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 January 14 - 17, 2013 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Esper Treatment Center was found not to be in compliance with the applicable chapters of 4 PA Code and 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(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 patient records, the narcotic treatment physician failed to document the dosage levels were reviewed at least twice a year, with each review occurring at least two months apart, to determine the patient's therapeutic dosage. The findings include:Sixteen patient records were reviewed on January 15-16, 2013. Four patient records were reviewed for documentation from the narcotic treatment physician's review of the patient's therapeutic dosage level. Three of four records failed to include documentation that the narcotic treatment physician reviewed the patient's dosage level at least twice a year, specifically patient records # 6, #7 and #14. Patient record #6 was admitted on 10-26-2011. The physician assistant completed a dosage review on 10-11-2012. Patient record # 7 was admitted on 11-16-2011. The physician assistant completed a dosage review on 11-15-2012. Patient record # 14 was admitted on 12-4-2007. The physician assistant completed a dosage review on 12-6-2012. The findings were reviewed with the project director and the clinical director and were not disputed.
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Plan of Correction
The physician will document all dose reviews on all patients twice a year. The physician will be the only person authorized to perform dose reviews. |
715.23(b)(4) LICENSURE Patient records
(b) Each patient file shall include the following information:
(4) The results of an initial intake physical examination.
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Observations
Based on a review of patient records, the facility failed to document the physician signature on a physical examination which was completed by the physician assistant. The findings include:Sixteen patient records were reviewed on January 15-16, 2013. Fifteen patient records were reviewed for physical examinations. Fourteen of the physical examinations were completed by the physician, and one of the physical examinations was completed by the physician assistant. The physical examination completed by the physician assistant did not include a co-signature of the physician, specifically patient record #14. Patient record # 14 was admitted on 12-4-2007. The physician assistant completed a physical examination on 1-10-2013. The physical examination completed by the physician assistant did not include a co-signature of the physician. The findings were reviewed with the project director and the clinical director and were not disputed.
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Plan of Correction
The physician will sign off on all physicals conducted by the PA. All physicals will be tracked and to ensure all physicals are signed off on the nurses will keep a tracking sheet and check it twice weekly to ensure all physicals are signed. |