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 October 4-6, 2010 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Alliance Medical Services 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 and a plan of correction is due on October 27, 2010.
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Plan of Correction
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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
Based on the observation of the administration of medication, facility failed to administer and dispense medication in a manner that protected the patient from disruption from other individuals.
The finding include:
The observation of the administration of medication occurred on October 5, 2010 from approximately 9:50 am to 10:20 am. It was observed during this time, that while a patient was dosing at the window, a staff member was engaging the patient in conversation. The same staff person was again observed speaking to a second patient at a dosing window.
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Plan of Correction
The Facility Director and the Clinical Supervisor will conduct in-house staff training on proper dosing procedures with both counselors and nurses. This will be documented through meeting minutes. Any further incidents of disturbing patients while dosing will be addressed through individual supervision. This will be done no later than 10/31/2010. |
715.23(b)(3) LICENSURE Patient records
(b) Each patient file shall include the following information:
(3) A complete medical history
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Observations
Based on review of the patient records, the facility failed to document a complete medical history in one of four patient records.
The findings include:
Fourteen patient records were reviewed on October 4-6, 2010. Four patient records reviewed were required to have documentation of a complete medical history. One of four patient records reviewed did not document a complete medical history.
Patient # 1 was re admitted on June 29, 2010. The patient record documented a medical history had been completed on July 9, 2009. There was no documentation that a medical history had been completed at the time of the patient's readmission on June 29, 2010.
An interview with the project director on October 6, 2010, confirmed the medical history documented in the patient record was dated July 9, 2009.
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Plan of Correction
Internal tracking procedures have been improved so that future annual exams and histories will be accurately scheduled. In addition, medical staff will be re-trained by the Facility Director on the readmission procedure for patients related to History and Physicals so that they are completed upon readmission if the existing one on file is older than 6 months. This will be complete no later than 10/29/10. |
715.23(b)(4) LICENSURE Patient records
(b) Each patient file shall include the following information:
(4) The results of an initial intake physical examination.
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Observations
Based on review of the patient records, the facility failed to document the results of an initial intake physical examination in one of four patient records.
The findings include:
Fourteen patient records were reviewed on October 4-6, 2010. Four patient records reviewed were required to have documentation of the results of an initial intake physical examination. One of four patient records reviewed did not document the results of an initial physical examination.
Patient # 1 was re admitted on June 29, 2010. The patient record documented a physical examination completed on July 9, 2009. There was no documentation that an intake physical examination had been completed at the time of the patient's readmission on June 29, 2010.
An interview with the project director on October 6, 2010, confirmed the last physical examination documented in the patient record was July 9, 2009.
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Plan of Correction
Internal tracking procedures have been improved so that future annual exams and histories will be accurately scheduled. In addition, medical staff will be re-trained by the Facility Director on the readmission procedure for patients related to History and Physicals so that they are completed upon readmission if the existing one on file is older than 6 months. This will be complete no later than 10/29/10. |