INITIAL COMMENTS
|
This report is a result of a complaint investigation conducted via telephone on February 1, 2022 by staff from the Bureau of Program Licensure. Based on the findings of the complaint investigation, Medmark Treatment Centers Washington was found not to be in compliance with the applicable chapters of 28 PA Code which pertain to the facility.
|
Plan of Correction
|
715.7(a)(1-2) LICENSURE Dispensing or administering staffing
(a) A narcotic treatment program shall be staffed as follows:
(1) If it operates an automated dispensing system, one full-time nurse or other person authorized by law to administer or dispense a controlled substance shall be available for every 200 patients.
(2) If it operates a manual or nonautomatic dispensing system, one full-time nurse or other person authorized by law to administer or dispense a controlled substance shall be available for every 150 patients.
|
Observations
Based on a staff interview conducted on February 1, 2022 and a review of the Dosing History for January 17, 2022, the facility failed to have one full time nurse or other person authorized by law to administer or dispense a controlled substance available for every 200 patients. The facility operates an automated dispensing system. It opened at 5:00 am on January 17, 2022, however, an employee authorized to dispense a controlled substance was not onsite until 8:30 am.
This finding was reviewed with facility staff during the investigation.
|
Plan of Correction
Director met with nursing staff day after storm on 1/18, and immediatley implemented that all nursing staff will be placed on schedule when a "potential or known" weather system exists, to ensure proper and adequate regulated needed coverage. |
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.
|
Observations
Based on a staff interview on February 1, 2022, the facility failed to ensure that all patients were medicated within 15 minutes of arrival at dispensing area on January 17, 2022. Regular dosing hours on Mondays are 5:00 am-11:30 am. The facility opened at 5:00 am, however, dispensing staff did not arrive until 8:30 am and dosing began at 9:00 am.
This finding was reviewed with facility staff during the investigation.
|
Plan of Correction
Director met with nursing staff and immediatley implemented that nursing will be allowed to stay/have a hotel-motel room within 15 minutes of the facility on "possible-known" weather developments, so that arriving to the faciltiy and being able to dose will not effect being delayed more than 15 minutes.
Director also implemented that Medical Director on duty will also be able to dispense medications should the need arise. |