INITIAL COMMENTS
|
This report is a result of an onsite follow-up inspection pertaining to the plans of correction for the July 18, 2011 through July 19, 2011 methadone monitoring inspection. The follow-up inspection was conducted on January 31, 2012 and February 1, 2012 by staff from the the Division of Drug and Alcohol Program Licensure. Based on the findings of the onsite follow-up inspection, Soar Corporation Chester 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.
|
Plan of Correction
|
715.9(e) LICENSURE Intake
(e) A narcotic treatment program shall secure a personal history from the patient within the first week of admission. The personal history shall be made a part of the patient record.
|
Observations
Based on the review of patient records, the facility failed to secure a personal history from the patient within the first week of admission in three of five patient records.
The findings include:
Thirteen patient records were reviewed January 31, 2012 through February 1, 2012. Five records were reviewed for documentation of the personal history that was to be secured within the first week of treatment. Patient records # 5, 12, and 13 did not have the personal history secured within the first week of admission.
Patient # 5 was admitted December 6, 2011. The personal history was documented and dated December 21, 2011.
Patient # 12 was admitted November 8, 2011. The personal history was documented and dated December 7, 2011.
Patient # 13 was admitted November 10, 2011. There was no personal history documented in the patient record as of the date of the inspection.
The findings wee discussed with the facility director, clinical supervisor and project director. The findings were not disputed.
This is a repeat citation from the methadone monitoring inspection that was conducted on July 18, 2011 through July 19, 2011.
|
Plan of Correction
New form is being developed which will allow personal history to be comleted as part of the intake process. As the personal history will be completed at intake, this is well within the time frame required by the State. Program Director will conduct an in service on the correct way to complete the personal history. Program Director will monitor for compliance through audit of each chart at point of intake. |
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.
|
Observations
Based on the review of patient records, the facility failed to demonstrate the physician made the determination of the patient's dose in four of four patient records.
The findings include:
Thirteen patient records were reviewed January 31, 2012 through February 1, 2012. Four patient records were reviewed for physician's documentation of the patient's initial dose and schedule. Four of the four patients were new to the methadone program and needed to be inducted onto methadone.
Patient # 7 was admitted to the facility October 4, 2011. The physician wrote a standing order for patient to be inducted starting with 30 mg on October 4, 2011, 40 mg on October 5, 2011, and 50 mg on October 6, 2011.
Patient #11 was admitted to the facility October 11, 2011. The physician wrote a standing order for patient to be inducted starting with 30 mg on October 13, 2011, 35 mg on October 14, 2011, 40 mg on October 15, 2011, 45 mg on October 16, 2011, and 50 mg on October 17, 2011.
Patient #12 was admitted to the facility November 8, 2011. The physician wrote a standing order for patient to be inducted starting with 15 mg on November 8, 2011, 20 mg on November 9, 2011, 25 mg on November 10, 2011, and 30 mg on November 11, 2011.
Patient #13 was admitted to the facility November 10, 2011. The physician wrote a standing order for patient to be inducted starting with 30 mg on November 10, 2011, 40 mg on November 11, 2011, 45 mg on November 12, 2011, and 50 mg on November 13, 2011.
A review of patient records # 7, 11, 12, and 13 revealed that there was no documentation by the admitting physician that addressed the rationale for an increase of methadone daily.
On September 4, 2007, all narcotic treatment programs were issued a letter regarding methadone dose orders, especially during the induction phase, by the Department of Health & Human Services, Substance Abuse and Mental Health Services Administration: (SAMHSA)
In part, the following is excerpted from the letter:
"Because methadone overdose deaths have occurred in early treatment due to the drug's
cumulative effects of the first several days, it is also important to be cautious when
adjusting the dose. According to the drug labeling, the peak respiratory depressant
effects of methadone typically occur later and persist longer than its peak analgesic effects, which can contribute to cases of iatrogenic overdose, particularly during treatment initiation and dose titration. With repeated dosing, "methadone may be retained in the liver and released slowly, prolonging the duration of action despite low plasma concentrations." The drug labeling also states that "steady-state concentrations are not usually attained until 3 to 5 days of dosing," and that doses "will 'hold' for a longer period of time as tissue stores of methadone accumulate." Therefore, patients should be closely monitored during the induction phase, and the increase in dose should be under the close supervision of a physician as stated in 42 CFR 8.12 (h)(4), ' Dosing and administration decisions shall be made by a program physician familiar with the most up-to-date product labeling'. "
The project director confirmed this finding. This is a repeat citation from the methadone monitoring inspection that was conducted on July 18, 2011 through July 19, 2011
|
Plan of Correction
Facility Physician will no longer write standing orders. Facility physician will see new patients 2 x wkly for the first 30 days of treatment. In addition, dosing nurse has the ability to do COWS assessment and call physician if it is determined that pt is in obvious, objective withdrawal. Program director will monitor through chart audits and weekly staff meetings which include physician and dosing nurse. |
715.23(b)(23) LICENSURE Patient records
(b) Each patient file shall include the following information:
(23) Discharge summary.
|
Observations
Based on a review of patient records, the facility failed to document all of the required information in four of four patient records.
The findings include:
Thirteen patient records were reviewed January 31, 2012 through February 1, 2012. Four patient records were reviewed for complete discharge summaries.
Patient # 2 was admitted June 30, 2011 and discharged November 8, 2011. The discharge summary was documented, but the summary did not include the services offered or the status of the patient upon discharge.
Patient # 3 was admitted June 24, 2011 and discharged October 29, 2011. The discharge summary was documented, but the summary did not include the services offered or the status of the patient upon discharge.
Patient # 8 was admitted June 17, 2011 and discharged November 24, 2011. The discharge summary was documented, but the summary did not include the status of the patient upon discharge.
Patient # 9 was admitted September 23, 2011 and discharged October 23, 2011. The discharge summary was documented, but the summary did not include the status of the patient upon discharge.
This finding was not discussed with the project director and was not disputed. This is a repeat citation from the methadone monitoring inspection that was conducted on July 18, 2011 through July 19, 2011
|
Plan of Correction
New form is being developed which will ensure that discharge summaries will meet DAPL standards. Pt status at discharge as well as any referrals will be clearly documented. Program Director will conduct an inservice on appropriate completion of the discharge summary. Program Director will monitor for compliance through in service for staff on proper completion of discharge summary and chart audit at time of discharge |