INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection and methadone monitoring inspection conducted on September 18-19, 2018 by staff from the Department of Drug and Alcohol Programs, Bureau of Quality Assurance for Prevention and Treatment, Division of Accountability and Program Improvement. Based on the findings of the on-site inspection, Alliance Medical Services was found not to be in compliance with the applicable chapters of 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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709.34 (c) (4) LICENSURE Reporting of unusual incidents
§ 709.34. Reporting of unusual incidents.
(c) To the extent permitted by State and Federal confidentiality laws, the project shall file a written unusual incident report with the Department within 3 business days following an unusual incident involving:
(4) Event at the facility requiring the presence of police, fire or ambulance personnel.
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Observations
The facility failed to file a written unusual incident report with the Department within 3 business days following an unusual incident involving an event at the facility requiring the presence of police personnel.
An incident occurred at the facility on June 4, 2018 which required police presence. There was no documentation an unusual incident report was sent to the Department within 3 business days.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Executive Director will ensure all required unusual Incidents are documented within 24 hours of the incident and the report will be emailed to the Division within 3 business days. The sent email will be printed and filed in the Incident report binder. All Incidents will be reviewed by the ED monthly for internal CI tracking to ensure completeness and documentation of required reporting. Incident report documentation will be reviewed quarterly by Corporate QI staff to ensure compliance. ED will review Unusual Incident policy with all staff by Oct. 23.
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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
The facility failed to document that take-home medications were given only to a patient the physician determined responsible and able to handle narcotic drugs outside the narcotic treatment program.
Patient record #2 was reviewed on September 19, 2018. Patient #2 was admitted on July 3, 2018 and was pregnant at the time of admission. Her initial dose of 30mg was given at the facility on July 3, 2018, and she was given a holiday take home medication bottle to be ingested on July 4th, 2018. There was no documentation that patient #2 was responsible and able to handle narcotic drugs outside of the program prior to being given take home medication on July 3, 2018 for July 4, 2018.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The MD will document in each pt chart if he feels the pt is responsible to handle one take home bottle. He will also reassess each pt that loses their take homes if they are responsible to have the one bottle or require courtesy dosing. ED will meet with the MD on 10-19-18 to review process for documentation related to responsible handling of sunday take home/holiday closures. Ongoing compliance will be ensured through monthly chart reviews by the ED.
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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
The facility failed to document that each medication order and dosage change was written and signed by the narcotic treatment physician in patient records reviewed on September 18-19, 2018.
Each dose change order was not written and signed by the physician in patient records #1, 2, 3 and 5.
The initial medication order for patients #1, 2, 3 and 5 stated that the patient was to be given "30mg - 50mg x 10 mg" increase for three days. Per the dose history, patients #1, 2, 3 and 5 were given 30mg on day 1, 40mg on day 2 and 50mg on day 3. All of these dose changes were written in the initial order and were not separated.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
ED met with MD and nurses on 9-21-18 and reviewed that there can not be standing medical orders. ED, nurses and PA will monitor orders to ensure that none are entered incorrectly. MD will immediately recheck orders when entering to ensure that this does not occur. ED will follow up with MD again on 10-19-18 to ensure understanding.
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