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 July 12, 2010 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Pa Associates Llc, D/b/a Mount Pocono Medical was found not to be compliance with the applicable chapters of 28 PA Code which pertain to the facility. Deficiencies were identified during this inspection and a plan of correction is due on July 7, 2010. .
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Plan of Correction
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715.17(b) LICENSURE Medication control
(b) A narcotic treatment program shall develop policies and procedures regarding verbal medication orders, including the issuing and receiving of orders, identifying circumstances when orders are appropriate and documenting orders, in accordance with applicable Federal and State statutes and regulations.
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Observations
Based on the review of patient records and a staff interview, the facility failed to ensure the physician dated the signature after submitting a verbal order within 24 hours of issuance in two of six patient records.
The findings include:
Six patient records were reviewed July 12, 2010. Six records contained documentation of a physician's verbal orders. While the physician did sign these verbal orders, the signature was late in patient records # 4 and 6. Patient # 4 had a verbal order issued on 5/13/10 but it was not signed until 5/19/10. Patient record # 6 recorded a verbal order on 5/12/10 but it was not signed until 5/19/10.
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Plan of Correction
715.17(b)
Facility Director reviewed medication order deficiences with physician on 7/28/10 for patient records #4 and #6. A new policy has been implemented where all verbal orders will be faxed to the physician, signed and faxed back to the clinic.
Nursing will monitor for compliance. |
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 the review of patient records and a staff interview, the facility failed to restrict the determination of a patient's dose to the physician in 4 of 6 patient records.
The findings include:
Six patient records were reviewed on June 3, 2010; all six patient records were reviewed for medication orders. Patient records # 3, 4, 5, and # 6 contained dosing orders that ordered changes in medication that included standing orders that took place without ongoing physician review. Additionally, the physician orders stipulated nursing staff could make determinations to change the dose of a patient.
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Plan of Correction
715.17(C)(1)(i-vi)
Facility Director reviewed the medication order deficiences with the physician on 7/28/2010 and records for patients #3, 4, 5 and 6 were updated to comply with the regulations. Physician orders will be written to state specific adjustments to dose with physician review. Physician has ceased writing orders that state; PRN when symptomatic, at nurses discretion.
Nursing will monitor for compliance. |
715.19(1) LICENSURE Psychotherapy services
A narcotic treatment program shall provide individualized psychotherapy services and shall meet the following requirements:
(1) A narcotic treatment program shall provide each patient an average of 2.5 hours of psychotherapy per month during the patient 's first 2 years, 1 hour of which shall be individual psychotherapy. Additional psychotherapy shall be provided as dictated by ongoing assessment of the patient.
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Observations
Based on a review of patient records, the facility failed to provide each patient an average of 2.5 hours of psychotherapy per month during the patient's first 2 years of treatment in 3 of 6 records.
The findings include:
Six patient records were reviewed on July 12, 2010; all were reviewed for compliance. Patients records # 1, 3 and 6 failed to provide documenting that the patients were receiving a minimum of 2.5 hours of psychotherapy month.
Patient record # 1 recorded 1.5 hours of psychotherapy for the month of April 2010, 2 hours for the months of May, and 2.5 for the month of June for an average of 2 hours of psychotherapy per month.
Patient record # 3 recorded 2 hours of psychotherapy for the month of April, 2010, 1.5 hours for the month of May and 3 hours for the month of June for an average of 2.16.
Patient record # 4 recorded 30 minutes of psychotherapy for the month of April, 2010 and 1 month for May, 2010 for an average of .75 hour.
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Plan of Correction
715.19 (1)
On 7/28/2010 all counseling staff were trained again on the requirements of psychotherapy and proper documentation using the tower system.
Facility Director and Lead Counselor will monitor for compliance |
715.20(4) LICENSURE Patient transfers
A narcotic treatment program shall develop written transfer policies and procedures which shall require that the narcotic treatment program transfer a patient to another narcotic treatment program for continued maintenance, detoxification or another treatment activity within 7 days of the request of the patient.
(4) The receiving narcotic treatment program shall document in writing that it notified the transferring narcotic treatment program of the admission of the patient and the date of the initial dose given to the patient by the receiving narcotic treatment program.
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Observations
Based on the review of patient records, the facility failed to document that it notified the referring facility of the admission and initial dosing of the patient in 4 of 6 patient records.
The findings include:
Six patient records were reviewed July 12, 2010. Six patient records were reviewed for documentation of notification to the referring facility of the admission and the initial dosing of the referred patient. Patient records # 1, 2, 3, and were referred by narcotic treatment programs but there was no documentation of the facility's notification to the referring facility of the admission and initial dosing of the patients.
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Plan of Correction
715.20(4)
A new admission and initial dosing verification form has been developed and implemented as of 7/28/2010 to reflect the dates of admission and initial dosing.
Nursing and Lead Counselor will monitor for compliance |