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 May 15-17, 2012 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Center for Behavioral Health-HA, Inc 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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Observations
Based on the review of administrative documentation, the facility failed to provide at least one hour of physician time a week, on site, for every ten patients.
The findings include:
Physician time sheets and and census reports for the months of January, February, March, April and May, 2012 were reviewed on May 15, 2012. There were insufficient onsite physician hours during January, February, March, April and May, 2012.
During the week of January 23, 2012 the census was 483 which required 48.3 physician hours. The physician's hours documented during this time period were 41.64 .
During the week of January 30, 2012 the census was 478 which required 47.8 physician hours. The physician's hours documented during this time period were 16.
During the week of February 6, 2012 the census was 478 which required 47.8 physician hours. The physician's hours documented during this time period were 16.
During the week of February 13, 2012 the census was 474 which required 47.4 physician hours. The physician's hours documented during this time period were 16.
During the week of February 20, 2012 the census was 465 which required 46.5 physician hours. The physician's hours documented during this time period were 15.50.
During the week of February 27, 2012 the census was 462 which required 46.2 physician hours. The physician's hours documented during this time period were 11.
During the week of March 5, 2012 the census was 452 which required 45.2 physician hours. The physician's hours documented during this time period were 15.
During the week of March 12, 2012 the census was 444 which required 44.4 physician hours. The physician's hours documented during this time period were 15.
During the week of May 1, 2012 the census was 448 which required 44.8 physician hours. The physician's hours documented during this time period were 43.05.
The findings were reviewed and confirmed with the Facility Director on May 15, 2012.
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Plan of Correction
The Program Director met with the Medical Director, Physician Assistant and Nurse Manager on May 21, 2012 to discuss results of the on-site inspection for Methadone Maintenance by the staff from the Division of Drug and Alcohol Program Licensure. Program Director will insure the Medical Directors hours will be in compliance according to DHNPA census and within the state regulations to include at lease on hour of physician time, on site, for every ten patients. This will be monitored by the Program Director. |