INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on May 23-25, 2017, by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Williamsport Family Medical Center 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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715.6(e) LICENSURE Physician Staffing
(e) A physician assistant or certified registered nurse practitioner may perform functions of a narcotic treatment physician in a narcotic treatment program if authorized by Federal, State and local laws and regulations, and if these functions are delegated to the physician assistant or certified registered nurse practitioner by the medical director, and records are properly countersigned by the medical director or a narcotic treatment physician. One-third of all required narcotic treatment physician time shall be provided by a narcotic treatment physician. Time provided by a physician assistant or certified registered nurse practitioner may not exceed two-thirds of the required narcotic treatment physician time.
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Observations
Based on a review of patient records conducted during the onsite inspection the facility failed to ensure that the medical documentation for patients had the required medical signatures.On November 10, 2016, Staff Person #10, a physician's assistant, performed the initial physical examination on patient #8 for the patient's admission to narcotic treatment, but the documentation of the exam was not countersigned by the medical director or a narcotic treatment physician. These findings were reviewed with facility staff as part of the licensing process.
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Plan of Correction
Facility Director will review/re-educate PA-C and Medical Director on countersignature expectations and procedures. Upon intake, the Clinical Supervisor will ensure all countersignatures are completed. An Intake Record Review tool will be utilized and completed by the Clinical Supervisor to ensure appropriate documentation is completed weekly. A follow up record review by the Facility Director monthly will ensure that the deficiency does not occur in the future. |