INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on March 4 and 5, 2014, by staff from the Department of Drug and Alcohol Programs, Program Licensure Division. Based on the findings of the on-site inspection, PA Care LLC D/B/A State College Medical was found not to be in compliance with the applicable chapters of 28 PA Code which pertain to the facility. The following deficiencies were identified during this inspection:
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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
Based on the review of patient records, the facility failed to ensure that the narcotic treatment physician made a face to face determination in five of ten patient records. The findings included:Eleven patient records were reviewed during the on-site inspection. Ten patient records were reviewed for the narcotic treatment physician documenting the face to face determination of dependency prior to admission. Four records, specifically # 3, 4, 5 and 9, failed to contain documentation.Patient # 3 was admitted on December 16, 2013. The physical exam was documented by the CRNP on December 12, 2013, with the determination of opiate dependence and "admit to MAT pending physician orders." The narcotic treatment physician signed "reviewed and approved." There was no documentation that the physician made the determination as required by regulation.Patient # 4 was admitted on September 26, 2013. The physical exam was documented by the CRNP on September 25, 2013, with the determination of "opioid dependence" and "admit to MMT pending physician orders." The narcotic treatment physician signed "above reviewed." There was no documentation that the physician made the determination as required by regulation.Patient # 5 was admitted on March 4, 2014. The physical exam form was dated 3/3/2014 with the physician signature not dated. The Determination of Opiate Dependency form had not been signed and dated. There was no documentation that the physician made the determination as required by regulation.Patient # 9 was admitted on January 29, 2014, and discharged on February 4, 2014. The physical exam was documented by the CRNP on January 28, 2014, with the determination of opiate dependence and "admit pending physician orders." The narcotic treatment physician signed "approved." There was no documentation that the physician made the determination as required by regulation.
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Plan of Correction
On 3/19/14 a meeting between the Medical Director and Facility Director occurred where the procedure for documentation of physician review of CRNP-conducted physicals was discussed. After reviewing the physical exam, and meeting with the patient, the medical director will document his determination of opiate dependence in the "Physician Impressions" section of the physical exam form, in addition to completing the Determination of Opiate Dependency form at the time of his face to face meeting with the patient to be admitted. Nursing staff will review this information to be sure it is completed before the first dose of methadone is administered. Facility Director will follow up to be sure this is being completed. |
715.9(c) LICENSURE Intake
(c) If a patient was previously discharged from treatment at another narcotic treatment program, the admitting narcotic treatment program, with patient consent, shall contact the previous facility for the treatment history.
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Observations
Based on the review of patient records, the facility failed to ensure that the previous narcotic treatment facility was contacted in three of three patient records. The findings included:Eleven patient records were reviewed during the on-site inspection. Three patient records contained information of the patient having previously been a patient at another narcotic treatment program. Patient records # 1, 4 and 9 did not contain patient consents with contact of the previous program for the treatment history.
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Plan of Correction
In the 3/18/14 Clinical Meeting, the facility director reviewed with the counseling staff the following information. When a patient indicates that they have previous NTP experience, a consent will be signed and a request for patient records will be sent to the prior NTP. Lead Counselor and Facility Director will monitor patient charts to ensure that this procedure is being executed. |
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 ensure that the narcotic treatment physician determined the proper dosage level in four of eleven patient records. Additionally, the narcotic treatment physician must document orders in accordance with applicable Federal and State Statues and regulations.The findings included:Eleven patient records were reviewed during the on-site inspection. All patient records were reviewed for the physician's documentation in determining the proper dose, specifically, # 4, 5, 7 and 8 had orders documented for determining the patient's dose for multiple days without physician assessment. Patient # 4 was admitted on September 26, 2013, and received an initial dose of 30 mg of Methadone on September 26, 2013. Documented in the patient record was an order dated September 26, 2013 for Methadone 30 mg. The physician order log noted the patient was to receive 40 mg on September 27, 2013, and 50 mg on September 28, 2013. The patient completed an assessment with the nurse on September 27, 2013, with an identified dose of 30 mg. The physician signed the assessment identifying no adjustment; however, the order log and the dosing history identified the patient was increased to 40 mg. The patient completed an assessment with the nurse on September 28, 2013, with an identified dose of 40 mg. The physician signed the assessment identifying