INITIAL COMMENTS
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This report is a result of an onsite licensure renewal and methadone monitoring inspection. The inspection was conducted on March 20, 2018 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the onsite inspection, Summit Medical Services 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 the inspection:
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Plan of Correction
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709.32 (b) LICENSURE Medication control
§ 709.32. Medication control.
(b) Verbal orders for medication can be given only by a physician or other medical professional authorized by State and Federal law to prescribe medication and verbal orders may be received only by another physician or medical professional authorized by State and Federal law to receive verbal orders. When a verbal or telephone order is given, it has to be authenticated in writing by a physician or other medical professional authorized by State and Federal law to prescribe medication. In detoxification levels of care, written authentication shall occur no later than 24 hours from the time the order was given. Otherwise, written authentication shall occur within 3 business days from the time the order was given.
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Observations
The facility failed to have the physician sign verbal orders within three business days of the when the order was given in one of one patient record reviewed on March 20, 2018.
Patient record # 1 - A Verbal Order was given on 12/3/17. There was no documentation that the order was signed by the physician.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Both the Facility Director and Medical Director are responsible for ensuring corrective actions are implemented and followed through with.
On 4/2/17, Facility Director discussed the verbal order procedure with the Medical Director. Facility Director reviewed that all verbal orders must be signed off on within 3 business days.
Also, when orders are signed off on, the Medical Director will review the order in SMART software system to ensure the signature was added and does not come up as "Invalid."
The Medical Director, will review this procedure with all other Summit doctors doctors at Summit Medical by 4/5/18. |
715.23(c)(1-7) LICENSURE Patient records
(c) An annual evaluation of each patient 's status shall be completed by the patient 's counselor and shall be reviewed, dated and signed by the medical director. The annual evaluation period shall start on the date of the patient 's admission to a narcotic treatment program and shall address the following areas:
(1) Employment, education and training.
(2) Legal standing.
(3) Substance abuse.
(4) Financial management abilities.
(5) Physical and emotional health.
(6) Fulfillment of treatment objectives.
(7) Family and community supports.
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Observations
The facility failed to document the signature of the medical director on the annual evaluation in one of the two records reviewed on March 20, 2018.
Two of the eleven patient records required an annual evaluation. One patient, # 6, had an annual evaluation that was signed by a treatment physician and not the medical director.
These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
Both the Facility Director and Medical Director are responsible for ensuring corrective actions are implemented and followed through with.
On 4/2/18, Facility Director reviewed this citation with the Medical Director. Facility Director reviewed with the Medical Director that the medical Director only is to sign the annual evaluations. It was also reviewed that other program physicians cannot sign these annual evaluations.
The Medical Director will review this policy with each of the other program physicians by 4/5/18. |