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 September 5, 6 and 7, 2007 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, RHJ Medical Center, Inc. Vandergrift 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 and a plan of correction is due on September 28, 2007. .
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Plan of Correction
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715.6(a) LICENSURE Physician staffing
(a) A narcotic treatment program shall designate a medical director to assume responsibility for administering all medical services performed by the narcotic treatment program
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Observations
Based on interviews with staff and review of documentation, the facility failed to ensure the medical director is onsite to perform those duties specifically delegated to the medical director.
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Plan of Correction
This facility does not file electronically, a Plan of Correction is on file with the Department of Health. |
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 review of clinical and medical record documentation, the facility failed to ensure that each medication order and dosage change was written by the physician in three of four patient records reviewed, #1, 2 and 3. The documentation reviewed demonstrated staff other than the physician completed the documentation and then the physician signed stating that he agreed with the medication order. Only the physician can determine and order dose and schedule changes.
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Plan of Correction
This facility does not file electronically, a Plan of Correction is on file with the Department of Health. |
715.20 LICENSURE Patient transfers
A narcotic treatment program shall develop written transfer policies and procedures which shall require that the narcotic treatment program transfer a patient to another narcotic treatment program for continued maintenance, detoxification or another treatment activity within 7 days of the request of the patient.
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Observations
Based on the review of the policy and procedure manual, the facility failed to document that the facility will initiate the required transfer to another treatment activity at the request of the patient within 7 days of the request, but rather stipulates that the facility determines if it will be in the best interest of the patient.
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Plan of Correction
This facility does not file electronically, a Plan of Correction is on file with the Department of Health. |
715.23(b)(23) LICENSURE Patient records
(b) Each patient file shall include the following information:
(23) Discharge summary.
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Observations
Based on the review three of three closed patient records, # 2, 3 and 4, the facility failed to document information specific to each patient; rather, the facility used pre-printed, standardized statement of reason for treatment and a list of the services the facility offers to all patients that was not specific to the patient's treatment experience.
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Plan of Correction
This facility does not file electronically, a Plan of Correction is on file with the Department of Health. |
715.26(b) LICENSURE Security
(b) Each narcotic treatment program shall provide the Department with a specific plan describing the efforts it will make to avoid disruption of the community by its patients and the actions it will take to assure responsiveness to the community. This plan shall designate a staff member to act as community liaison.
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Observations
The facility failed to develop a specific plan to minimize community disruption that may be caused by the facility, its patients or staff. The plan needs to address who is doing what activity to foster positive community relationships and maintain an open dialogue on issues critical to the community.
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Plan of Correction
This facility does not file electronically, a Plan of Correction is on file with the Department of Health. |