INITIAL COMMENTS
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This report is a result of an onsite licensure renewal and methadone monitoring inspection. The inspection was conducted on August 10, 2017 through August 11, 2017 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the onsite inspection, Addiction Medicine and Health Advocate, Inc. 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 the inspection:
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Plan of Correction
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709.28 (c) 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.
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Observations
Based on a review of 11 patient records, the facility failed to document a complete consent to release information form in 1 record.
Patient #4 was admitted on 5/16/17 and was an active patient at the time of inspection. The record contained a consent to release information form to the primary care physician, signed on 5/11/17, which did not specify any of the information to be released.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
AMHA will conduct a staff training on 9/12/17 on PA code 255.5. This training will review the proper completion of consent forms. In reviewing the chart of patient #4, it was noted by her counselor that she no longer sees this provider so there was no need to get an updated consent form. The Clinical Program Manager will be responsible for conducting the training with staff. The Clinical Program Manager, in conjunction with the Program Director, will be responsible for ongoing monitoring of adherence to Pa code 255.5 and the proper completion of consent forms. |
709.32 (b) LICENSURE Medication control
§ 709.32. Medication control.
(b) Verbal orders for medication can be given only by a physician or other medical professional authorized by State and Federal law to prescribe medication and verbal orders may be received only by another physician or medical professional authorized by State and Federal law to receive verbal orders. When a verbal or telephone order is given, it has to be authenticated in writing by a physician or other medical professional authorized by State and Federal law to prescribe medication. In detoxification levels of care, written authentication shall occur no later than 24 hours from the time the order was given. Otherwise, written authentication shall occur within 3 business days from the time the order was given.
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Observations
Based on a review of 11 patient records, the facility failed to ensure that verbal orders were signed by the ordering physician within the regulatory timeframe in 1 patient record.
Patient #4 was admitted on 5/16/17 and was an active patient at the time of inspection. The record contained documentation of verbal orders taken on 6/1/17 and 6/19/17, which were not signed by the ordering physician until 6/22/17 and 7/3/17, respectively.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
This citation was reviewed with our Medical Director and Nursing Supervisor. A system was developed to ensure that verbal orders would be considered priority and signed within 24 hours of the order being given by the physician. The Nursing Supervisor will be responsible for monitoring this system and ensuring that it is being followed. |
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 the physician timesheets for the months of March, April, May, and June 2017, the facility failed to provide at least one hour of on-site physician time a week for every ten patients during the following weeks:
For the week of March 13-19, 2017, the patient census was 500. The facility was required to provide at least 50 physician hours. There were 31 physician hours documented.
For the week of March 20-26, 2017, the patient census was 500. The facility was required to provide at least 50 physician hours. There were 35 physician hours documented.
For the week of March 27-April 2, 2017, the patient census was 500. The facility was required to provide at least 50 physician hours. There were 28 physician hours documented.
For the week of April 3-9, 2017, the patient census was 500. The facility was required to provide at least 50 physician hours. There were 28.5 physician hours documented.
For the week of April 10-16, 2017, the patient census was 500. The facility was required to provide at least 50 physician hours. There were 26.25 physician hours documented.
For the week of April 17-23, 2017, the patient census was 500. The facility was required to provide at least 50 physician hours. There were 27.5 physician hours documented.
For the week of April 24-30, 2017, the patient census was 500. The facility was required to provide at least 50 physician hours. There were 43 physician hours documented.
For the week of May 1-7, 2017, the patient census was 496. The facility was required to provide at least 49.6 physician hours. There were 15.5 physician hours documented.
For the week of May 8-14, 2017, the patient census was 496. The facility was required to provide at least 49.6 physician hours. There were 21 physician hours documented.
For the week of May 15-21, 2017, the patient census was 49.6. The facility was required to provide at least 49.6 physician hours. There were 18.5 physician hours documented.
For the week of May 22-28, 2017, the patient census was 496. The facility was required to provide at least 49.6 physician hours. There were 18.5 physician hours documented.
For the week of May 29-June 4, 2017, the patient census was 500. The facility was required to provide at least 50 physician hours. There were 20.5 physician hours documented.
For the week of June 5-11, 2017, the patient census was 500. The facility was required to provide at least 50 physician hours. There were 6.5 physician hours documented.
For the week of June 12-18, 2017, the patient census was 500. The facility was required to provide at least 50 physician hours. There were 23.75 physician hours documented.
For the week of June 19-25, 2017, the patient census was 500. The facility was required to provide at least 50 physician hours. There were 33.25 physician hours documented.
