INITIAL COMMENTS
|
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 December 29, 2011, by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, PA Care LLC, D/b/a State College Medical 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.
|
Plan of Correction
|
715.6(a)(3)(ii) 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.
(3) The medical director 's responsibilities include the following:
(ii) Supervision of licensed practical nurses if the narcotic treatment program does not employ a registered nurse to supervise the nursing staff. In addition, the medical director in these instances shall ensure that licensed practical nurses adhere to written protocols for dispensing and administration of medication.
|
Observations
Based on the review of personnel records, the facility failed to provide documentation of supervision of the licensed practical nurses.The findings include:Six personnel records were reviewed on December 29, 2011. The nursing staff was comprised of two licensed practical nurses. A review of the contract for the medical director found no requirement of the supervision of the licensed practical nurses.
|
Plan of Correction
The Facility Director will draft an addendum to the Medical Director's contract, which will include the description of his supervision duties with regards to the LPNs on staff. This will be reviewed and signed by the Medical Director by February 1, 2012. The medical director's contract, outlining his job duties (including supersvision of the LPNs)will be reviewed annually. It will be the responsibility of the Facility Director to implement this contract addendum and to review annually with the Medical Director. |
715.11 LICENSURE Confidentiality of patient records
A narcotic treatment program shall physically secure and maintain the confidentiality of all patient records in accordance with 42 CFR 2.22 (relating to notice to patients of Federal confidentiality requirements) and § 709.28 (relating to confidentiality).
|
Observations
Based on direct observation, the facility failed to physically secure and maintain confidentiality of patient records.The findings include:Discharge patient records were found underneath a counselor's desk during the onsite monitoring inspection on December 29, 2011. The facility failed to secure the patient file in a locked, limited access storage container as required by regulation.The facility director found the charts under the counselor's desk and confirmed the fact that the records had not been securely maintained.
|
Plan of Correction
Effective immediately, all patient charts, including discharged charts, will be placed in locked filing cabinets, only accessible to staff. It will be the responsibility of medical and clinical staff to be sure that records are secure when not in use. Facility Director will monitor record storage and provide training to staff about record confidentiality as needed. |
715.17(c)(2) 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:
(2) Drug storage areas. A narcotic treatment program shall develop and implement written policies and procedures regarding storage of medications and access to the medication storage area. Agents shall be stored in a locked safe that has been approved by the DEA under 21 CFR 1301.72 and 1301.74 (relating to physical security controls; and other security controls).
|
Observations
Based on a physical plant tour, the facility failed to document the staff members by position who are permitted access to the medication storage area. The findings include:The medication storage area was observed on December 29, 2011. A listing of the staff members permitted access by position was not displayed.The dispensing nurse confirmed the lack of the required listing.
|
Plan of Correction
On 1/9/2012, a list of staff who are permitted in the medication storage area was posted in that space.
This list will be updated by Facility Director reflecting any changes, as needed. |
715.23(b)(6) LICENSURE Patient records
(b) Each patient file shall include the following information:
(6) Results of laboratory tests or other special examinations given by the narcotic treatment program.
|
Observations
Based on a review of patient records, the facility failed to document the results of laboratory tests in two of three patient records.The findings include:Three patient records were reviewed on December 29, 2011. Three patient records were reviewed for the results of laboratory tests; specifically a tuberculosis Mantoux test (PPD). The facility failed to document the results of a Mantoux test in patient records # 2 and 3.Patient # 2 was admitted into treatment on July 28, 2011 and discharged on August 19, 2011. There was no documentation of the results of a Mantoux test in patient record # 2 at the time of the review.Patient # 3 was admitted into treatment on November 26, 2011 as a transfer. There was no documentation of the results of a Mantoux test in patient record # 3 at the time of the review.The facility director confirmed the facility did not conduct a Mantoux test for patients # 2 and 3.
|
Plan of Correction
Facility Director provided training to LPNs on 1/9/2012 about the administration of Mantoux tests. Mantoux tests will be administered to new patients upon intake. If the patient is a transfer, records will be requested from the transfering clinic. Should records not be received within one week, a new Mantoux test will be administered on site. A tracking system was developed/implemented by LPNs on 1/20/2012 to ensure that no Mantoux test is missed. This is in the form of a medical chart checklist which is now in place in all patient medical charts. Facility Director will monitor this.
Patient #3 has now had his Mantoux test. |
704.11(c)(2) LICENSURE CPR CERTIFICATION
704.11. Staff development program.
(c) General training requirements.
(2) CPR certification and first aid training shall be provided to a sufficient number of staff persons, so that at least one person trained in these skills is onsite during the project's hours of operation.
|
Observations
Based on a review of personnel training records, the facility failed to document a sufficient number of staff persons trained in CPR and First aid in two of two records.The findings include:Six personnel records were reviewed on December 29, 2011. Two records were reviewed for CPR and First Aid certification. Two of two records did not have documentation of current training in CPR and First Aid at the time of the review. The findings were reviewed and confirmed with the facility director.
|
Plan of Correction
On 12/30/2012, one staff brought in most recent copy of CPR certification. This staff will complete First Aid training by 2/29/2012.
Second staff is scheduled to attend CPR training on 2/1/2012 and First Aid training on 2/8/2012.
Facility Director will follow up with these staff members to ensure that these courses are completed. Facility Director will also offer First Aid/CPR training to all staff members throughout the year to increase the number of trained staff.
Facility Director will track CPR/First Aid expiration dates and prompt staff to register for recertification trainings. |