no adjustment; however, the order log and the dosing history identified the patient was increased to 50 mg. There was no documentation that the narcotic treatment physician used the assessment of the patient to determine if an increase in the patient's dose was needed. Patient # 5 was admitted on March 4, 2014, and received an initial dose of 30 mg of Methadone on March 4, 2014. Documented in the patient record was an order dated March 3, 2014, for Methadone 30 mg on 3/4/2014, 40 mg on 3/5/2014 and 45 mg on 3/6/2014. The order was not signed at the time of the review. A nursing note stated the urine drug screen results were received and reported to the physician. A verbal order was documented that confirmed the dose schedule. There was no documentation that the narcotic treatment physician planned to continue to assess the patient to determine if an increase in the patient's dose was needed. Patient # 7 was admitted on November 11, 2013, and received an initial dose of 30 mg of Methadone on November 11, 2013. Documented in the patient record was an order dated November 11, 2013 for Methadone 30 mg. The physician order log noted the patient was to receive 40 mg on November 12, 2013. The patient completed an assessment with the nurse on November 12, 2013, with an identified dose of 30 mg. The physician signed the assessment identifying no adjustment; however, the order log and the dosing history identified the patient was increased to 40 mg. There was no documentation that the narcotic treatment physician used the assessment of the patient to determine if an increase in the patient's dose was needed. Patient # 8 was admitted on December 9, 2013, and received an initial dose of 30 mg of Methadone on December 9, 2013. Documented in the patient record was an order dated December 9, 2013 for Methadone 30 mg. The physician order log noted the patient was to receive 40 mg on December 10, 2013, and 50 mg on December 11, 2013. The patient completed an assessment with the nurse on December 10, 2013, with an identified dose of 30 mg. The physician signed the assessment identifying no adjustment; however, the order log and the dosing history identified the patient was increased to 40 mg. The patient completed an assessment with the nurse on December 11, 2013, with an identified dose of 40 mg. The physician signed the assessment identifying no adjustment; however, the order log and the dosing history identified the patient was increased to 50 mg. There was no documentation that the narcotic treatment physician used the documented assessment of the patient to determine if an increase in the patient's dose was needed. An interview was conducted with the facility director and confirmed that the physician did not assess the patient prior to the requested dose increases. This is a repeat deficiency from the on-site licensing renewal visit of April 16, 2013.
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Plan of Correction
In a 3/19/14 meeting between Medical Director and Facility Director, the following protocol for induction was discussed. The Medical Director will determine initial dose after his face to face assessment of the patient upon intake. Patients will submit dose assessment forms daily to nurses thereafter. The Medical Director will be notified (via telephone, should he be off-site) of the patient's symptoms and make a determination of dose adjustment, if necessary, through verbal order telephone read back. Verbal orders will be signed by the physician within 24 hours. Facility Director will monitor medical charts to ensure that this protocol is being followed. |
709.92(c) LICENSURE Treatment and rehabilitation services
709.92. Treatment and rehabilitation services.
(c) The project shall assure that counseling services are provided according to the individual treatment and rehabilitation plan.
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Observations
Based on the review of patient records, the project failed to ensure the counseling services were provided according to the treatment plan in three of five patient records. The findings included:Eleven patient records were reviewed during the on-site inspection. Five patient records were reviewed for treatment plan documentation and the services provided. Three records, specifically # 3, 7 and 8, did not contain documentation of service being provided based on the treatment plan.Patient # 3 was admitted on December 16, 2013. A treatment plan was created with the patient on January 8, 2014. The treatment plan identified the services to be provided were individual and group sessions per month. At the time of the review, the patient had not received any services for the month of February 2014.Patient # 7 was admitted on November 11, 2013. A treatment plan was created with the patient on December 11, 2013. The treatment plan identified the services to be provided were individual and group sessions. At the time of the review, the patient had not been offered group counseling.Patient # 8 was admitted on December 9, 2013. A treatment plan was created with the patient on January 9, 2014. The treatment plan identified the services to be provided were individual and group sessions. At the time of the review, the patient had not been offered group counseling.
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Plan of Correction
In the 3/18/14 Clinical Meeting, counselors were instructed to document any no-shows or cancellations of individual and group sessions in the clinical chart to reflect that services are being offered in accordance with the treatment plan. Counselors should monitor the patients' treatment plans regularly and be sure that the patients' treatment is corresponding to what was outlined on treatment plan. Lead Counselor will follow up with this when she reviews charts, and will report to the Facility Director |