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 June 26 - 27, 2013 by staff from the Program Licensure Division. Based on the findings of the on-site inspection, RHJ Medical Center, Inc. / Vandergrift LLC 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(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 narcotic treatment program failed to document the consultation between the narcotic treatment physician determining the initial dose and the narcotic treatment physician performing the examination in seven of seven patient records.
The findings include:
Twelve patient records were reviewed on June 26-27, 2013. Seven patient records were required to document a consult between the narcotic treatment physician determining the initial dose and the narcotic treatment physician performing the physical examination. The documentation was not completed in records # 3, 4, 5, 7, 10, 11 and 12.
Record # 3 - Patient was admitted on 1-29-13. The Physician Assistant (PA) completed the physical examination on 1-25-13. The narcotic treatment physician determined the initial dose on 1-28-13, but failed to document the consultation with the Physician Assistant who completed the physical examination.
Record # 4 - Patient was admitted on 11-27-12. The Physician Assistant (PA) completed the physical examination on 11-5-12. The narcotic treatment physician determined the initial dose on 11-14-13, but failed to document the consultation with the Physician Assistant who completed the physical examination.
Record # 5 - Patient was admitted on 1-11-13. The Physician Assistant (PA) completed the physical examination on 1-10-13. The narcotic treatment physician determined the initial dose on 1-11-13, but failed to document the consultation with the Physician Assistant who completed the physical examination.
Record # 7 - Patient was admitted on 4-13-13. The Physician Assistant (PA) completed the physical examination on 4-1-13. The narcotic treatment physician determined the initial dose on 4-12-13, but failed to document the consultation with the Physician Assistant who completed the physical examination.
Record # 10 - Patient was admitted on 4-9-13. The Physician Assistant (PA) completed the physical examination on 4-8-13. The narcotic treatment physician determined the initial dose on 4-8-13, but failed to document the consultation with the Physician Assistant who completed the physical examination.
Record # 11 - Patient was admitted on 2-26-13. The Physician Assistant (PA) completed the physical examination on 2-25-13. The narcotic treatment physician determined the initial dose on 2-26-13, but failed to document the consultation with the Physician Assistant who completed the physical examination.
Record # 12 - Patient was admitted on 3-22-13. The Physician Assistant (PA) completed the physical examination on 3-21-13. The narcotic treatment physician determined the initial dose on 3-22-13, but failed to document the consultation with the Physician Assistant who completed the physical examination.
The finding was reviewed with the Clinical Supervisor and was not disputed.
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Plan of Correction
The project director and medical director are responsible to ensure that the consultation between the physician or physician assistant and the physician determining the initial client dosage is documented as necessary. In order to ensure that the consultation is properly documented the project director has added a statement on the intake history and physical exam stating that the consultation occurred if the physician prescribing the initial dose of methadone is not the physician who completed the initial history and physical. The project director will meet with all physicians and physician assistants to discuss the regulation and provide the updated form. In order to maintain continued compliance, random chart audits will be completed to ensure that the documentation is being completed as necessary. |
715.28(c)(1-5) LICENSURE Unusual incidents
(c) A narcotic treatment program shall file a written Unusual Incident Report with the Department within 48 hours following an unusual incident including the following:
(1) Complaints of patient abuse (physical, verbal, sexual and emotional).
(2) Death or serious injury due to trauma, suicide, medication error or unusual circumstances.
(3) Significant disruption of services due to a disaster such as a fire, storm, flood or other occurrence.
(4) Incidents with potential for negative community reaction or which the facility director believes may lead to community concern.
(5) Drug related hospitalization of a patient.
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Observations
Based on the review of administrative documentation, the facility failed to file a written unusual incident report to the Department for an incident on 1-5-2013 involving serious injury due to unusual circumstance.
The findings include:
Administrative documentation that included the unusual incident reports was reviewed 6-26-2013. It was noted the facility had documentation of an incident, but failed to complete an unusual incident report and then file that report with the Department.
The finding was discussed with clinical supervisor and was not disputed.
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Plan of Correction
The project director and clinical supervisor are responsible to ensure compliance with this regulation. In order to ensure compliance the project director will provide a copy of the list of reportable unusual incidents to the clinical supervisor and discuss the regulation. The project director will also instruct the clinical supervisor to contact the project director with any unusual incident. If a report is required the project director or clinical supervisor will then completed the unusual incident report and file the report with Department in a timely manner. |