INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection and methadone monitoring inspection conducted on March 10-11, 2020 by staff from the Department of Drug and Alcohol Programs, Bureau of Quality Assurance for Prevention and Treatment. Based on the findings of the on-site inspection, Summit Medical Services 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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709.28 (c) (2) LICENSURE Confidentiality
§ 709.28. Confidentiality.
(c) The project shall obtain an informed and voluntary consent from the client for the disclosure of information contained in the client record. The consent must be in writing and include, but not be limited to:
(2) Specific information disclosed.
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Observations
The facility failed to obtain an informed and voluntary consent from the client which included the specific information disclosed in three of nine client records.
Eleven client records were reviewed on February 10-11, 2020. Eleven were reviewed for informed and voluntary consents.
Client # 1 documented releases to a third-party payor and three government agencies. The information to be released exceeded 4 Pa Code 255.5.
Client # 6 documented a release to an agency. The information to be released stated " coordination of care".
Client # 8 documented a release to a third-party payor. The information to be released exceeded 4 Pa Code 255.5.
These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
The Facility Director and the Clinical Supervisor are responsible to address this issue. This was done when both the Clinical Supervisor and Facility Director addressed all clinical staff in a meeting on 3/12/20 with the results of the audit.
Overall completion of consents were reviewed. Addressing Chart 1 and 8, we discussed, listed and reviewed the proper information to be given to government agencies (5-point info) as well as insurance agencies and how this differs from other consents (ex. - another providerer, family member, etc). We discussed and reviewed with all clinical staff the limited nature of this information (with government agencies - we listed/reviewed the 5-points) and with insurance companies (payment information and other limited information allowed) and provided examples of both.
Also reviewed was proper completion of all authorizations, and what should be in each section. WE reviewed the need to carefully complete each section to ensure a consent is not completed with error such as client #6, where the wrong statement was put in the wrong section in error.
To ensure this does not occur in the future, Clinical Supervisor and lead counselor will both be responsible ongoing for corrective action and do chart reviews weekly with each clinical staff and in particular, review consents, t ensure proper completion. Facility Director will also be responsible for corrective action by monitoring and overseeing this process.This will also be reviewed ongoing at least monthly in clinical meetings by Clinical supervisor, lead counselor and facility Director.
Again, this was reviewed with staff and necessary changes were made by 3/12/20. |
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
The facility failed to ensure the narcotic treatment physician is determining the proper dosage level for a patient.
Eleven patient records were reviewed on March 10-11, 2020. Nine were reviewed as methadone patients and required documentation the narcotic treatment physician was determining the proper dosage level for a patient.
Patient # 1 documented a dose increase on February 14, 2020 that was ordered by the physician assistant.
These findings were reviewed with facility staff during he licensing inspection.
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Plan of Correction
Both the Facility Director and Medical Director are responsible to make changes to remedy this issue. This was reviewed with Facility Director, Medical Director and Physician Assistant on 3/13/20.
This issue occurred as the PA was meaning to sign a verbal order for the doctor to sign off within the next 72 hours. She instead signed in place of the doctor in error, thus enacting the dosage change. Myself and the Medical Director reviewed proper protocol for posting verbal orders for the Medical Director to later sign with the PA. PA did understand proper protocol. All changes made to address error by the end of the day, 3/13/20.
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