. The amount of physician hours documented is less than the amount of hours required.
During the week of December 6-10, 2010, the patient census was 183. The facility was required to provide at least 18.3 physician hours. There were 18 physician hours documented. The amount of physician hours documented is less than the amount of hours required.
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Plan of Correction
The Dr will put in no less than 20 hours a week. The current census is 187. The census will be updated weekly and at the point when the census is 200 the dr. will add more hours predicated on census. |
715.15(a) LICENSURE Medication Dosage
(a) The narcotic treatment physician shall review the dosage levels at least twice a year, with each review occurring at least 2 months apart, to determine a patient 's therapeutic dosage.
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Observations
Based on a review of ten patient records on January 5-6, 2011, three were required to have documentation that the narcotic treatment physician reviewed the dosage levels at least twice a year, with each review occurring at least 2 months apart. The narcotic treatment program failed to document the physician's dosage review in one of three patient records.
Findings:
Patient record #4 was admitted on 7-30-10 and was discharged on 10-11-10. A dose review was documented on 10-2-10 via a nursing note. There was no documentation that a dose review was completed by the narcotic treatment physician.
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Plan of Correction
Dose reviews had been completed quarterly. It is in our policy and procedures that the doctor will review the doses at least twice a year. The doctor will document and confirm the dose and sign off on the patient chart as the dose review comes due. The nurse will give the doctor a list of patients that are due for dose reviews, the dr will cross check each patient on the AMS and document and sign the dose review. |
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 ten patient records on January 5-6, 2011, eight were required to have documentation that the narcotic treatment physician determined a patient's initial dose and schedule. The narcotic treatment program failed to document that this occurred in five of eight patient records.
Findings:
Patient record #1 was admitted on 12-8-10. The initial medication order was documented on 12-8-10. The medication order was written by the licensed practical nurse and was signed by the physician. The narcotic treatment physician is to determine the patient's initial dose and schedule. Due to the fact that the order was written by the licensed practical nurse, it was unclear if the licensed practical nurse or the physician determined the initial medication dose.
Patient record #2 was admitted on 4-22-10. The initial medication order was documented on 4-22-10. The order was written by the licensed practical nurse and was signed by the physician. The narcotic treatment physician is to determine the patient's initial dose and schedule. Due to the fact the that the order was written by the licensed practical nurse, it was unclear if the licensed practical nurse or the physician determined the initial medication dose.
Patient record #3 was admitted on 9-29-10. The initial medication order was documented on 9-29-10. The order was written by the licensed practical nurse and was signed by the physician. The narcotic treatment physician is to determine the patient's initial dose and schedule. Due to the fact that the order was written by the licensed practical nurse, it was unclear if the licensed practical nurse or the physician determined the initial medication dose.
Patient record #7 was admitted on 9-9-10. The initial medication order was documented on 9-9-10. The order was written by the licensed practical nurse and was signed by the physician. The narcotic treatment physician is to determine the patient's initial dose and schedule. Due to the fact that the order was written by the licensed practical nurse, it was unclear if the licensed practical nurse or the physician determined the initial medication dose.
Patient record #10 was admitted on 10-29-10. The initial medication order was documented on 10-29-10. The order was written by the licensed practical nurse and was signed by the physician. The narcotic treatment physician is to determine the patient 's initial dose and schedule. Due to the fact that the order was written by the licensed practical nurse, it was unclear if the licensed practical nurse or the physician determined the initial medication dose.
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Plan of Correction
The intake orders will be documented by the physician after the initial examnination is conducted. The physicians orders will be documented by the physician and he will sign off on the orders. The nursing supervisor willthen put the orders in the computer. The physician will determine all intital and on going doses. |