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 June 24-25, 2013 by staff from the Program Licensure Division. Based on the findings of the on-site inspection, RHJ Medical Center, 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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715.15(b) LICENSURE Medication dosage
(b) The narcotic treatment physician shall determine the proper dosage level for a patient, except as otherwise provided in this section. If the narcotic treatment physician determining the initial dose is not the narcotic treatment physician who conducted the patient examination, the narcotic treatment physician shall consult with the narcotic treatment physician who performed the examination before determining the patient 's initial dose and schedule.
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Observations
Based on a review of patient records, the narcotic treatment program failed to document the consultation between the narcotic treatment physician determining the initial dose and the narcotic treatment physician performing the examination in one of one patient records.
The findings include:
Twelve patient records were reviewed on June 25, 2013. One patient record was required to document a consult between the narcotic treatment physician determining the initial dose and the narcotic treatment physician performing the physical examination. The documentation was not completed in records # 6.
Record #6 - Patient was admitted on 12-28-12. The Physician Assistant (PA) completed the physical examination on 12-27-12. The narcotic treatment physician determined the initial dose on 12-28-12, but failed to document the consultation with the Physician Assistant who completed the physical examination.
The finding was reviewed with the Clinical Supervisor and was not disputed.
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Plan of Correction
The project director and medical director are responsible to ensure that the consultation between the physician or physician assistant and the physician determining the initial client dosage is documented as necessary. In order to ensure that the consultation is properly documented the project director has added a statement on the intake history and physical exam for stating that the consultation occurred if the physician prescribing the initial dose of methadone is not the physician who completed the initial history and physical. The project director will meet with all physicians and physician assistants to discuss the regulation and provide the updated form. In order to maintain continued compliance, random chart audits will be completed to ensure that the documentation is being completed as necessary. |