INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection and 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 October 19-20, 2016 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Jade Wellness, LLC was found not to be in compliance with the applicable chapters of 28 PA Code which pertain to the facility.
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Plan of Correction
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715.9(a)(4) LICENSURE Intake
(a) Prior to administration of an agent, a narcotic treatment program shall screen each individual to determine eligibility for admission. The narcotic treatment program shall:
(4) Have a narcotic treatment physician make a face-to-face determination of whether an individual is currently physiologically dependent upon a narcotic drug and has been physiologically dependent for at least 1 year prior to admission for maintenance treatment. The narcotic treatment physician shall document in the patient 's record the basis for the determination of current dependency and evidence of a 1 year history of addiction.
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Observations
The facility failed to document that a narcotic treatment physician made a face-to-face determination of whether an individual was currently physiologically dependent upon a narcotic drug and has been physiologically dependent for at least 1 year prior to admission for maintenance treatment and the basis for that determination in four of six client records reviewed on October 19-20, 2016.
Ten clients records were reviewed. Six records reviewed were Suboxone clients. In client records # 2, 3, 4 and 6 the face-to-face determination of current physiologically dependency and 1 year dependency were not documented by the narcotic treatment physician.
Client # 2 was admitted on 5/12/16. A nurse completed the medical history on 5/12/16 which included the documentation of the current and 1 year dependency. The history was co- signed by the physician on 5/12/16. The physical examination completed by the narcotic treatment physician on 5/12/2016, did not include the documentation of the current and 1 year dependency. There was no documentation that dependency was determination by a treatment physician.
Client # 3 was admitted on 3/17/16. A nurse completed the medical history on 3/8/16 which included the documentation of the current and 1 year dependency. There was no documentation that the history was co- signed by the physician. The physical examination completed by the narcotic treatment physician on 3/8/16, did not include the documentation of the current and 1 year dependency. There was no documentation that dependency was determination by a treatment physician.
Client # 4 was admitted on 2/12/16. A nurse completed the medical history on 2/22/16 which included the documentation of the current and 1 year dependency. There was no documentation that the history was co- signed by the physician. The physical examination completed by the narcotic treatment physician on 2/22/16, did not include the documentation of the current and 1 year dependency. There was no documentation that dependency was determination by a treatment physician.
Client # 6 was admitted on 1/14/16. There was no documentation of a current and 1 year dependency.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
It will be the job of the Clinical Supervisor to train each JADE physician to adequately document the face-to-face determination of whether an individual is currently physiologically dependent upon a narcotic drug and has been physiologically dependent for at least 1 year prior to admission for maintenance treatment. The JADE treatment physician will make this determination by examining the client prior to client receiving any buprenorphine services and will date and time stamp said determination.
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