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 June 15-16, 2009 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Alliance Medical Services 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 July 20, 2009.
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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 per week of onsite services for every ten patients The findings include:The Narcotic Treatment Program Monitoring Questionnaire was reviewed on June 15, 2009. The physician hours were reviewed on June 16, 2009. The questionnaire had sufficient hours documented, but the corresponding physician time sheets did not match the documentation of the questionnaire for four of sixteen weeks reviewed. During the week of March 2, 2009, the census was between 494 and 500. The physician hours were 37.5 for the week. During the week of April 6, 2009, the census was between 496 and 500. The physician hours were 37.5 for the week. During the week of May 18, 2009, the census was between 493 and 497. The physician hours were 37.5 for the week. During the week of June 1, 2009, the census was between 498 and 500. The physician hours were 37.5 for the week.
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Plan of Correction
The facility did not provide the required physician hours for a census of 500 patients. The facility is required to provide a minimum of 50 physician hours for 500 patients. Regardless of the census, the physician is required to provide 1 hour of service for every 10 enrolled patients.
The Facility Director will be responsible to adjust the physicians schedule to meet the requirement of 50 hours. The physician will provide the necessary coverage. The Facility Director will be responsible for ongoing compliance through regular review of the physician timesheets. |
715.15(d) LICENSURE Medication dosage
(d) A narcotic treatment program shall label all take-home medication with the patient 's name and the narcotic treatment program 's name, address and telephone number and shall package all take-home medication as required by Federal regulation.
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Observations
Based on the review of the packaging of take home medications and interviews with nursing staff, the facility failed to ensure that all of the required information was consistently printed on the take home medication bottle labels.The findings include:The take home labels were reviewed for documentation on June 16, 2009. The physician's name was not listed on the label. The nursing staff reported the prescribing physician's name was printed on about 50% of the take home medication prescription labels. (This is a repeat deficiency.)
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Plan of Correction
The physicians name was not consistently appearing on take-home labels. The Facility Director has contacted the software provider who has adjusted the formatting to allow for consistency in providing all required information on take home labels.
The supervising nurse(crnp) is responsible for monitoring for ongoing compliance and will communicate with the Facility Director if further intervention is required. The Facility Director is responsible to facilitate any necessary corrections related to further inconsistencies in consultation with the software provider. |
715.17(c)(1)(i-vi)) LICENSURE Medication control
(c) A narcotic treatment program shall develop and implement written policies and procedures regarding the medications used by patients which shall include, at a minimum:
(1) Administration of medication.
(i) A narcotic treatment physician shall determine the patient 's initial and subsequent dose and schedule. The physician shall communicate the initial and subsequent dose and schedule to the person responsible for the administration of medication. Each medication order and dosage change shall be written and signed by the narcotic treatment physician.
(ii) An agent shall be administered or dispensed only by a practitioner licensed under the appropriate Federal and State laws to dispense agents to patients.
(iii) Only authorized staff and patients who are receiving medication shall be permitted in the dispensing area.
(iv) There shall be only one patient permitted at a dispensing station at any given time.
(v) Each patient shall be observed when ingesting the agent.
(vi) Administering and dispensing shall be conducted in a manner that protects the patient from disruption or annoyance from other individuals.
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Observations
Based on the review of patient records, the facility failed to restrict dose determination to the physician in three of twelve patient records. The findings include:Twenty one patient records were reviewed on June 15-16, 2009. Twelve patient records were reviewed for medication orders and dose changes. Patient # 1 requested a dose change on May 6, 2009, following the facility process of taking the request first to the counselor. The counselor failed to complete the process by forwarding to the physician for dose determination; the patient record contained no documentation that identified the physician reviewed the dose change request. Patient # 11 contained documentation completed by the clinical staff on July 1, 2009 for an administrative detoxification which the physician signed without completing the order.Patient # 12 contained documentation completed by the clinical staff on July 1, 2009 for an administrative detoxification which the physician signed without completing the order.
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Plan of Correction
The physician is responsible for determining the dosage on all patients.
As part of the process, the counselor completes the dosage change request form with the patient. This form is submitted to the physician and after evaluating the case record, request form, and any other pertinent data will order the dosage change. This will pertain to routine requests for increase or decrease in dosage as well as any administrative discharge process.
The physician will document this order in the electronic record for dosing which will record the amount adjusted and in the case of administrative detoxification the length and decrease of dosage schedule. Upon completion of the order the physician will provide his signature as verification.
Training will be provided to counseling staff to clearly understand their role as consultative and to provide information pertinent to the case in order to assist the physician to make the necessary determination regarding any medical orders related to dosage adjustment. The Clinical Supervisor and Medical Director will provide training to all counseling staff as it relates to this issue.
The Facility Director is responsible for oversite and compliance through routine inspection of the written order documentation. |
715.23(e) LICENSURE Patient records
(e) Patient file records, information and documentation shall be legible, accurate, complete, written in English and maintained on standardized forms or electronically.
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Observations
Based on the review of patient records and staff interviews, the facility failed to ensure documentation was legible and complete in 21 of 21 patient records. The findings include:Twelve patient records were reviewed on June 15 -16, 2009. Twenty one records required legible handwriting. Staff #11's documentation was illegible in all patient records reviewed. Nursing staff was interviewed on June 16, 2009 and the nursing staff reported they had to request a verbal report of staff #11's documentation because they were unable to read what he had written.
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Plan of Correction
Alliance Medical Services failed to ensure documentation was legible and complete in 21 of 21 patient records.
The physician documentation was not legible and in some cases incomplete. It is the responsibility of the physician to write and complete orders in a manner understandable to all staff.
The Facility Director will meet with the physician and review the POC. The discussion will focus on the necessity of the physician to write legibly and that all orders are to be complete. The Facilty Director will conduct ongoing monitoring of compliance in this regard and will provide further direction to the physician as needed.
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