For the week of June 26-July 2, 2017, the patient census was 500. The facility was required to provide at least 50 physician hours. There were 26 physician hours documented.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
AMHA has identified an additional narcotic treatment physician to join the agency for 20 hours per week. This is in addition to our Medical Director increasing his weekly hours. Between the two physicians, AMHA will have the required onsite physician hours needed relative to our patient census. Additionally, AMHA has a contract with a staffing agency that has been used in the past for physician coverage. We will utilize this staffing agency if needed for additional hours. The Program Director will be responsible for monitoring physician coverage and ensuring that we have the appropriate number of hours. |
715.7(b) LICENSURE Dispensing or Administering Staffing
(b) Dispensing time shall be prorated for patient census. There shall be sufficient dispensing staff to ensure that all patients are medicated within 15 minutes of arrival at the dispensing area.
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Observations
Based on a physical plant inspection and observation of dosing administration on August 11, 2017 at approximately 10:45 A.M., it was observed that the facility failed to ensure that patients were administered their medication dose within the regulatory timeframe. The dosing wait-time for one patient was monitored upon the Licensing Specialist's arrival to the dosing area. The patient had still not received his/her medication dose prior to the Licensing Specialist's departure from that area, which was seventeen minutes later.
The findings were reviewed with facility staff during the licensing inspection process.
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Plan of Correction
This citation was reviewed with the Medical Director, Nursing Supervisor and dispensing staff. It was determined that during peak dispensing periods, a second dispensing nurse will be utilized to assist with medicating the patients at a second dispensing window to ensure that their wait time once arriving in the dispensing area is no greater than 15 minutes. Additionally, we will be utilizing a pool nurse on our high volume days as well as using existing nursing staff to assist at other times as they arise. The Nursing Supervisor will be responsible for monitoring this process and scheduling nurses in the dispensing area as needed. |
715.15(a) LICENSURE Medication Dosage
(a) The narcotic treatment physician shall review the dosage levels at least twice a year, with each review occurring at least 2 months apart, to determine a patient 's therapeutic dosage.
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Observations
Based on a review of 11 patient records, 7 patient records were reviewed for documentation from the narcotic treatment physician's review of the patient's therapeutic dosage level. 1 of 7 records failed to include documentation that the narcotic treatment physician reviewed the patient's dosage level at least twice a year.
Patient # 5 was admitted on 4/24/14 and was still an active patient. There was documentation that the narcotic treatment physician conducted a medication dosage review on April 6, 2017. This was the only dose review documented in the record from August 2016 through August 2017.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Each patient currently has their dosage level reviewed by the physician at their annual physical exam. If there has been no change in the patient's dosage for 6 months after the exam, the counselor will initiate a dosage level review with the physician. This will allow for a minimum of 2 dose reviews per year, at least 2 months apart. The Clinical Program Manager will be responsible for assisting the counselors with developing a tracking system and responsible for overseeing that the reviews are completed timely. |
715.23(b)(5) LICENSURE Patient records
(b) Each patient file shall include the following information:
(5) The results of all annual physical examinations given by the narcotic treatment program which includes an annual reevaluation by the narcotic treatment physician.
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Observations
Based on a review of 11 patient records, 4 patient records were required to document the results of an annual physical examination. 1 of the 4 records reviewed did not have an annual physical examination.
Patient # 7 was admitted on 11/22/14 and was discharged on 12/22/16. The record did not contain any documentation of an annual physical conducted after the initial physical examination.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
A system will be developed to track patients due for their annual physical exams, the date of the scheduled exam appointment, and attendance at these appointments. Patients who do not attend these appointments will be identified and re-scheduled. For patients who are out of treatment for a period of time due to circumstances like hospitalization or incarceration, they will be immediately scheduled upon their return to treatment at AMHA. The Nursing Supervisor will be responsible for developing this tracking system and monitoring adherence to the system. |
715.28(c)(1-5) LICENSURE Unusual incidents
(c) A narcotic treatment program shall file a written Unusual Incident Report with the Department within 48 hours following an unusual incident including the following:
(1) Complaints of patient abuse (physical, verbal, sexual and emotional).
(2) Death or serious injury due to trauma, suicide, medication error or unusual circumstances.
(3) Significant disruption of services due to a disaster such as a fire, storm, flood or other occurrence.
(4) Incidents with potential for negative community reaction or which the facility director believes may lead to community concern.
(5) Drug related hospitalization of a patient.
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Observations
Based on the review of the facility's unusual incident reports, the facility failed to notify the Department within the regulatory timeframe following the unusual incidents below, which were discovered during the licensing process.
The incident dates and incident reason are:
July 24, 2017 - Ambulance presence onsite
July 14, 2017 - Ambulance presence onsite
July 14, 2017 - Facility informed of the death of a patient
June 27, 2017 - Ambulance presence onsite
May 5, 2017 - Physical assault by patient
March 22, 2017 - Ambulance presence onsite
March 12, 2017 - Ambulance presence onsite
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
This citation was reviewed and discussed with the members of the Health and Safety Committee responsible for reporting these incidents to the Department in the appropriate time frame. A re-training on the reporting policy was conducted we these individuals on 8/22/17. The Nursing Supervisor will be responsible for ensuring that incidents are documented and reported to the Department within the appropriate time frames. |