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 and buprenorphine, in the treatment of narcotic addiction. This inspection was conducted on January 29-31, 2013 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, The Family Center of Thomas Jefferson University (MATER) 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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715.16(a)(1) LICENSURE Take-home privileges
(a) A narcotic treatment program shall determine whether a patient may be provided take-home medications.
(1) A narcotic treatment program may give take-home medications only to a patient who the narcotic treatment physician has determined is responsible and able to handle narcotic drugs outside the narcotic treatment program.
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Observations
Based on a review of patient records, administrative documentation and discussions with administrative staff, the facility failed to grant take home medications only to those determined to be responsible and able to handle narcotic drugs outside the narcotic treatment program.
The findings include:
Eleven patient records were reviewed January 29-30, 2013. The administrative documentation of patients who had been discharged as non-compliant was reviewed January 29, 2013. Two patients records, # 1 and # 2, contained documentation of the patient's being given take home medication bottles to cover the "five day" detoxification they were given for a physical altercation on the grounds of the facility. The letters of termination stated the patients were given five days detoxification via take home bottles.
Patient #1 was administratively discharged on September 29, 2012 with five take home bottles. She was provided with the take home medication after being discharged due to physical violence against another patient at the facility.
Patient # 2 was administratively discharged on September 29, 2012 with five take home bottles. She was provided with the take home medication after being discharged due to physical violence against another patient at the facility.
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Plan of Correction
Any patient exhibiting life-threatening behaviors to another patient or staff, will be terminated for the safety of the community. In compliance with regulations regarding take-home priviledges, the patient will not receive any further methadone The revised policy, which will be the responsibility of the Program Director, will state acts of violence will be grounds for immediate termination and, as such, no detoxification will occur.
Person(s) responsible: Medical Director, Program Director, and Clinical Supervisor.
Timeframe for completion: 02/26/2013 |
715.17(c)(1)(i-vi)) 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:
(1) Administration of medication.
(i) A narcotic treatment physician shall determine the patient 's initial and subsequent dose and schedule. The physician shall communicate the initial and subsequent dose and schedule to the person responsible for the administration of medication. Each medication order and dosage change shall be written and signed by the narcotic treatment physician.
(ii) An agent shall be administered or dispensed only by a practitioner licensed under the appropriate Federal and State laws to dispense agents to patients.
(iii) Only authorized staff and patients who are receiving medication shall be permitted in the dispensing area.
(iv) There shall be only one patient permitted at a dispensing station at any given time.
(v) Each patient shall be observed when ingesting the agent.
(vi) Administering and dispensing shall be conducted in a manner that protects the patient from disruption or annoyance from other individuals.
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Observations
Based on a review of patient records, the facility failed to restrict the determination of patient dose to the physician for multiple patients on at least two occasions in September and October 2012.
The findings include:
Eleven patient records were reviewed January 29-30, 2013. Two patient records contained a copy of an e-mail sent to a program physician for approval of verbal orders.
On September 27, 2012 at 4:31 PM, a dosing nurse from the Family Center sent an e-mail to the program physician responsible for approving verbal order requests. The introduction was regarding "some verbal orders" for today. There was then a list of patients with their respective doses and the amount of an increase or decrease dose. The physician responded by stating that "all orders approved."
On October 2, 2012 at 2:18 PM another e-mail was sent to the same physician with another list of patients with their respective current doses and the amount of either an increase or decrease dose. The physician responded by stating that "all orders approved."
There was also a list of four patients who were "denied an increase by clinical staff" in the e-mail sent on this date.
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Plan of Correction
The Medical Director, Program Director, and Nurse Coordinator will develop a protocol that specifically addresses the repeating back of the verbal orders. This form will be implemented after the iniital phone call to the Medical Director and then printed out upon confirmation of the order. Any verbal change in orders is at the sole discretion of the Medical Director. Staff do not have the authority to deny and dose changes. However, their input regarding behaviors is considered by the Medical Director. The Clinical Supervisor will conduct a review of this protocol with the staff in weekly group supervision and document same.
Person(s) responsible: Medical Director, Nurse Coordinator, Dispensing Nurses, Program Director, and Clinical Supervisor.
Timeframe for completion: 2/28/13. |