INITIAL COMMENTS
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This report is a result of an on-site complaint investigation conducted on January 9-10, 2020 by staff from the Bureau of Quality Assurance for Prevention & Treatment. Based on the findings of the on-site complaint investigation, White Deer Run Inc. Allenwood was found not to be in compliance with the applicable chapters of 28 PA Code which pertain to the facility.
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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
Facility staff did not observe each patient ingesting medication.Client chart reviews and interviews confirmed that clients were cheeking medications to misuse and/or divert to other clients.
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Plan of Correction
Please see appeal letter- emailed to Laura Rostolsky on 1/22/20 @08:00
1. We will continue to observe all medication administration as we always have.
2. We implemented mouth checks on every medication administered. This went into effect on 1/20/2019. Protocols for NTP medications remain the same as previously defined.
3. We implemented patient speaking back to nurse after administration of every medication administered. This went into effect on 1/20/2019. Protocols for NTP medications remain the same as previously defined.
4. Support staff (technician) will be present at all medication administration areas to ensure patient speaks back to nurse and that mouth check is completed. This individual will radio to clinical team in the event the patient refuses or becomes uncooperative.
5. We completed a new medication administration building on November 13th. This building is designed to reduce traffic at the Building 10 administration area and will allow us to separate males and females during administration times. It also reduces the volume of patients waiting for entry to the existing medication administration area.
a. Females will use the Building 10 medication dispensing area at designated times
b. Males will use the Building 5 Annex medication dispensing area at designated times.
c. DEA conducted an inspection of the new building on November 19, 2019.
d. DEA gave official approval to begin using the new building on January 15, 2020. Copy of approval attached.
e. We will begin using the new building as soon as we have hired/trained additional nurses to support the new Building 5 Annex process. Target is tentative at March 1, 2020.
6. Medication Administration Policies will be updated to reflect the changes noted above by February 28th (This later date is indicated due to time required for corporate approval process).
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