INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on May 4, 2021 by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, Polaris Renewal Services Inc. 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:
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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
Based on a review of patient records, the narcotic treatment physician failed to document the proper dosage level for a patient by writing standing orders for the patient's induction phase in two of four patient records reviewed on May 4, 2021.The following standing order was documented by the physician in patient records # 4 and 6: "30 mg on the first day, 40 mg on the second day and 50 mg on the third day".Patient # 4 was admitted October 19, 2020 and discharged March 18, 2021. The standing order was documented on October 19, 2020.Patient # 6 was admitted February 1, 2021. The standing order was documented on February 1, 2021.The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Polaris Executive Director has reeducated the Polaris Medical Director on what constitutes a standing order and also in his documentation of initial dose orders, with the initial and induction doses being reviewed specifically. The Medical Director will order the initial dose and document as such in the electronic medical record. Any subsequent dose changes will be based on the medical director's assessment of patient need and ordered one at a time. The nursing staff was also instructed to notify the Executive Director if they see any induction phase orders from the medical director that would be standing orders and to have the medical director properly order and document each dose separately based on daily assessment
The Executive Director will periodically review the induction orders to ensure that they are being ordered and documented appropriately.
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715.20(4) LICENSURE Patient transfers
A narcotic treatment program shall develop written transfer policies and procedures which shall require that the narcotic treatment program transfer a patient to another narcotic treatment program for continued maintenance, detoxification or another treatment activity within 7 days of the request of the patient.
(4) The receiving narcotic treatment program shall document in writing that it notified the transferring narcotic treatment program of the admission of the patient and the date of the initial dose given to the patient by the receiving narcotic treatment program.
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Observations
Based on a review of patient records, the facility failed to document in writing that it notified the transferring narcotic treatment program of the admission of the patient and the date of the initial dose given in one of two patient records reviewed on May 4, 2021.Patient # 7 was admitted December 14, 2020.The findings were reviewed with facility staff during the licensing process.This is a repeat citation from the October 14, 2020 licensing inspection.
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Plan of Correction
A written notice of admission and initial dose of all transfers to Polaris will be contained in their record. The office administrator will complete and fax the notice of admission and first dose to the referring clinic of each patient within 7 days of patient admission. The notification letter and fax confirmation will be uploaded by the administrator into the patient record. In the event that the office administrator is out of the office the clinical supervisor will complete and send the notice of transfer to the referring facility and upload into the patient record. The supervisor will conduct chart reviews on each discharged chart to verify that the notification was sent and is present in the patient chart. The director reviewed this process with supervisor and office admin. |