INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection, buprenorphine inspection and methadone monitoring inspection conducted on June 8-9, 2015 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, WPIC Narcotic Addiction Treatment Program 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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715.15(b) LICENSURE Medication dosage
(b) The narcotic treatment physician shall determine the proper dosage level for a patient, except as otherwise provided in this section. If the narcotic treatment physician determining the initial dose is not the narcotic treatment physician who conducted the patient examination, the narcotic treatment physician shall consult with the narcotic treatment physician who performed the examination before determining the patient 's initial dose and schedule.
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Observations
Based on a review of patient records, the facility's physician failed to adhere to the dosing protocol listed on the medication by ordering that single dose Suboxone film be cut in one of four patient records. The medication packaging identifies this as a single dose medication.
The findings include:
Four buprenorphine patient records were reviewed on June 8-9, 2015. All narcotic treatment medication prescriptions are to adhere to the dosing protocol listed on the medication. The physician did not adhere to the dosing protocol listed on the medication in patient record #8.
Patient #8 was admitted on February 3, 2015. On February 3, 2015 the narcotic treatment physician wrote a prescription for the patient to take 1/2 strip of Suboxone 8mg/2mg every four hours.
Suboxone film is not formulated to be cut into smaller doses. Prescriptions need to be for the manufactured quantities of 12 mg/3 mg, 8 mg/2 mg, 4 mg/1 mg or 2 mg/.5 mg doses.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Under the direction of the Clinical Administrator or her designee NATP will ensure that physicians will adhere to the dosing protocol for Suboxone. This medication packaging identifies Suboxone as a single dose medication which should not be cut into smaller doses. AMS Medical Director will review this dosing protocol with physicians by 7/15/15. The AMS Medical Director will review Suboxone prescriptions monthly to ensure that we are in compliance. If AMS Medical Director determines that this is not occurring then further follow up and re-education with physicians will occur and be documented. Plan of correction is effective 7/15/15. |
711.94 (g) LICENSURE Medical Assistance Provider Agreement
711.94. Project management services.
(g) Outpatient projects which receive reimbursement under the medical assistance program shall have a current, signed provider agreement with the Department of Public Welfare and comply with 55 Pa. Code Part III (relating to Medical Assistance Manual).
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Observations
Based on a review of client records, the facility failed to document a physician signature on the individual treatment plan and updates for medical assistance clients within the time frame established by the Office on Medical Assistance in three of six client records reviewed.
The findings include:
Ten client records were reviewed on June 8-9, 2015. Six of the clients reviewed were funded by medical assistance. All six medical assistance client records were required to have a physician signature on the individual treatment plan and updates within the time frame established by the Office on Medical Assistance. Client records #1, 7 and 8 did not include a physician signature on the individual treatment plan and updates within the time frame established by the Office on Medical Assistance.
Client #1 was admitted to treatment on September 20, 2014. The individual treatment plan / updates developed on May 15 and February 20, 2015 and December 20 and October 21, 2014 did not include a physician signature.
Client #7 was admitted to treatment on October 20, 2014. The individual treatment plan / updates developed on May 22, March 23, January 20, 2015 and November 20, 2014 did not include a physician signature.
Client #8 was admitted to treatment on February 3, 2015. The individual treatment plan / updates developed on March 3 and April 30, 2015 did not include a physician signature.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Under the direction of the Clinical Administrator or her designee NATP will ensure that all treatment plans are signed by the physician. Physicians will receive electronic reminders that treatment plans are due for review and signature. Supervisors will review all treatment plans weekly and will provide a monthly report to the Program Director indicating that treatment plans have been signed within 2 weeks of the review. If treatment plans are not signed within 2 weeks the Director will follow up with physicians to ensure they are reviewed and signed. All clinicians will be re-trained on the electronic treatment plan process for adding a physician to the treatment plan by 7/15/15. Plan of correction is effective 7/15/15. |